1 Introduction

Augmentative and alternative communication (AAC) aims to enable a variety of interactions and participation possible for those with complex communication needs because their natural communication methods are insufficient to meet their everyday communication needs [1]. AAC systems are diverse and typically classified into two broad categories: unaided and aided methods [1]. Unaided methods refer to, e.g., signing and body language with no need for external tools, while aided methods use external tools and materials. Aided AAC is further divided into low- and high-technology systems. Low-technology systems include, e.g., tangible pictures, communication boards, and communication books, while high-technology systems include computer-based systems and speech-generating devices (SGDs) that are commonly accessed by finger-pointing or swiping. The diversity of AAC systems expands as technology evolves, offering new techniques and solutions that are mainly realized in mobile technologies [2]. Mobile technologies include smart glasses, smart phones and tablets, as well as sensors and accessories connected to them, and providing access to many different AAC applications.

Despite the many advantages of AAC supports [1, 3] and the acknowledged importance and fundamental right of communication for everyone [4], many are continually unable to utilize these supports [5,6,7,8,9], so they may abandon or reject them [10]. Johnson et al. [10] define abandonment as the inappropriate discontinuance of the AAC system. Respectively, rejection refers to situations in which a person rejects the AAC from the beginning. For example, only approximately 40% of AAC systems introduced to persons who require AAC were used by them for more than one year [10]. Therefore, the use of both unaided and aided AAC is low.

Research has identified many barriers to the successful use of different AAC systems, which relate to the AAC system, the environment, and one’s abilities [7,8,9]. Regarding high-technology AAC, common system-related challenges relate to availability and technical difficulties, such as unreliability [7] and poor usability [11]. For example, limited battery span [8] and general technical difficulties [3, 12] prevent the use when needed. Moreover, the technology breakdowns impede the progress in learning to use the device [13] and may cause frustration [3].

Poor usability and user satisfaction have been linked to high rates of abandonment [10]. Baxter et al. [7] and Donato et al.’s [8] review articles found that the AAC device is hard to use, thus requiring significant time and effort to learn [14]. This is particularly concerning to those with intellectual disabilities, as studies show they rarely use high-technology AAC [5, 6]. Poor usability may affect the environmental factors which have been found to be one of the most common barriers that AAC technology users face. For example, family support and attitudes, decision-making process and service provision and knowledge and skills of staff all influence the use of these supports [7].

Furthermore, one’s functional abilities, such as physical impairments, cognition, motivation, and other factors, including anxiety, inflexibility, and challenging behaviors [8] affect the use of technology and its overall usability. Physical impairments, such as in fine motor abilities, may hinder the ability to use communication aids, making utilizing the aid slower and inefficient and, therefore, frustrating [2, 25]. For example, having to use swiping or finger-pointing, which is common when using mobile technologies, can prevent these systems from being used [1, 7]. In fact, researchers highlight the need to create novel technologies for those with motor impairments [2, 15, 16].

The motivation to learn and use the AAC system seems to be one of the key factors when it comes to learning and using the AAC system. Motivation has been identified as a barrier in several articles [8, 17, 18] because the successful usage of AAC requires motivation, attention, and interest [8]. The self-determination theory explains the different aspects of motivation—intrinsic and extrinsic—and psychological wellness [19]. Intrinsic motivation refers to doing something because it is considered interesting and enjoyable. Extrinsic motivation encompasses praise and external rewards. The theory primarily focuses on autonomy (feeling a sense of control), competence (feeling capable and competent), and connection (feeling a sense of belonging). Therefore, if AAC does not enable these, then the motivation may decrease.

Overall, researchers agree that novel technologies must be designed and developed (17, 22–24). The design must consider a broad range of factors to create useful technologies that are available within different environments. The path that focuses only on technological advances and practice alone hardly suffices given the diversity of AAC and of those who require AAC [20]. Parsons et al. [21] ask the fundamental question: “How can we match those who see solvable problems with those who can engineer solutions?”. An answer to this question would be to establish a common platform that combines the expertise from different fields in a detailed way and leads to shared understanding of the diversity of functional abilities and the crucial role environmental factors play in the AAC field.

The International Classification of Functioning, Disability and Health Framework (ICF) may provide this common platform [22] because it offers a framework for understanding the diverse factors that affect the use of AAC and those requiring supports. The ICF is a classification of health and health-related domains, including environmental factors [23]. It is widely implemented in clinical settings for data registration, evaluating outcomes, and measuring disability [24].

The categories of ICF are body functions, body structures, activities and participation, and environmental factors [18]. Personal factors, such as gender and age, are acknowledged but not coded in the ICF [18]. The categories are further broken down into chapters and levels depending on the different levels of specification [23]. The following example illustrates the structure of the third level in the chapter of communication.

Category

 

Activities and participation

Chapter

d3

Communication

Second level

d335

Producing nonverbal messages

Third level

d3351

Producing signs and symbols

Thus, the ICF provides a detailed tool that presents a comprehensive perspective of a person’s overall situation, capturing the medical and social aspects of disability [25, 26]. In the AAC field, the use of ICF has been realized by emphasizing the results of AAC in rehabilitation [9, 27]. Recently, Moorcroft et al. [9] conducted a systematic review to explore the barriers identified in using low-tech and unaided AAC systems using ICF as a framework. In addition to the environmental factors, body functions affect the provision and use of unaided and low-tech AAC, including mental, voice and speech, movement, and sensory functions, as well as pain.

The use of textiles, providing a direct way to measure body functions, is a novel approach to enhance AAC technologies. Embedding sensing technologies (technologies that use sensors to acquire information by detecting e.g., the touch or motion) into textiles would be worth investigating because clothing and other textiles are a natural part of everyone’s daily life [28, 29]. Hence, these technologies would have the characteristics of being accessible by anyone—anytime and anyplace [28]. So far, textile-based technologies are rarely mentioned when considering their possibilities in supporting those with complex communication needs, despite the significant rise in developing wearables and textile-based technologies in health care [30]. The limited amount of work toward this has mostly focused on the field of interpreting signs [31].

Recently, Fager et al. [16] discussed the limited amount of information about the use of wearable sensor technology, specifically capacitive-sensing technology, in two studies [32, 33]. These studies highlight their emerging possibilities in providing an access method and environmental control for those with severe motor difficulties. Interpreting signs has received wider interest. For example, Ahmed et al. [31] reviewed systems-based sensory gloves for sign language recognition. However, the technologies were considered expensive and bulky, and the portability posed problems. As such, they are not yet useful for those with complex communication needs. Recently, a budding interest in designing novel touch-based technologies has arisen [34,35,36].

Implementing the ICF framework is well suited to explore the possibilities that novel technologies may offer. Furthermore, it offers a platform where experts from different fields can collaborate in an understandable way. Such an approach could help reach the needed universal principles in AAC and assistive technology that Weed et al. [37] provide, including principles of minimal learning, energy, and interference; best fit; and practicality and use. Hence, specific attention must be given to the availability of the device, ease of use, and general suitability to participate in different situations [38].

For this study, we defined textile-based AAC (TAAC) as a wireless technology embedded into clothing or other textiles.

To the best of our knowledge, no research attempts can be found to bring forth the clinical perspective when designing novel high-technology AAC implementing the ICF. A significant challenge in creating novel technologies is understanding various factors contributing to AAC not being utilized. Without the clarity of these barriers and their contribution to one’s ability to participate, the barriers remain, and the potential of novel technologies will not be realized.

This study’s objective was to establish a connection between speech-language pathologists (SLPs) and technology developers, such as hardware and software engineers and human–computer-interaction specialists, by providing a common platform for collaboration via the ICF framework. Therefore, we aimed to identify barriers to the successful use of currently available AAC systems and to elicit user stories to identify the factors that could be affected when using TAAC.

We aim to answer the following research questions:

RQ1. What factors do SLPs perceive as barriers to successfully using AAC within the ICF framework?

RQ2. What factors in the ICF framework are affected when using TAAC technology?

The remaining part of the paper proceeds as follows: Sect. 2 outlines the methods used, including participant recruitment, data collection, and procedures for data analysis. Section 3 then presents the results of the barriers and the user stories implementing the TAAC. Section 4 discusses the findings related to the research questions. Finally, Sect. 5 provides the conclusion and future research directions.

2 Methods

A deductive thematic analysis [39] was undertaken for this study using the ICF framework as a code book [23]. Data were generated via an online survey and two focus group discussions. The importance and originality of this study are that it explores the barriers using the ICF framework to understand how they affect one’s body functions and structures, activities, and participation. Furthermore, it identifies what factors within the ICF framework use this technology affect and what follows the usage from the SLP’s perspectives. Focus groups were chosen because they are used in UCD methods for gathering requirements in the phase of early design [40].

A pilot study (for two persons from the target population) was conducted remotely before the data gathering to clarify the questions asked [41] and understand how the novel TAAC technology should be introduced to elicit user stories. These data were not included in the analysis.

2.1 Participants

We used SLPs as proxies for those with complex communication needs to create user stories about textile-based AAC (TAAC) technologies. SLPs were chosen because they are crucial in assessing and selecting AAC systems and are primarily involved in AAC rehabilitation [42]. Involving experts and proxies is common in the design process with minimally verbal children [21, 43]. Purposeful sampling [41] and in-person recruitment were implemented to reach specifically knowledgeable and experienced SLPs in the AAC field. The criteria for including the participants in this study were (a) at least three years of experience working as an SLP and (b) during the previous year, experience in implementing AAC methods at least once a week.

A recruitment letter with a description and objectives of the study was sent to an email distribution list from the Finnish Association of Speech and Language Therapists for 1338 subscribers. The recruitment letter was also posted on two social media platforms with 2357 subscribers to increase the possibility of participating. Altogether, 13 people expressed interest in participating via email or phone calls. One interested person did not meet the criteria. Therefore, 12 consenting SLPs were invited to complete an online survey (for demographics and data generation) and partake in a focus group discussion of their choice between two options arranged remotely using Zoom.

SLPs reported that their work experience was 6–36 years, with a mean of 20.4 years. Most SLPs in this study worked with children (n = 6); one only worked with adults, and two worked with children and adults. Three SLPs did not reveal this information.

All participants implemented unaided methods during the previous year with their clients, including gestures, body language, and signs. Low-technology methods were also widely implemented. Eleven used picture-communication methods (including communication books, communication boards, and tangible pictures), five used real objects, six used writing, and ten used drawing. However, whether the participants meant writing with a pen or writing using, e.g., computer-based systems, was unclear. Ten used high-technology supports, including speech-generating devices, computer-based communication systems, and mobile technologies with communication applications. One participant reported using other methods with environmental management equipment, such as fans and button-operated toys.

As detailed in Table 1, the most experience was reported with those with intellectual disabilities, developmental language disorder, and autism spectrum disorder (ASD). None had experience in using AAC with those with cleft lip or palate or acquired communication disorders, such as aphasia.

Table 1 Client groups with whom the participants used AAC methods
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2.2 Data generation and data sets

The data generation was triangulated to affirm that the participants had multiple opportunities to express their perspectives and thus increase the validity and reliability of the results. A focus group topic guide was developed based on literature to ensure both groups received the same information, flow, and questions. Each discussion lasted for approximately two hours. The first author was a moderator and focused on building rapport throughout the discussions. Five other researchers were also in the groups but did not participate in the discussions. These data were collected as part of a previous study that explored the SLPs’ views and ideas in using novel, wireless textiles for communication. The data for this study were generated in four phases.

2.2.1 Phase 1

The online questionnaire (Microsoft forms) was designed to engage the SLPs in thinking of their personal experiences in advance [44], gather demographics, and generate data. They were asked to freely describe the barriers they experienced using existing AAC methods, to which all participants replied. The online questionnaire also asked the SLPs to name facilitators to the successful use of available AAC and give three examples of what their clients can express using different AAC methods. Only data referring to the barriers were included in the analysis. This approach elicits thinking in advance and brings ideas to the discussions to save time [45].

2.2.2 Phase 2

A list of the barriers collected in the first phase was roughly organized by the first author and presented to the SLPs to evaluate the results during the focus group discussions after introductions and a task for breaking the ice. An opportunity to add to the list was provided.

2.2.3 Phase 3

While still looking at the list of barriers, the SLPs were asked to discuss the purposes for using textile-based, wireless AAC technology and in what situation it could be useful. This was done to elicit user stories that can be real or imagined [46] in UCD approaches that focus on the user [47]. More specifically, they describe the user, their needs and capabilities, and how the person may interact with the technology [43]. The SLPs were reminded several times to ideate freely and not consider the technological perspective. The moderator asked clarifying questions (who, how, what), if necessary. Furthermore, two additional questions were asked to elicit more user stories: (1) What if the caregiver is not in the same space? (2) What if a year has passed and the textile-based AAC had worked wonders?

The last part of the discussions consisted of scenario development. These scenarios are not published here. However, the user stories related to this study’s objectives were included in the analysis.

2.2.4 Phase 4

After discussions, another online questionnaire was conducted to allow the participants to ideate further and give their opinions freely. Most participants returned the survey (11/12), but no additional barriers or ideas were offered.

Consequently, the data generation resulted in two data sets. Data set 1 includes the results from the Forms survey and the additions the participants made during the discussions concerning the barriers to successfully using AAC. Data set 2 includes the data retrieved from the focus group discussions regarding user stories.

2.3 Data analysis

Deductive thematic analysis was undertaken using the ICF framework as a code book following the common form of analyzing data [39]. Moreover, the coded data were grouped inductively into themes. These data were analyzed in three steps. A detailed audit trail was kept throughout the analysis process.

2.3.1 Step 1: the barriers

The written responses from the online survey were transferred to Excel for analysis. During focus group discussions, the participants made 15 additions to the list of barriers. The additions were transcribed verbatim and first managed in Atlas.ti 9, which the first author checked for accuracy. The first and second authors extracted the text segments about the barriers, which the first author later checked for accuracy; these segments were finally transferred to Excel. The text was divided, where the researchers noted a shift in meaning.

Data segments regarding barriers were excluded if they did the following:

  1. (1)

    Involved only a lack of speech, referencing the need for supports rather than a barrier to using currently available AAC systems;

  2. (2)

    Lacked necessary information about the barrier;

  3. (3)

    Required interpretation (latent analysis) that was unclear from the content.

The first and second authors coded the text segments using ICF independently after practicing coding together. Each segment was linked to the 2nd level ICF coding, if available, when coding semantically. A detailed codebook for deductive analysis with instructions was drawn together (see Appendix 1, Sect. 1). Intercoder agreement was established for the entire data set using subjective intercoder agreement [41] and discussed until an agreement was reached. The data were organized in several iterative rounds into ICF codes and then inductively to themes [41].

Results were presented to the whole research group to comment and avoid researcher bias. Descriptive quotes were retrieved from the data and translated from Finnish to English by the first author. Because the data from the online survey were collected anonymously it was not possible to separate the participants by e.g., numbers.

2.3.2 Step 2: user stories

The focus group discussions were transcribed verbatim and first managed in Atlas.ti 9. After carefully familiarizing with the text several times, the first author extracted user stories related to using TAAC. The text segments were then transferred to Excel, which the second author checked for accuracy. The analysis for each user story consisted of two phases because the analysis clearly revealed two different perspectives. First, the first and second authors coded the area of functional ability to which aspect of using TAAC mainly aims to influence. Second, the same authors coded the area of functional ability that is immediately affected when using TAAC. Again, the text segments were first linked to ICF chapters and then to the 2nd level, if applicable. Appendix 1 (Sect. 2) presents the used ICF codes and instructions for applying coding. Text segments regarding user stories were excluded if they provided insufficient information on both required perspectives.

The researchers made every attempt to avoid interpretations or researcher bias. The first and second authors re-checked the analysis after a period of time to increase validity and reliability. The data and analysis were discussed several times among the research group to avoid research bias and increase validity. In the case of uncertainty regarding coding, e.g., e3 (support and relationships) and e4 (attitudes), due to their close nature, the coding was conducted semantically focusing strictly on context and what was said.

After analyzing the data, the first author translated descriptive quotes from Finnish to English. In quotations, the participant is referred to as SLP and further identified with a number 1–12.

3 Results

This section details those codes deemed most pertinent to the research questions concerning the barriers and the user stories.

3.1 Barriers to successfully using currently available AAC

SLPs described 119 barriers to successfully using the currently available AAC. These data were linked to 21 different ICF categories. SLPs viewed the environmental factors as the most prominent barriers, and 74 quotes referring to them were identified. Within the environmental factors in ICF, the products & technology, support & relationships, attitudes, and stakeholders fall into the categories of e125, e3, e4, and e580, respectively (see Table 2).

Table 2 Barriers to successfully using currently available AAC within the ICF
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Most barriers were identified within the products and technology (n = 29 quotes). According to the SLPs, the barriers include the AAC being unavailable, not meeting users’ individual needs, having technical issues, being hard to modify, and changing regarding technology. The unavailability includes the portability issue and was considered important because, in these cases, the AAC was unavailable when it was needed at a certain place or moment. These SLPs viewed, e.g.,

Sometimes the pictures are lost at the very moment when they are needed.

There is too little vocabulary and does not meet the [communicative] needs.

The batteries may be dead.

The device is still there and working, but the application is no longer available anywhere.

It has been difficult to activate meaningful content with the aids.

Modifying the aid is difficult or complicated.

According to the SLPs, the support & relationships category fundamentally affects the use of AAC, which was identified 23 times from the data. The inability to use or understand the preferred modality of AAC prohibits using such systems, resulting in fewer opportunities for communication and the risk of not being understood. The SLPs noted that learning to sign or use pictures effectively in everyday life takes time, and the demand for learning slows the provision of AAC. Furthermore, in some cases, the turnover rates are high, and new people may have to relearn the system from the beginning, requiring more training from other stakeholders. Low advocacy and proactiveness reduce the amount of support offered, leading to the AAC not being utilized for communication. Updating the device refers to close ones not updating the device to meet the person’s current needs. The SLPs acknowledged the difficulty of providing adequate support. For example, one SLP stated during the focus group discussion that “…nowadays, it is rather a big thing, especially with all these digital gadgets that are used, with changing environments…and then you have to, even with a similar gadget, do more work.” Furthermore, updating the AAC may rest on one person’s shoulders, and the vocabulary content in everyday life is chosen by guessing. The following quotes extracted from the survey elaborate the SLPs’ perspectives:

Sometimes, despite everything, the immediate stakeholders’ capabilities, enthusiasm, or resources are inadequate, and the system will be left unused.

The communication partner must be very active and create situations for communication.

…or they don’t help with using it [the AAC system], they won’t learn signs, they [pictures] are detached or lost, they don’t notice the child’s gestures, facial expressions, or functional attempts to communicate.

The attitudes of close stakeholders (e4) were also considered significant barriers. SLPs discussed unrealistic expectations, lack of confidence, not understanding the importance of AAC, and personal views and judgments:

Open or silent opposition of the surrounding environment to the [AAC] method…

AAC is perceived as cumbersome and hinders interaction.

There is also a fear that AAC, either technical or manual, would be used incorrectly.

These attitudinal barriers can lead to the AAC system never being used or diminishing the amount of, e.g., augmented input or modeling, thus decreasing the opportunities to learn and communicate via the AAC system.

Only four text segments were linked with e580 (Health services, systems, and policies). These SLPs felt the effective use of all AAC methods is sometimes hindered by the lack of professionals and needed guidance. For example, one SLP wrote, “Too little guidance for close ones.”

Returning to Table 2, SLPs viewed that movement-related functions and mental and sensory functions can be considered barriers to successfully implementing AAC, as well as factors related to communication and learning and applying knowledge. Movement-related functions were combined from b7 and b760 (Neuromusculoskeletal and movement-related functions), and d4 was further divided into d415 and d440. Presenting b7 and b760 together was because the data did not clearly expose the distinction. However, motor disabilities were often labeled a barrier to AAC systems. SLPs also described the difficulty of maintaining posture (d415) and using their hands (d440) as barriers.

Mental and sensory functions were identified ten times; five related to motivation, and the rest were single remarks. Regarding motivation, the SLPs viewed that sometimes those with severe disability are uninterested in communicating via the AAC system or that the motivation can vary from moment to moment. For example, one SLP stated, “The motivation of a client with a severe disability may vary enormously depending on what is available to do.”

Among the reported barriers were factors related to Chapter d3 (Communication), such as unclear or indefinite signs in producing nonverbal messages (d335), difficulty in initiating conversation (d350), and using communication devices and techniques for communication (d360).

…when the client is in a new environment, no one there understands them [unclear signs].

…even a professional may miss those very subtle initiations when we talk about [the] severely disabled or those with autism…

…people who can’t use these devices, for example, a cell phone, etc.…

Only three barriers were linked to Chapter d1 (Learning and applying knowledge). These SLPs viewed that sometimes learning is prohibited when one is occupied with different activities, e.g., exploring the object with their mouths or throwing objects around.

3.2 Factors that using TAAC could affect

In focus group discussions, SLPs created 87 user stories on how the proposed TAAC technology could affect one’s functional ability within their environment. Each user story had two viewpoints relating to research question 2: (a) The area in the ICF that using the TAAC aims to influence; and (b) The area in the ICF that is immediately affected after using the TAAC. Table 3 presents a comprehensive list of the functional abilities according to the ICF framework. These results are collated according to the four main themes identified when analyzing the areas that using the TAAC aims to influence: communication, using TAAC technology, learning & applying knowledge, and Motivation. The number of text segments linked to the ICF category is presented in brackets. Examples of essential characteristics of TAAC viewed by these SLPs are compiled in Table 3. Appendix 1 (Sect. 2) contains the descriptions of all codes.

Table 3 Major themes of communication, Using TAAC technologies, learning & applying knowledge, and Motivation with ICF codes for factors that using TAAC could affect
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3.2.1 Communication

Most user stories (n = 39) were envisioned to affect the communication area in the ICF. The main underlying barriers discussed here were the inability to produce understandable signs or gestures because of the person’s motor difficulties or the environment’s inability to understand them.

The most pertinent topic was producing non-verbal messages (d335) that the environment could easily understand (e3). To this end, TAAC should be designed to learn individual movements and interpret them as, e.g., speech or pictures. Signing understandably could also increase the environment’s activity.

…a stranger can’t recognize at all the means that the person is using to communicate, but then, when they do that some gesture, the clothing would say, ‘I am hungry. (Extract from SLP9)

…when they sign very fast with approximate signs, these e-gloves can quite accurately interpret their signs. (Extract from SLP5)

…it would actually support those who use sign language. One could sign with these gloves, and it [technology] recognizes the motions, gestures, and finger positions. After that, the application could speak out loud what was signed. (Extract from SLP2).

In a few other stories, touches would have symbolic meanings, e.g., expressing wants was made possible by pressing individually designed spots in clothing to produce visual feedback and help the environment understand. For example, SLP7 ideated: “If you press here [showing their sleeve] on the picture of the slide or the spot that means ‘I want to go down the slide,’ then the picture of the slide would appear on the screen in the middle of the shirt. And then, when you press the other [sleeve] that says, ‘Now I want to make sand cakes,’ the picture of the sand cake will appear and so on.” Another application could be designing clothing with a specific meaning for touching different spots like haptics:

…a little like signs have specific meanings…these touches could be developed into their own specific meanings…when a person touches the clothing, it [technology] could interpret them somehow. (Extract from SLP2).

…It [clothing] could have different tactile detection points: one could feel that here it is rough and… a pimple-like [a bump in the fabric] …and it could recognize them [touches]… (Extract from SLP7).

Initiating conversations (d350) was mentioned in ten user stories to increase participation and the environment’s understanding. SLPs viewed that creating such technology that supports the smallest effort in initiating would create opportunities to start an interchange of thoughts and ideas and enable contacting someone further away. To this end, the following was suggested:

” …even if not in the same space and [a person] initiates, then it would somehow make a sound, etc., so the communicative partner would immediately notice something going on now. (Extract from SLP5)

SLP3 wondered whether TAAC may also increase the number of initiations for those whose initiation skills are somehow stiff: “…if there were a nice sleeve to touch, would that also increase the number of initiations?” By turning the gestures and initiations into speech or pictures, the environment could notice the initiations better. Furthermore, it was viewed that sometimes other people could wear the TAAC to enable even more initiations: “If the adult’s clothing had these initiation-making things too, it would be great as a tool to make contact because they would seek out the adult to discuss the matter.” (Extract from SLP7).

Enabling discussion (d355) was identified seven times by touching designated areas or motion detection to activate spoken words or ready-made phrases.

…important [words] from the core vocabulary could be coded… if there were a limited amount of what it [TAAC) can recognize, then [the person] could somehow participate by commenting: fun, stupid… (Extract from SLP3).

Some user stories were mentioned only once, such as enabling phone calls via TAAC and clicking designated spots containing whole written words, as well as technology that interprets unintelligible speech and technology that interprets speech into drawings or writing, thus helping a child understand speech.

3.2.2 Using TAAC technology

User stories on specifically using TAAC technology were identified 23 times and spanned across two very different areas in the ICF—d210 and e125—undertaking a single task and products and technology for communication, respectively. These areas were combined because both revealed how the technology would support independence.

A general view when aiming to enable undertaking a single task was that those with severe disabilities would have independent access to something meaningful utilizing their motor capabilities.

…a person who lives in a group home and is immobile and can’t reach for the call button or use a handheld device…could somehow press a specific spot and with that specific movement, they could accomplish something. (Extract from SLP1).

…if I slap my knee…music starts playing. (Extract from SLP3)

A few stories were created to enable writing or support executing tasks. SLP11 wondered if an adult who could write could wear a keyboard on their wrist. Afterwards, the adult could use their ability to write in all situations. SLP10 thought that TAAC would help one complete a task, if available, and produce pictures for executing the task if the child had difficulty following verbal instructions: “…they would see the pictures [produced by technology activated by TAAC] right in front of their faces…The carer would slap the picture of handwashing [on TAAC]…usually, the pictures [used for AAC] are kept in some folders and somewhere farther away; by no means are they [pictures] with them when they are needed. One user story, created by SLP8, contained technology that would give instructions piece by piece and then acknowledge the task as done. This kind of solution could help those with dementia, e.g., in making coffee independently.

In four stories, the outcome would reduce the dependency on support when designed to be activated by one’s voluntary movements. After that, the person could complete tasks themselves using this device that is available, easier to use, and reachable with their existing motor abilities.

…the adult is not present to interpret the messages [when signing] or something, but they [child] can [via TAAC] talk to their friend and the friend would understand it. (Extract from SLP5)

Earlier, unavailability was identified as one of the prominent barriers to using AAC. The SPLs created several user stories where the TAACs’ availability was emphasized. A general view was that the technology in the garment and a suitable place for the person to enable its easy activation would naturally increase availability and accessibility. A few examples included a specific location for the technology, such as in the bathroom, on the bedspread, or in horseback riding clothes. To further increase availability, the TAAC was considered removable or a wearable that can be worn on top of other clothing, thus reducing the effort to create opportunities to practice social interaction because the material would always be with them on their clothes. Therefore, increasing technology’s availability increases opportunities to use the device independently.

3.2.3 Learning and applying knowledge

SLPs viewed that TAAC could help one learn and apply knowledge by rehearsing (d135), focusing their attention (d160), and acquiring skills (d155), thus, in most cases, enabling language learning.

Again, the recommended aspects for the technology were like the previous ones. Learning becomes possible if the device is available and accessible, including motor accessibility and meaningful feedback, and contains relevant content concerning learning. One user story emphasized this ease: “It could be that the introduction of technology could be easier…it [TAAC] could somehow be easier to implement, while with signs, the environment must learn them to understand or use them….and if one has a communication book, one must practice how to use that too, know where the pictures are located…” (Extract from SLP5).

SLPs saw that through rehearsing, one could learn various communicative functions, such as making choices and answering “yes” and “no” in different contexts and activities. For example, SLP12 stated “…if they are practicing ‘yes’ and ‘no’ in different contexts, you could ask them if they want to play maracas or another toy so that they could make those choices there.” SLP10 highlighted that having a removable vest could enable practicing in, for example, a gym or therapy.

Furthermore, learning signs could be made easier if technology interpreted gestures or touch and produced an image or hologram to support it. For example, SLP7 created the following user story: “The hologram idea is in use…, i.e., when they sign the sign for a dog so that the corresponding image will appear…” SLP10 continued the idea by expanding it: “…[mother and father] could model the sign with their hands, which will, of course, be rewarding, as the correct image will be visible on the hologram. This will concretely teach how to correctly produce the sign.” Moreover, TAAC could enable practicing the meaning of a picture or symbol if the picture appeared on the textile.

Focusing attention was discussed in four user stories in which the TAAC would flash or produce a sound to attract attention. Such technology would help one focus on the device, the communicative partner, and modeling. Furthermore, focusing on the device would be easier if it were attached to something for those who sometimes want to throw their AAC away.

3.2.4 Motivation

While the content was considered crucial in all categories in this study, motivation was identified 11 times, without any clarifications for what the purpose for using TAAC would be otherwise. Motivation was understood as the foundation of everything and was considered enhanced when the technology was easy to use, worked using one’s movements, and signaled that something significant for the person would happen.

…it [TAAC] would somehow tempt you to continue and practice more, thus increasing the client’s motivation and the environment’s. (Extract from SLP5)

Sometimes, the device itself was considered motivating:”…a little thing that could be carried around always. They [children with complex communication needs] don’t carry their communication books around, but what if it was this lovely ‘Hello Kitty’ bag that could be attached to the wrist…that could be quite motivating.” (Extract from SLP10).

3.2.5 Other

A few user stories were discussed concerning play but did not contain enough information to be coded as the codebook required.

4 Summary

As concluded earlier, the main barriers to using currently available AAC systems in the ICF framework were identified within the environmental factors. However, most user stories affected the areas of Communication, Learning and applying knowledge, and General tasks and demands, including undertaking a single task, specifically. General tasks and demands were not identified as barriers, but the user stories contained several solutions to facilitate this area. Table 4 presents the results at a glance and shows a chain pattern. These SLPs envisioned that the TAAC would affect the functional ability in different parts of the chain when it is available in a certain place and at a certain moment whenever it is needed and is activated with minimal effort by designing it according to one’s motor capabilities.

Table 4 An overview of identified barriers and the areas that affect the functional ability when using TAAC
Full size table

Furthermore, motivational content was considered fundamental to achieving meaningful outcomes for the person in question, and meaningful things for the person in question must be achieved through this content. Several user stories envisioned that implementing the TAAC to facilitate activities and participation will also affect the environmental factors, specifically the area of support and relationships. For example, enabling communication will facilitate the goal of communicating better and immediately affect the environment by providing a means to interact understandably.

Overall, these results from the perspective of SLPs indicate that TAAC can affect several factors that are identified as barriers to successfully using currently available AAC when designed to be easy and motivating.

5 Discussion

In this study, 12 experienced SLPs described the barriers to successfully using currently available AAC systems and created user stories of how TAAC technologies could offer a viable AAC solution. Implementing the ICF as part of the research and development of novel technologies is a valid choice because it is an internationally recognized reference framework. Therefore, it can form the needed connection between clinicians and the technology developers in the AAC field to create feasible technology and answer the fundamental question of “How can we match those who see solvable problems with those who can engineer solutions?” which Parsons et al. [21] addressed. Furthermore, it offers the research community more tools to understand these complex phenomena.

Our results indicate that using AAC is subject to a wide variety of factors in one’s functional ability within their environment. This study revealed the interrelated nature of factors affected when using TAAC technology. Understanding these factors by implementing ICF in AAC research and utilizing them in developing novel technologies results in better outcomes.

One fundamental barrier to successfully using currently available AAC is the AAC’s unavailability when needed [3, 8, 9], referring to low- and high-technology systems commonly referred to as “portable”. The SLPs in this study discussed the issue of TAAC’s availability in several contexts. First, the TAAC would be persistently available if the technology were embedded in clothing. These perceptions mirror the apparent advantages of textile-based technologies, as Marculescu et al. [10] stated. We are all used to wearing clothes and enjoy the aesthetics of doing so. Adding technology to textiles to process information could facilitate the access of information always [28].

Second, it was viewed that the persistent availability of TAAC diminishes dependency and the need to have a communication partner present. As noted, the success of currently available AAC often depends on the communicative partner’s presence to facilitate the use of AAC [8, 48]. For example, the caregivers must introduce the device, learn it, and continuously support its usage, such as by modeling [22]. Moreover, certain technologies, e.g., eye gaze technologies, require assistance for set up and a certain light that prevents its usage in all situations [38]. Therefore, even a successful AAC modality in some environments may be unsuccessful in others.

Overall, an environment’s role is significant in AAC [6, 7, 9]. The key question is to what extent TAAC technology can shift the support and attitudes of the environment and how. The attitudes were not directly mentioned in the user stories. However, these data suggest that, in many cases, such technology would reduce the required support and increase autonomy through the chain pattern. For example, these user stories indicate that increasing the possibilities for one to initiate independently will increase the environment’s involvement. Independent access to AAC for spontaneous communication facilitates AAC usage and brings forth positive outcomes, making the communicative partners likely to continue using AAC [8]. Green et al.’s [49] empirical findings support this perspective, empirical findings support this perspective, finding that child invitations, self-efficacy, time, and energy correlate with parental involvement in their home activities. This emphasizes the need to create technology that can be accessed autonomously to make the necessary invitations.

However, these necessary invitations are only possible if one is motivated, and their motivation level affects the motivation of others. For example, if a child is unmotivated to use their AAC system, the parents may be reluctant to use it [8, 12]. Therefore, focusing on motivation seems to be a significant perspective in using AAC and creating novel approaches. According to the self-determination theory, motivation can be external or internal [19]. In this study, the user stories affecting communication and learning and applying knowledge would mainly support external motivation. Therefore, suitable and appropriate content for the user, e.g., vocabulary, promotes the use of the device [6, 50]. After that, the person is motivated to use the device and practices using it more [51], emphasizing the external motivation of self-determination theory [19]. Furthermore, these data also suggest that intrinsic motivation [19] promotes using the technology to control the environment so that the user can achieve tasks important to them. The themes of using TAAC technology and Motivation are closely related to intrinsic motivation.

Supporting autonomy in the AAC field is not easy, nor are there easy solutions. First, one’s functional abilities are impermanent and unstable. They seem prone to change if any of the factors are affected. A change can occur for several reasons. In some cases, one’s functional ability may deteriorate, such as in amyotrophic lateral sclerosis (ALS) [50]. Conversely, one’s functional ability may improve as one develops or learns through rehabilitation [1]. Thus, they may accept further training or a different device. Furthermore, as environmental factors are the most prominent barrier for AAC, a change is also possible in this context, e.g., due to training and support. Ongoing evaluation and providing access to different devices or systems is needed to continually ensure communication opportunities [1, 50]. Therefore, the need for assistive technology may change or require a set of supports.

Second, the ability to undertake a single task (d210) was not present in the barriers but was emphasized in the user stories, which researchers and clinicians must consider more. For those with complex communication needs, the successful use of AAC, independence, and autonomy in conducting, completing, and sustaining a task would increase not only motivation for social interaction but also feelings of self-worth and satisfaction. For example, according to research by Stancliffe et al. [5], not having an efficient and feasible way to interact socially can lead to loneliness and marginalization [20].

This study often mentioned movement functions as barriers to successfully using AAC systems. However, they were not identified in the user stories where the SLPs envisioned TAAC’s influence on one’s functional abilities in their environments, even though the underlying barrier was the inability to use AAC because AAC is never designed to change one’s motor abilities but to enable, e.g., communication. Therefore, the TAAC bypasses the motor abilities issue when it utilizes the existing abilities, focusing on communication, and learning and applying knowledge, using TAAC technology and motivation.

While this study indicates that the TAAC may affect many areas of one’s functional ability and even one’s environment, the technology itself is not magic and will not miraculously erase the barriers. However, technology suited for one’s capabilities, as well as their bodily and mental functions, while considering the environmental factors—which include the features of the technology, the support and attitudes of the environment, and the stakeholders’ perspectives—can lead to an effective system. Functional technology can accommodate reaching the desired communicative purpose in a certain place, at a certain time, for a certain activity, and in a certain environment or context.

5.1 Limitations and future work

A relatively small sample size of SLPs was included in two focus groups. However, for this study’s purposes, we are confident the sample sufficed to elicit user stories to elaborate on the many effects technology has on one’s functional abilities. The SLPs’ perspectives of the barriers largely mirroring the literature strengthens this view. That said, the small number of SLPs working with adults, especially the lack of experience in aphasia, may have resulted in only a few user stories for them. Furthermore, some critical voices have been raised that SLPs do not always acknowledge, e.g., parents’ knowledge and expertise concerning their children [51].

SLPs were aware of this study’s purpose, designing novel textile-based technology when considering the barriers to using AAC, which may have influenced their thinking and contribution. SLPs are not professionals in designing technology, nor were they expected to be. However, they are professionals in AAC -aided and unaided- and communicating with people with complex communication needs. Through thorough triangulation of data generation, it was possible to understand the views and experiences of these SLPs regarding the barriers to the existing systems and the user stories they propose.

The present study focused on establishing a common platform for SLPs and technology developers for deeper collaboration when creating AAC systems, i.e., to show how technology can affect one’s functional abilities within their environment. The other side of the coin would be educating SLPs on the possibilities of technology, e.g., continuous training. Sennott et al. [52] even propose that those who support individuals with complex communication needs would benefit from learning about artificial intelligence (AI) to open opportunities “to leverage these impactful tools”. In that respect, educating the SLPs about these novel opportunities can raise awareness and understanding of such possibilities, leading to better technology.

To date, personal factors are acknowledged but not coded in the ICF. However, they must be considered in addition to the ICF categories because they substantially influence the success of any assistive technology [53].

6 Conclusion

The present study establishes the connection between SLPs and technology developers by presenting the many levels and layers of functional ability, and emphasizes the environment’s role in an understandable language provided by the ICF framework. Furthermore, the study addresses the crucial aspects of designing novel TAAC technologies that aim to affect communication.

On a more practical level, the results provide detailed information about the direction in which the TAAC should be developed and what issues must be addressed. While TAAC was specifically considered, the guidelines and design aspects apply to all technologies and will help design novel, inclusive technologies that meet the needs of those who require them. On the other hand, projects like this will provide AAC community knowledge about what is possible to accomplish through evolving technology.

The TAAC has such potential to affect functional abilities and environment either directly or indirectly, but identifying only potential is not enough. The success of TAAC must be verified, e.g., by developing prototypes that are tested and modified by the end-users. Only then will we know if TAAC can overcome some of the known barriers.