The Reasons for Noncompliance with Adaptive

Equipment in Patients Returning Home After a Total

Hip Replacement
Whitney N. Thomas, BS, OTS
Lauren A. Pinkelman, BS, OTS
Cassie J. Gardine, BA, OTS

ABSTRACT. The purpose of this study is to determine the most frequent reasons
for nonuse of adaptive equipment prescribed by occupational therapists in patients
returning home after a total hip replacement surgery. Ten participants were obtained
through a convenience sample and phone interviews were conducted. The results of
this study indicate that patients are not involved in the process of deciding which pieces
of adaptive equipment to purchase. Having identified the top reason for noncompliance
with adaptive equipment, occupational therapists are now equipped with the knowledge
to prevent future noncompliance by remaining client centered and considering client
factors when recommending adaptive equipment.
KEYWORDS.

Total hip replacement, adaptive equipment, occupational therapy

One of the out-of-pocket costs that commonly accrue after many hospital stays
is adaptive equipment (Montin, Suominen, Katajisto, Lepisto, & Leino-Kilpi, 2009).
Adaptive equipment is a collection of devices that allows people to complete everyday
tasks by compensating for decreased mobility, strength, or other deficits that prohibit a
person from completing these tasks. This type of equipment is often prescribed by occupational therapists. Occupational therapists recommend pieces of adaptive equipment
to enable individuals to participate in meaningful and purposeful activities of daily life.
After total hip replacement surgery, occupational therapists commonly recommend
pieces of adaptive equipment to patients before they return home (Poliner, 2003). Patients
Whitney N. Thomas is affiliated with the Occupational Therapy Program, College of Saint Mary,
Omaha, Nebraska.
Lauren A. Pinkelman is affiliated with the Occupational Therapy Program, College of Saint Mary,
Omaha, Nebraska.
Cassie J. Gardine is affiliated with the Occupational Therapy Program, College of Saint Mary,
Omaha, Nebraska.
Address correspondence to: Whitney N. Thomas, College of Saint Mary, Occupational Therapy,
7000 Mercy Road, Omaha, NE 68106 USA (E-mail: wthomas89@live.com).

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Available online at http://informahealthcare.com/potg


C 2010 by Informa Healthcare USA, Inc. All rights reserved.
doi: 10.3109/02703181003698593

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171

who have had a total hip replacement need adaptive equipment because they are unable
to perform certain motions for a time period after the surgery in order to prevent
dislocation of the new hip joint. These movement restrictions are per surgeons orders.
The motions that are to be avoided are bending over, lifting the knee higher than the
hip, crossing legs, and turning toes inward. These restrictions limit their ability to care
for themselves in activities such as dressing, bathing, and toileting.
This study is designed to determine the most frequent reasons for the nonuse of
equipment by patients returning home after a total hip replacement. The pieces of
adaptive equipment that are being investigated in this study are a reacher or grabber, a
raised toilet seat, a sock aid, a long handled shoehorn, a long handled sponge, elastic
shoelaces, and/or a shower or tub chair. Studies show that 2050% of patients who were
prescribed adaptive equipment do not use it consistently in the home (Gitlin, Levine,
& Geiger, 1993). This study is being conducted to determine the most frequent reason
for nonuse and enable occupational therapists to increase compliance with the use of
adaptive equipment.
LITERATURE REVIEW
After an in-depth review of the literature, the researchers have found four common
reasons for noncompliance in patients using adaptive equipment:
1. The patient was not included in deciding what pieces of adaptive equipment to
purchase.
2. Inadequate instruction given by the occupational therapist.
3. The patients medical condition improves to the point that they no longer need the
adaptive equipment.
4. The patients environment is conducive to their condition so that they do not need
to use the adaptive equipment (e.g., their spouse helps them), (Wielandt & Strong,
2000).
Research has shown that giving patients a role in deciding what equipment to purchase
affects compliance positively (Wielandt & Strong, 2000). Being able to decide what
pieces of equipment to purchase, especially because the equipment is an out-of-pocket
expense, is important to patients. This was also proven true in a study looking at
factors that predict use of assistive devices in older adults (Gitlin, Schemm, Landsberg,
& Burgh, 1996). This study speaks of assistive devices, which includes adaptive and
mobility aids such as a walker, cane, wheelchair, or crutches. Another study found that
the patients perceptions of the benefit of using pieces of adaptive equipment appear to
influence compliance (Wielandt, McKenna, Tooth, & Strong, 2001).
One study conducted an audit of past total hip replacement patients in order to
determine the cost-effectiveness of providing hip packs. Hip packs include all pieces
of adaptive equipment that a patient recovering from a total hip replacement would
possibly need. This study found that this procedure was not cost-effective because
it did not consider what pieces the patients would need or use once they returned
home (Davidson, 1999). Following this theme, protocol based on diagnosis may be
appropriate, this type of policy does take into account the patients home environment,
help or support available, patient needs, and values (Neville-Jan, Piersol, Kielhofner,
& Davis, 1993, p. 13).

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Inadequate instruction by the occupational therapist on how to properly use the

adaptive equipment was the second theme. Many studies have looked into the carryover
of use of adaptive equipment in the hospital and in the home. In each new environment
the patient must learn how to use their adaptive equipment. This means that a patient
can learn to use the adaptive equipment at the hospital but it does not always work
as efficiently in the home because the environments are set up differently. One study
found that only 8% of patients received home instruction, even though that is where
the equipment would primarily be used (Neville-Jan et al., 1993). There have been no
studies to date that have determined the adequate frequency or duration of education
and training of adaptive equipment prior to discharge home.
Other studies have looked at the education needed for post-operative patients. One
study found that there is consistency in patient precaution education across regions of
the United States, but this study did not describe the type of education or prescription
of adaptive equipment (Neville-Smith, Trujillo, & Ammundson, 2000). Kraskowsky
and Finlayson (2001) found that training is one of the main factors that influence
compliance. Although no research has been done to see how many patients perceive their
noncompliance as a result of inadequate instruction, it has been shown that compliance
is directly related to the patient education process (Finlayson & Havixbeck, 1992).
Typically, noncompliance is seen as a negative factor in the health care field. However,
if the patients medical condition improves to the point that he or she no longer needs the
adaptive equipment; it is not a negative factor. In the case of hip replacement surgery,
physical limitations or hip precautions are typically in place for 6 weeks to 3 months
after surgery. This is not the same with other diagnosis that were also considered in
some of the research reviewed.
One study investigated the use of adaptive equipment in patients who had a stroke,
total hip replacement, or lower limb amputation. The study found that use of adaptive
devices in the home declined from month 1 to month 2 (Gitlin et al., 1996). This study
shows, especially in the case of stroke and lower limb amputations, that many patients
discontinue use of adaptive devices after their medical condition improves. Another
study by Gitlin et al. (1993) found that by the end of the first month, 45% of the
equipment was seldom or never used in the home due to increased functional abilities
of the patients.
With orthopedic patients, like hip replacement patients, studies have found that
functioning improved over time and they only needed their equipment for a short period
(Neville-Jan et al., 1993). It seems obvious to assume that if the patients condition
improves, he or she will no longer need the equipment prescribed. Many studies have
cited this as limitation in their research because the issue was not addressed.
Lastly, research indicates in some cases the patients environment is conducive to his
or her condition. This decreases the need to use the adaptive equipment. An example
of this, as previously stated, is when a patients spouse is able to help the patient with
dressing, bathing, or toileting. Many patients may prefer the help of a person rather
than using equipment to serve the same purpose. Davidson (1999) found that many
patients with willing caregivers at home to help were more likely to not use the adaptive
equipment prescribed to them. This study also suggests that further research is needed
to determine if there is a difference in compliance in those living alone or living with
another when returning home from the hospital.
After an in-depth literature review, the four most common reasons for nonuse of adaptive equipment in patients who have had a total hip replacement are that the patients
were not included in deciding what pieces of adaptive equipment to purchase, inadequate

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173

instruction given by the occupational therapist, the patients medical condition improves
to the point that they no longer need the adaptive equipment, and the patients environment is conducive to their condition so that they do not need to use the adaptive
equipment (e.g., their spouse helps them) (Wielandt & Strong, 2000). Previous research
has determined the rate of noncompliance and the top four reasons for noncompliance; this study is being conducted to determine the top reason for noncompliance
with adaptive equipment. The results will enable occupational therapists to adapt their
treatment sessions to increase compliance with each individual piece of adaptive equipment. In addition, being aware of the reasons behind noncompliance for specific pieces,
adaptive equipment will allow occupational therapist to take a holistic approach when
recommending adaptive equipment to individuals.

METHOD
Participants
All participants were obtained through a convenience sample of the researchers.
Eligibility for this study included participants that had returned to their home after a
total hip replacement surgery and all participants were recommended to purchase at
least one piece of adaptive equipment by an occupational therapist during their hospital
stay in various area hospitals located in three small to mid-sized Midwestern cities.
Of the 10 initial participants that were contacted, nine completed the interview. Participant number two was unable to be reached. The phone interviews were completed by
three male and six female participants totaling nine participants. The ages of the participants ranged from 4684 years at the time of surgery. The average age of the participants
was 66 years. Seventy-eight percent of the participants attended an educational session
about hip replacements before their surgeries. The length of time elapsed since surgery
ranged from 3 months to more than 4 years, as seen in Table 1. Participants spent a range
of 1 to 7 days in the hospital directly following the hip replacement surgery, as seen in
Table 2. Participants received occupational therapy services two to six or more times
while in the hospital, as seen in Table 3. One participant was unable to remember the
total number of times seen by an occupational therapist. Seventy-eight percent of the
participants had someone available to help them after they returned home from the
hospital, if needed. Thirty percent of the participants received at least one home care
service including occupational therapy, physical therapy, and/or bathing services.
Overall, the participants were more than willing to share their experiences and follow
through with the phone interview.

TABLE 1. Length of Time Since Surgery

Number of participants

36 Months

711 Months

13 Years

4+ Years

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TABLE 2. Length of Hospital Stay
13 Days

47 Days

814 Days

15+ Days

Number of participants

Data Collection
An informed consent form that was approved by the Institutional Review Board connected with the College of Saint Mary was mailed to each of the participants. Verbal
consent was obtained from all participants at the beginning of the survey. The data collected for this study were obtained through the completion of a standardized procedure
that used personal phone interviews (see Appendix A for example of questionnaire).
The phone interview questionnaire was developed by the researchers. To help ensure
inter-rater reliability, the researchers did pilot the questionnaire once prior to actual use,
and this individual was included in the study due to a limited number of participants.
The phone interview questionnaire was used for all participants and took 15 to 20
min each. The information collected included demographic information and questions
concerning the participants reasons for nonuse of adaptive equipment. Prior to starting
the questionnaire, the administrating researcher made sure the participant had received
and agreed to the consent form. A researcher consistently administered the questionnaire
to each of the participants while two researchers took written notes during the phone
interviews. The interviews were completed by asking each participant the questions on
the questionnaire in numerical order.
After all nine interviews were completed, the researchers identified that the majority,
72%, of the participants responded that they always used their adaptive equipment.
This percentage was obtained by tallying how often each piece of equipment was used
and divided by the total number of responses. After this percentage was calculated, the
researchers identified the majority response for each of the four common themes for
noncompliance that were identified in previous research. The overall results can be seen
in Table 4. Additional notes from the researchers not administering the questionnaire
were used to justify common themes identified in the results section.
RESULTS
Involvement in Decision-Making
Participants were asked if they purchased each piece of adaptive equipment from
a list of seven pieces. The results show that all nine participants purchased a reacher
or grabber, eight purchased a long handled shoehorn, seven purchased a raised toilet
TABLE 3. Number of Visits by an Occupational Therapist While in the Hospital

Number of participants

1 Visit

23 Visits

45 Visits

6+ Visits

Unknown

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175

TABLE 4. Reasons for Noncompliance of Adaptive Equipment

Involvement in
Decision-Making
78% little or not included
22% very or somewhat
included

Adequate Instruction
from Occupational
Therapist on Adaptive
Equipment Use

Affect of Improvement of
Medical Condition on
Length of Time Using
Adaptive Equipment

Influence of Environment
on Use of Adaptive
Equipment

85% yes
15% no

51% yes
49% no

57% yes
43% no

seat, sock aid, and shower or tub chair, six purchased a long handled sponge, and three
of the nine participants purchased elastic shoelaces. Of the nine participants, seven
responded that they felt not included in deciding which pieces of equipment to purchase.
Participant 4 stated that the occupational therapist offered items so I purchased them.
The occupational therapist brought in a bag and I was told what I needed to buy
(Participant 10). Participant 3 stated, I was so sick I didnt even know what was going
on; I was appalled by how people force you to buy equipment.

Adequate Instruction from Occupational Therapist on Adaptive Equipment Use

The majority of the respondents said they felt they had adequate instruction from
the occupational therapist on how to use each piece of equipment. Adequate instruction
was consistent through all pieces of adaptive equipment. This question had the most
consensus of all the questions asked. The occupational therapist made sure I got it
(Participant 10).

Affect of Improvement of Medical Condition on Length of Time Using Adaptive

Equipment
A very slight majority of the participants felt that improvement in their medical
condition did affect the length of time for which they used adaptive equipment. Although
this was the majority, contradicting comments were noted. It made me feel safer to use
it (Participant 4). Many of the participants indicated that they still used their piece of
adaptive equipment, regardless of the length of time since their surgery.

Influence of Environment on Use of Adaptive Equipment

The home environment did influence the nonuse of adaptive equipment for a majority
of the participants. I would have used it longer, but it was too inconvenient with visitors
(when speaking about the raised toilet seat), (Participant 3). Participant 1 responded, I
used the equipment less because I had people to help me. The design of my bathroom
made it so I did not need the raised toilet seat. I had a new bathroom built with a raised
toilet in it, (Participant 6).

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DISCUSSION
The results of this study will benefit future occupational therapy practice in many
ways. The results have led to the following three main points: the majority of patients
are using their adaptive equipment when they return home; the majority of patients
are not being included in deciding what pieces of adaptive equipment to purchase;
and other areas concerning adaptive equipment, such as instruction, are adequate as
reported by the participants of this study. Applying these results into daily practice will
benefit occupational therapy in two ways. The first is that occupational therapists will
be more effective in their treatment by identifying the unique needs of the patient. The
second way is that patients will feel more included in deciding which pieces of adaptive
equipment to purchase and, thus, hopefully that will increase compliance.
The results indicated that 72% of the participants always used the adaptive equipment
they purchased, leaving 28% not using the equipment as recommended by occupational
therapists. These results are consistent with previous research, which states that adaptive
equipment is being used by patients after they return home from the hospital (Gitlin,
Levine, & Geiger, 1993). Although this is a fairly consistent use, there is still a need
for identifying why almost one-third of patients do not use adaptive equipment as
recommended by occupational therapists.
The researchers found that 78% of the participants felt little or no inclusion in deciding
what pieces of adaptive equipment to purchase, as seen in Table 5. This is an alarming
result within a profession that strives to remain client-centered. Gitlin et al. (1993) also
found that occupational therapists do not always consider the specific and unique needs
of each patient when recommending adaptive equipment to them. The health care field
is continually transitioning. Years ago, the medical model of health care held physicians
and other members of the medical team as the expert in a patients care. Today, the
patient is considered the expert in his or her own health care. The desires of the patients
should be a priority when suggesting adaptive equipment. This enables occupational
therapists to stay on the cutting edge of the health care field and its trends.
Past literature has identified inadequate instruction with adaptive equipment as a
reason for noncompliance. The results of this study illustrate this to be false in the target
population of this particular study. As it has been found that occupational therapists are
providing adequate instruction on use of adaptive equipment, the focus must shift to
patient involvement in the decision-making process. It is important for therapists to be
aware of current research and utilize the evidence in practice.
Surgeons recommend up to 3 months of movement restrictions for patients after
a total hip replacement (Montin et al., 2009). This study indicates that about half of
the participants length of use of adaptive equipment was affected by improvement in
his or her medical condition. However, many participants contradicted these results
by mentioning that they continued to use certain pieces of adaptive equipment until
TABLE 5. Extent of Involvement in Deciding Which Pieces of Adaptive
Equipment to Purchase

No. of participants

Very
Included

Somewhat
Included

A Little
Included

Not
Included

Thomas et al.

177

today (Participant 4). The researchers have found inconsistencies with this assumption
in general.
Another theme also leads to the conclusion that occupational therapists need to
remain client centered in their treatment. The results of this study indicate that the home
environment, which differs for each patient who receives a hip replacement, does affect
the use of adaptive equipment. Whether the participants had someone at home to help
them, the equipment was inconvenient to use, or if their home was set up in a way that
prohibited adaptive equipment use, the majority indicated that their home environment
affected whether or not they were compliant with adaptive equipment use. These results
indicate to occupational therapists that it is important to obtain an understanding of a
patients home environment when recommending adaptive equipment before discharge.
LIMITATIONS
The pilot study was conducted without problems, giving the researchers the assumption that all questions were valid. Despite using a pilot study, the researchers were
unclear whether all questions were understood as intended. To increase external validity, a larger and more comprehensive sample size would be needed. The sample used for
this research was a convenience sample from mid-sized Midwestern cities. Participants
from large cities and rural areas would also need to be included for the results to be
generalized. The sample is nonrepresentative of the population. The sample consisted
only of patients who have had a total hip replacement, excluding many other individuals
who use adaptive equipment with varying diagnoses. Further research is necessary to
determine what motivates a client to use adaptive equipment that has been purchased,
as opposed to this study, which focused on the most cited reason for nonuse.
CLINICAL IMPLICATIONS
Adaptive equipment can be the key to unlocking independence and improving functional performance while preventing further decline with patients after receiving a total
hip replacement. This study is unique to the body of current literature in that it has
identified the most frequent reason for noncompliance with use of adaptive equipment. This study provides occupational therapists with the knowledge to prevent future
noncompliance by remaining client centered and considering client factors when recommending adaptive equipment. Involving patients in the decision-making process may
help increase compliance with using adaptive equipment. Evidence-based practice is
important in the occupational therapy profession. Using and doing what has been proven
by research can improve the effectiveness of treatment.
Declaration of interest: The authors report no conflict of interest. The authors alone
are responsible for the content and writing of this paper.

REFERENCES
Davidson, T. (1999). Total hip replacement: An audit of the provision and use of equipment. British
Journal of Occupational Therapy, 62(60), 5458.

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Finlayson, M. & Havixbeck, K. (1992). A post-discharge study on the use of assistive devices.
Canadian Journal of Occupational Therapy, 59(4), 201207.
Gitlin, L., Levine, R. & Geiger, C. (1993). Adaptive device use by older adults with mixed disabilities.
Archives of Physical Medicine & Rehabilitation, 74(2), 149152.
Gitlin, L., Schemm, R., Landsberg, L. & Burgh, D. (1996). Factors predicting assistive device use in
the home by older people following rehabilitation. Journal of Aging & Health, 8(4), 554.
Kraskowsky, L. & Finlayson, M. (2001). Factors affecting older adults use of adaptive equipment:
Review of the literature. American Journal of Occupational Therapy, 55(3), 303310.
Montin, L., Suominen, T., Katajisto, J., Lepisto, J. & Leino-Kilpi, H. (2009). Economic outcomes from
patients perspectives and health-related quality of life after a total hip arthroplasty. Scandinavian
Journal of Caring Sciences, 23(1), 1120.
Neville-Jan, A., Piersol, C., Kielhofner, G. & Davis, K. (1993). Adaptive equipment: A study of
utilization after hospital discharge. Occupational Therapy in Health Care, 8(4), 318.
Neville-Smith, M., Trujillo, L. & Ammundson, R. (2000). Special feature: Consistency in postoperative education programs following total hip replacement. Topics in Geriatric Rehabilitation, 15(4),
6876.
Poliner, D. (2003). Standard of care: Inpatient occupational therapy intervention for total hip arthroplasty. Retrieved from http://www.brighamandwomens.org/RehabilitationServices/Occupational
%20Therapy%20Standards%20of%20Care-Protocols/Hip-%20Total%20Hip%20Arthroplasty.pdf
Wielandt, T., McKenna, K., Tooth, L. & Strong, J. (2001). Post-discharge use of bathing equipment prescribed by occupational therapist: What lessons to be learned? Physical & Occupational
Therapy in Geriatrics, 19(3), 4965.
Wielandt, T. & Strong, J. (2000). Compliance with prescribed adaptive equipment: A literature review.
British Journal of Occupational Therapy, 63(2), 6575.

APPENDIX A
Section 1: General Information
1. How long ago was your hip replacement surgery?
a. 36 months ago
b. 712 months ago
c. 13 years ago
d. 4 or more years ago
2. Did you attend an educational session about your surgery beforehand?
a. Yes
b. No
3. How long was your hospital stay?
a. 13 days
b. 47 days
c. 814 days
d. 15 or more days
4. How many times did an occupational therapist visit you while you were in the
hospital?
a. 1 time
b. 23 times
c. 45 times
d. 6 or more times

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179

5. When you returned home from the hospital, was there someone there to help you if
needed it?
a. Yes
b. No
6. Did you receive homecare services after you returned home from the hospital?
a. Yes
b. No
If yes, which? (Circle all that apply)
a. Physical Therapy
b. Occupational Therapy
c. Home Health Aid
d. Bath Aid
Section 2: Adaptive Equipment
1. Did you buy any of the following:
a. Reacher or Grabber
b. Raised Toilet Seat
c. Sock Aid
d. Long Handled ShoeHorn
e. Long Handled Sponge
f. Elastic ShoeLaces
g. Shower/Tub Chair
2. To what extent did you feel your occupational therapist included you in deciding
what pieces of adaptive equipment to purchase?
a. Very included
b. Somewhat included
c. A little included
d. Not included
The questions below were asked for each piece of adaptive equipment the participants either purchased or already had at home.
Piece of Equipment:
1. How often did you use this piece of equipment?
a. Always
b. Frequently
c. Seldom
d. Never
2. Did you feel like you had adequate instruction from the occupational therapist on
how to use this piece of adaptive equipment?
e. Yes
f. No
Additional Comments:
3. Did improvement in your medical condition affect the length of time you used your
adaptive equipment?

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PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS

a. Yes
b. No
Additional Comments:
4. Did you feel like your environment (e.g., who you live with and how your home is
set up) influenced your use of adaptive equipment?
a. Yes
b. No
Additional Comments:

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