Digital technologies for social inclusion of individuals with disabilities

Information technology can be an important facilitator of social inclusion for people with disabilities into society. However, the goals specified in this area by organizations such as the European Commission have not yet been achieved in their totality. The aim of this paper is to explore which types of information communication technology-based applications and/or digital services have been suggested to facilitate the social integration of people who suffer from different types of disabilities. We performed a literature review that included studies published during a period of 6 years (2010–2016). The results show that, in the data we have had access to, no concrete patterns can be identified regarding the type of technology or technological trends that can be used to support the social integration of individuals with disabilities. This literature review is of relevance to the identification of further research areas and to the identification of issues which have to be considered in the context of the development and implementation of technological innovations that are aimed at promoting or facilitating social inclusion of individuals with disabilities.


Introduction
People with disabilities 1 face a number of challenges in today's society [1][2][3]. According to the European Commission, the overall employment rate of people with disabilities in Europe is 48%. Only 27.8% of people with a disability obtain a tertiary level degree or diploma [4], and approximately 70% of people with disabilities face poverty or issues that are related to social inclusion [5]. The absence of effective support services, for example, that allow for or facilitate access to transportation, building access, access to information and communication in different formats and through different platforms and systems results in a situation where people with disabilities are forced to rely on their families, something which, we claim, prevents them from being socially included and integrated into society [6]. Digital technology has been described as a facilitator for social inclusion, because it allows for the delivery of real-time services that can enable individuals to learn, work, travel, socialize, shop, and interact with the community without being subject to physical barriers [7,8]. Digital technologies have also been identified as one of the most important factors that can contribute to reducing existing social gaps and can be used to encourage and support social inclusion and increase people's quality of life [9]. However, for different reasons, the implementation of IT in this specific area has not yet been fully realised. Consequently, technology-based applications are still not used as generic enablers in the promotion of social inclusion for people with disabilities.
According to National Council Disability [10], Bthe more reliant society becomes on technology to perform fundamental aspects of every-day living, how we work, communicate, learn, shop, and interact with our environment, the more imperative it is that people with disabilities have access to that same technology, and the more costly will be the consequences of failure to ensure access^. Although there are a number of different information technologies that have been used to develop applications for disabled people [11], only a few empirical studies have been conducted into examining the technology trends used to develop applications for disabled people.
Some research studies [9][10][11][12][13][14][15][16] indicate that, despite the number of emerging technologies that have been suggested to support individuals with disabilities, the expected goals with respect to the integration of individuals with disabilities into society have not been achieved. We also note that there is but a limited number of studies that discuss technologies that are aimed at supporting the development of applications that focus on how social inclusion for people with disabilities can be facilitated [11][12][13][14][15][16].
The aim of this paper is to explore the various ICT-based applications and/or digital services that have been suggested to support individuals with disabilities in their integration into society 2 [17].

Method
A literature review was performed covering a period of time of 6 years (July 2010 to November 2016) with a focus on studies that describe either the design or the development of ICTbased applications and web-based services for people with disabilities. The International Classification System of Functioning, Disability and Health (ICF) [18] definition was used to search for and select the studies that were included in this literature review.
The search for the relevant publications was conducted by using databases such as Scopus, the ACM digital library, and Jonkoping University's library which has access to a number of databases, including Science Direct, Elsevier, Sage, the Wiley Online library, Taylor & Francis Online, and Springer. The search process included several steps. At the first step, we collected articles that included the search terms (see Fig. 1, below) in the title, abstract, or in the keywords of the sample. We also searched for publications that used alternative terms such as impairment, special needs, software, system, and services. We limited our search to articles that were published in scientific journals, in English. Books, abstracts, and studies published in non-peer-reviewed journals were not considered. The search process is illustrated in Fig. 1.
In total, we found 383 articles that contained one or more of the search terms. After removing 78 duplicated articles, 305 articles were selected in the first round. Further 197 articles were excluded because: (i) they did not present a discussion of how ICT-applications or digital services can support disabled individuals in their social integration, (ii) they focused on assistive devices, such as power wheelchair, robots, electric canes, for example, (iii) they focused on how diagnosis, treatment, and rehabilitation programs can be improved with the use of ICT (iv) they focused on how policies should change in response to the use of ICT-based applications. Articles that presented discussions of applications or web-based services that can be used by therapists, care givers, and physicians in their work with disabled individuals were also excluded from the sample. The reason why these articles were excluded was they did not have the stated aim of facilitating the social inclusion of disabled individuals. Instead, they described how certain technologies can be used to facilitate interaction between experts and patients, or to support experts in their daily work. The fact that the notion of 'social inclusion' was not addressed in these articles was the reason for their exclusion from the literature review set.
In the next step, articles that discussed or focused on issues such as the implementation, design, and development of technology-based applications for disabled individuals with the aim to support them in their daily routines or to support them in their interaction with society were included. A total of 108 articles were read their totality. Out of these 108 articles, an additional 62 articles were excluded after a second review because they discussed the benefits of assistive devices for smart homes in general, but they did not mention or suggest applications that could be used to support individuals with any kind of disability.
The data included in this paper consists of 46 articles that include a discussion of technologies that can be used to support disabled individuals with their inclusion into society. From the selected articles, the following information was extracted: (i) publication year, (ii) study objective, (iii) the technology discussed in the study, (iv) the type of application(s) or service(s), (v) the functionality of the application(s), and (vi) the type of disability they aim to interact with. (See Appendix 1.)

Results
This section presents the results of the literature review described in the previous section. The results show (i) the number of articles included in the review, year by year, (ii) the type of technologies that were discussed in the articles, and (iii) the different types of disability that the technological solutions aimed to support.

3.1
The number of studies that described or discussed technologies that can be used to support different types of disabilities Below, Fig. 2 shows the distribution of the 46 selected studies in terms of their year of publication.
From the table above, we can see that no specific pattern or year-by-year systematic increase in the number of publications that were included in our literature review data set was identified. However, what is clear is that the number of published studies has increased during 2015 and 2016.

The types of technologies that were discussed in the articles
Different terms were used in the various articles to discuss or describe technologies that can be used support different types of disabilities over the time. A list of the terms that were used is presented in Table 1.
The results shown that the study published in 2010 [1] used the general term such as communication technology to develop services for people with disabilities.
The studies published in 2011 have used more terms as compared to studies published in 2010 such as: adaptive technology [2], assistive technology [3,4], instructional technology [5], and web technology [6]. The terms web technology and instructional technology were kept as general terms. Moreover, the terms adaptive technology that has made a thoughtful change in attitude and technology [7] was also used in the mentioned year. It is important to mention here that the terms 'adaptive technology' and 'assistive technology' were often used interchangeably and the adaptive technology considered as a subset of assistive technology [7].
The studies published during the year 2012 used some new terms to design and develop services such as: tele-rehabilitation technology [8] and internet-based technology [9,10]. Apart from this, some already used terms during the year 2010-2011 have also been discussed in 2012. For instance, communication technology [11], assistive technology [11,12], web technology [13,14].
The studies published in 2013 shown advancement in the technology because a number of new terms discussed during this year such as: [15], mobile technology [16], speech-recognition technology [16], and gerontechnology [17]. It has observed that the studies published during this year also discussed sustainability of aging society and thus used the term Gerontechnology to provide good health, independent living and full social participation up to a high age [18]. Some other terms such as communication technology [19,20], assistive technology [16,21], instructional technology [15] also used in these studies.
Virtual technology [22] is another new term that was used in studies published during the year 2014 for enabling physical activity with the aim to improve impairments, activity limitations, or participation. We also found a term assistive technology [23][24][25] with the focus to enhance physical activities of people with disabilities. Some general terms such as: telecommunication [26], electronic technology [23], and access technology [24] were also discussed in studies published in 2014.
Studies published in 2016 used terms such as assistive technology [36][37][38][39][40], tele-rehabilitation technology, Mobile technology [37], virtual technology [41], GPS technology [42,43], screen reader technology [36], and rehabilitation technology [44,45]. During 2016, the articles also included terms not previously used, including game technology [46],  voice recognition technology [38,39], and 3D printing technology [47]. A common term that was used across most of the time period under examination (from 2011 to 2016) is assistive technology. There is, however, no specific definition of what assistive technologies consist of in the selected studies. Other terms that were used in the various articles seem to follow some technological trends and innovations to support people with disabilities [55,[57][58][59]63]. Further details on technologies can be seen in the appendix.

The various types of disability that were discussed in the selected articles
A number of different types of disability were discussed in the articles included in our literature review. In Table 2 below, the number of articles and the type of disability they discuss are presented.
The results presented in Table 2, shown that in 2010, one (1) publication focused on the area of cognitive disability [19]. The purpose for concentrating on this area was to keep people with cognitive disability, healthy and increasing their engagement in the online health care system (see appendix). The studies published during the year 2011 had a different focus than studies published in 2010. The studies published in 2011, focused on physical disability [20,21], visual impairment [22], or disability in general with no specific definition of the kind of disability referred to [23,24]. However, the studies published in 2012, only added one new type of disability (Parkinson's disease [30]) that had not been discussed before in studies published during the year 2010 and 2011.
The studies published in 2013, have broadened the focus and added more disabilities to discuss in the studies that include physical disability [34], cognitive disability [32,36], and elderly [33,37], and also areas such as intellectual disability [32,35] and disability in general [33]. The same patterns can be observed in publications from 2014 as the studies focused on Parkinson's disease [42], cognitive disability [38,40], and intellectual disability [39]. It is important to mention here that, the studies published during the year 2014, had not only discussed about disability but also elderly [40,41].
Similarly, the studies published in 2015 also discussed elderly [45]. Apart from elderly, different types of disabilities had been discussed in these studies such as: physical disability [46,47,51], disability in general [43], Parkinson's disease [49], intellectual disability [44,50], intellectual disability, and cognitive disability [48]. Furthermore, the results shown a high number of occurrences of studies during the year 2016, thus, found 13 studies this year. The year 2016 is also important because only during this year, all the disabilities mentioned in Table 2, along with the concept of elderly have been discussed in the studies. For example, publications from 2016 found with focus on physical disability [62], intellectual disability [52,54,56], visual disability [63], disability in  general [53], cognitive disability [57,[59][60][61], and elderly [59]. It is important to note that the majority of the studies focus on cognitive disabilities (n = 4). Looking at the total number of studies published over the years, it seems that this area has captured the major focus of interest in this area.

ANALYSIS AND DISCUSSION
A general concern that is raised in the articles that were included in this study is that there exists no common definition of the terms that are used, for example, assistive technology. None of the articles selected for inclusion in this study discuss conceptual differences associated with the various technologies or provide definitions of terms such as assistive technology, tele-rehabilitation, or web-based technologies.
The absence of definitions that can be used in the proper classification of the applications and services that are described in the articles makes any meaningful comparison of the various outputs of these applications and services somewhat of a challenge.
In general, the technological solutions that were suggested or reported on in the articles were aimed at (i) reducing certain limitations related to people's disabilities in generic terms, and (ii) supporting increased interaction between disabled individuals and their caregivers or teachers, for example. All of the articles were consequently optimistic and assumed that disabled individuals would be able to actively participate in society if they just use the suggested technological solutions. No consideration of any potential infrastructural, socio-technical, cultural, or legal obstacles was made in any of the articles.
Only a small number of the articles included in our literature review discussed or suggested technologies that might assist individuals to become active on the labour market [33] or suggested services and applications that might support active participation [59] in social activities [44,51], or could facilitate a disabled person's access to educational opportunities [20,31].
It is of further interest to note that the articles did not present any discussion of the following important issues: (i) the level of IT-literacy of the users, (ii) any possible economic restrictions associated with buying or renting the suggested services or applications or any possible complimentary help from the user's next-of-kin or from society in general with respect to the use of suggested services, and, perhaps even more importantly, (iii) the level of disability and the user's ability to use and adopt digital innovations. The studies were, in general, limited to the description of, or the suggestion of, prototypes [34,63] or examples of technologies that can support some disabilities [38][39][40]. We also note that no analysis of the criteria that the users have to fulfil if they are to successfully use the various technologies is present in these articles. Furthermore, the majority of the technologies suggested in the articles were aimed at solving one single issue related to a person's disability, and they did not discuss how these technologies might be integrated into the user's home or work environment or whether they are compatible with other existing technologies that might already be in use.
A major issue that we identified with the articles included in this literature review is the fact that the majority of the studies merely describe or discuss early 'proof of concept studies' and suggest how certain technologies can be triggered in the market [36,38,39]. Mainstream adoptions or broad market applicability of the suggested technology-based applications and web services have not been studied empirically. None of the studies discuss the effects results of the delivery of services for the organizations in charge of supporting individuals with disabilities, or the prerequisites that these technologies have to fulfil before they are granted permission to be implemented. These prerequisites may include specification of systems and guarantees concerning the level of data security and right to privacy, for example. Other requirements may include the issuing of licences, depending on the country the technology is to be used in.
Creating a 'digital edge' so as to remove issues that limit the participation and integration in society of individuals with disabilities implies taking advantage of technological innovations that will create new solutions; solutions that bring together physical-and digital resources, as well as the physical-and virtual spheres of existence [64]. The main challenges that face both industries and decision-makers is how they are to (i) integrate technologies and services in everyday routines, [65] and (ii) how organizations can take advantages of technological innovations in their efforts to create and offer alternatives that support social integration. Furthermore, the generic nature of the proposals presented in the articles included in the present study reduced the suggestions that were made to the level of theory only. The absence of any analysis of the level/degree of disability suffered by individuals and of any user-differences related to gender, age, culture, socio-economic position [66] and differences between various social insurance systems made the adoption of the suggested technologies and services a problematic venture. In future studies, it will be necessary to (i) define technical terms clearly, (ii) describe the goals associated with each technology properly, and (iii) analyse the proposed technological solutions in the light of existing policies and guidelines so as to enable a more grounded discussion about the technologies that can be implemented and the manner in which they can satisfy the needs of individuals with disabilities in their efforts to engage in social integration. Social inclusion cannot be achieved only by developing technologies or virtual services for the area of health-and social care. The labour market, the educational market, and the political sphere are also factors relevant to the achievement of real, and meaningful, social inclusion for all individuals in society [67]. In the case of individuals with disabilities, these three areas should stand as important priorities for the researcher if the goals (facilitating people with disabilities to integrate into the society) stated by the European Union are to be achieved [9].
Acknowledgments This work has been supported by the Prosperity 4 all-European project financed by the EU-commission.
Funding The funding for this research has been provided by MIT Research School, Sweden.

Compliance with ethical standards
Conflict of Interest The authors declare that they have no conflict of interest.
Ethical approval This article does not contain any studies with human participants or animals performed by any of the authors.   To improve speech recognition. physical disability [36] 2013 To examine the effectiveness of an intervention package on skill acquisition and interaction behaviour when used by two students with autism, and one student with a moderate intellectual disability.

Instructional Technology
SMART Board: Electronic Interactive Whiteboard (IWB), Notebook 10 application Helps students to access instructional materials by using the touch screen of the SMART Board IWB with their fingers and use pens and an eraser to self-monitor task performance.
intellectual disability [37] 2013 To measure the user's willingness to share health or activity data with user's doctor or family members and to examine concerns about privacy or security of monitoring, over one year of study participation.

Gerontechnology Video-based Home Monitoring System
To provide care at home. elderly [33] 2013 To explore the representation/presence of disability and aging using frames, Facebook, and LinkedIn groups. Target identity/member groups on Facebook and LinkedIn were catalogued to explore the presence and representation of disability and aging identities in a socially-networked setting.

Communication Technology
Facebook and LinkedIn -online communities Used by people with disability and elderly for communityand employment participation, not just in the specific function of activities, but as a link to larger communities of practice and professional connections. Learning tools used in the class. intellectual disability To help students in learning process at the compulsory school level.

Assistive Technology
Tablet-based application (activity-schedule system) To enhance the participation and learning skills in the classroom of children with autism and intellectual disabilities. The application shows the list of activities to students that they will perform in class.
intellectual disability [45] 2015 To show some weaknesses in automatic speech recognition that must be addressed, as well as the need for better adaptation to the user and the environment.
Assistive Technology e-lio application in SWEET-HOME Provides home services to elderly people through the e-lio box (e.g., video-conferencing, calendar, photos). SWEET-Homes enables users to contact their physician through voice or tactile interface.
elderly and visually impaired [49] 2015 To present a wearable system for the support of people with Parkinson's disease (PD) and freezing of gait (FoG). The system is designed for independent use. The study also investigates the at-home acceptance of the wearable system in a study with nine PD subjects.

Wearable
Technology, Healthcare Technology Wearable System application: The system consists of three components. First, FoG episodes are detected in real time using wearable inertial sensors and a smartphone as the processing unit. Second, a feedback mechanism triggers a rhythmic auditory signal to the user to alleviate freeze episodes in an assistive mode. Third, the smartphone-based application features support for training exercises.
It enables motor training and gait assistance at home and other unsupervised environments.

Communication Technology
Improvehealth.eu To support collaborative care management and active patient engagement, and online and phone-based care management performed by trained psychologists cognitive disability [57] 2016 A one-month randomized controlled trial with 18 stroke patients in and outpatients from two rehabilitation units: 9 performing a VR-based intervention and 9 performing conventional rehabilitation.
Virtual Technology Reh@City Involves memory, attention,visual-spatial abilities and executive functions tasks that are integrated to perform several daily routines.
cognitive disability [28] 2012 To design a social-software environment, called RareICT, to help patients and family members in their everyday, additional un-paid work.

Web Technology
RareICT Designed for self-care and independence in everyday living and health maintenance at the home.
visual impairment [24] 2011 A summary of the legal requirements and standards that govern the presentation of health information using technology and practical guidelines for accessible health education programs.
Web Technology Web Accessibility in Mind (Web AIM) Provides health-related information online. disability in general [59] 2016 To report on the validity of the GPS data collected and to answer the question: To what degree are older adults able to fulfil the requirements of a GPS assisted study?

GPS Technology Global Positioning System Technology
To increase their participation in the community.