Abstract
BACKGROUND:
Assistive Technology (AT) devices are vastly used by individuals with disabilities in their workplace to accommodate their disability and enable productivity. However, barriers and gaps with integration and use of AT in workplace are well documented in literature.
OBJECTIVE:
This research study demonstrates the application of a systematic evaluation framework, the Usability Scale for Assistive Technology-Workplace, to examine the usability of work-related AT devices for employees, employers, and vocational rehabilitation providers to identify gaps and optimize the implementation of AT. The framework is fundamentally driven by the employee’s vocational context and range of work-related tasks, and comprehensively accounts AT devices and related accommodations that address each task.
METHODS:
Five employees with different motor and sensory impairments are presented as case scenarios to highlight the application of the evaluation framework.
RESULTS:
By using the evaluation framework, it was found that the employees in general were successful in the use of AT devices and rated their productivity as high. However, some unique as well as common barriers were also reported and pertained to technical knowledge and training, reliability and compatibility of the AT devices, and limitations in accessibility.
CONCLUSION:
Future research is required to derive and establish a standardized evaluation tool using the framework.
Keywords
Introduction
Individuals with disabilities may need a wide range of supports to participate in and be productive at work. Assistive Technology (AT) enables them to perform major work functions such as communication, computer access, environmental control, cognitive functions and mobility. The use of AT at workplace has been facilitated by legislation such as the Section 508 of the Rehabilitation Act and Title I of the American with Disabilities Act. Despite some research evidence and the legislative mandates supporting the use of AT in the workplace, employers continue to be concerned about the cost effectiveness and efficiency of using AT in the workplace. For the employee with disability, successful workplace AT use will depend on the adoption, optimal use and integration of specific set of technology. The barriers to the use of AT in the workplace stem from inadequacies in service provision, lack of awareness about AT solutions on part of the employee and limited commitment from the employer. These barriers can be successfully addressed through the application of an established framework and a systematic process for AT service provision. The purpose of this article is to demonstrate an evaluation framework for examining the usability of workplace AT to facilitate its effective implementation for individuals with disabilities.
Background
Assistive technology is a central component of reasonable accommodations required by individuals with disabilities to participate in employment. As per the Assistive Technology Act (2004), an AT device is any item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities. In the context of workplace, AT includes a wide spectrum of low-tech, mid-tech and high-tech devices that directly support work-related tasks involving computer access, communication, information processing, reading, and composing to those that provide seating, mobility and ergonomic adaptations needed by the individual to optimally interact with the work environment (Cook & Polgar, 2008: Dove 2012). When all precursory factors (such as qualification, skills, and motivation) to finding or returning to employment are met, the potential of an individual with disability to sustain and perform the job productively will depend on the selection and use of the right set of AT devices (Inge, Strobel, Wehman, Todd & Targett, 2000; Schwanke & Smith, 2005). However, the fundamental question hinges not so much on the specific technology, but on the process wherein the employee adopts, becomes accustomed, and integrates the technology into his or her workplace. To this end, how do we ensure that an individual with a disability acquires and skillfully uses the right set of AT devices required for performing his or her job effectively and efficiently?
Employees with disabilities often attribute their own disability as a barrier to employment (Yeager, Kaye, Reed & Doe, 2006). The findings speak to the general lack of awareness about AT options that are widely available to individuals with disabilities. In a survey study, it was reported that about 60% of persons with disabilities receive little or no information about AT in general or how to obtain AT (Carlson, Ehrlich, Berland, & Bailey, 2001). In addition to the overall lack of awareness, the stigma and reluctance associated with self-disclosure of disability and requesting for accommodations are major barriers in the use of workplace AT (Driscoll, Rodger, & Jonge, 2001).
From the employer’s perspective, fear associated with implementation of AT despite legal mandates is often cited as a barrier (Stumbo, Martin & Hendrick, 2009). A common perception among employers has been that implementation of AT will demand an undue level of resources and funding. On the contrary, it has been shown that a vast majority of AT devices required by individuals with physical disabilities to participate in employment are low-cost and low-tech devices (Inge et al., 2000). However, when some AT devices do require time for training, employers in fact may have concerns with time delays and loss of productivity of the employee (De Jonge & Rodger, 2006).
Despite the preliminary, yet promising, evidence supporting the use of AT in the workplace (Hedrick, Pape, Heinemann, Ruddell, & Reis, 2006), service providers report several knowledge gaps in the evaluation and implementation of workplace AT. The complex interplay of factors such as failure to involve the employer, a mismatch between the job demands and AT, and the lack of a coordinated team effort to account for employee’s needs and preferences have been linked to ineffective AT service provision in workplace (De Jonge & Rodger, 2006; De Jonge, Rodger, & Fitzgibbon, 2001; Stumbo et al., 2009). As a matter of fact, studies also indicate the incompatibility and complexity of AT combined with inadequate employee training to be a key barrier in optimizing its use in the workplace (De Jonge & Rodger, 2006; Driscoll, Rodger & De Jonge 2001). Specific to training, state vocational rehabilitation counselors indicated in a survey that in order to provide effective AT services they needed to: Further their knowledge of AT, better manage services, and be clearer in conveying information to consumers. In general, their response averages reflected “a total lack of confidence” in identification of AT needs and services (Noll, Owens, Smith & Schwanke, 2006, p. 417).
Although there are established conceptual models such as the Human Activity Assistive Technology (Cook & Polgar, 2008) and the Matching Person & Technology (Scherer & Craddock, 2002) for AT service provision, there are no consensus, best practices, or guidelines for their operational application in specific contexts such as workplace (Arthanat, Simmons, & Favreau, 2012). The lack of a standardized AT service method has led to a “fragmented AT service system” with ineffective communication among providers, manufacturers and clients, resulting in inefficient resource allocation and suboptimal outcomes (Elsaesser & Bauer, 2011, pg.1). Assistive technology service provision is an intricate process requiring the need to systematically match the human abilities and skills to the right AT device in a given environment and activity context (Arthanat, Bauer, Lenker, Nochajski, & Wu, 2007). To this end, the method of effectively studying and integrating AT devices in accordance to the employee’s job demands, his/her skill-set and employer resources has not yet been clearly established.
Purpose
This research project was conducted to operationalize and demonstrate a novel evaluation framework, the Usability Scale for Assistive Technology (USAT)-Workplace. The framework is designed to guide effective provision of AT services through measurement and optimization of the usability of technology used by employees with disabilities within the assigned repertoire of work roles. It addresses prevailing barriers with integration of AT in workplace by identification of the strengths and barriers in the interaction of an employee with disability and his/her AT devices.
The USAT was developed based on a human factors science model, the Human Activity Assistive Technology (Cook & Hussey, 2008) that exemplifies the interaction of the user and an AT device to accomplish an activity in a given context. The USAT serves as a framework for measurement of AT usability based on this interaction (Arthanat et al., 2007). The framework has been applied towards measurement of AT usability in the context of mobility (Arthanat, Nochajski, Lenker, Bauer, & Wu, 2009; Arthanat, Desmarais, & Eikelberg, 2012).
As seen in Fig. 1, the USAT-Workplace uses a systematic approach to underscore AT usability in the context of employment. At the outset, the evaluation framework gives priority to the work roles of the employee with a disability. The required tasks associated with each role are then delineated. The AT devices being used to carry out the tasks are taken into account and the skills of the employee and the accommodations corresponding to the use the devices are then factored in. On the whole, the support provided by the device, the skills of the employee to optimally use the device and the extent of accommodations provided for each task will determine the usability of each AT device. Retrospectively, the usability of each AT device reflects the effectiveness and efficiency with which the individual performs his corresponding job tasks and taken collectively, exemplifies the productivity with which he/she fulfills his or her work related roles.
Methodology
The research involved a case series design to demonstrate the application of the USAT-WM with a small cohort of five individuals with disabilities in the context of their workplace. The participants were interviewed using the USAT framework and a pilot questionnaire modeled on the framework was completed by each of them (see Appendix). The interview data in conjunction with the evaluation ratings was analyzed to delineate the merits and limitations of the AT devices in the context of the individual’swork.
Participants
The research protocol was reviewed and approved by the Institutional Review Board of the University of New Hampshire. Participants were recruited through referrals from the UNH Institute on Disability, Granite State Independent Living, and Northeast Passage. To be eligible to participate in the study, participants had to meet the following criteria: Have a physical and/ or sensory impairment, are currently employed, and use AT devices. Brief participant descriptions are given below. To maintain anonymity, pseudonyms are used and the identity of their employer is excluded.
The first participant, Peter, is a 42-year-old male with a diagnosis of muscular dystrophy, who works as a music teacher at a middle school. His roles for this position at the school consist of teaching instruments, instruction in music topics, and assisting with student projects. Peter also works on an advisory committee, runs the recycling club, and helps to negotiate contracts.
The second participant, Erin, is a 34-year-old female with a diagnosis of dwarfism and hearing impairment. She works as a referral counselor within a not-for-profit agency where she participates in front desk tasks such as answering calls, sending emails and entering information into the database. She also often does presentations within and outside of her office.
The third participant, Kate, is a 45-year-old female who is diagnosed with retinitis pigmentosa, which classifies her as legally blind. Kate is an information and referral coordinator for the supports department at a facility for individuals with disabilities who need assistance in their homes.
The fourth participant, Tim, is a 35-year-old male with a C4 spinal cord injury. He is the director of family services at a community center, where he manages programs, fundraising and staff, and works with children.
The fifth participant is Sarah, a 36-year-old female with cerebral palsy who works as a rehabilitative equipment associate. Her position as a customer service representative consists of answering the phone, faxing papers, and using an electric filing system.
Data collection – interview and questionnaire
Semi-structured interviews were conducted with each participant. The USAT-Workplace framework was used to derive the interview questions. The participants were first asked about the nature of their job and to outline their roles and responsibilities. Specifically, tasks associated with each role was then discussed. The AT devices they used at their work site were discussed in accordance to each job task. Participants were also enquired about the skills, training and environmental accommodations pertaining to each AT device as they related to the required job tasks. A pilot version of the USAT-Workplace with 5-point Likert scale ratings assigned to the AT device, associated skills, accommodations, and productivity for each tasks was also filled out by each participant. The support provided by the device, the skills required and accommodation were rated as “1- Very Inadequate, 2- Inadequate, 3- Somewhat Adequate, 4- Adequate, and 5- Very Adequate”. The perceived productivity of the tasks was rated as 1- Very unproductive, 2- Unproductive, 3- Somewhat Productive, 4- Productive, and 5- Very Productive. The interview, along with the questionnaire, required about an hour for completion. The interview questions in conjunction with sample questions from the pilot questionnaire are provided as an Appendix in the end.
Analysis
Responses of the participants were examined by content analysis by each member of the research team. Meaningful codes pertinent to the ratings assigned on the questionnaire were assembled. A summary of the participant’s perspective showing links with the questionnaire ratings were sent to each participant as member check. Participants were asked to review the summary and clarify or add any missing information if needed. Four out of the five participants responded to the member check with no objection or request for revision to the summary. One of them was not available when contacted with the summary. Themes that were unique to each participant as well as commonly represented in the study sample were identified and elucidated.
Results
The findings for this study are outlined for each participant. The focus is directed on their job roles and involved tasks, the AT devices utilized to carry out each role and the influence of the environment.
Peter
Based on Peter’s description of his work as a music teacher, his work roles were delineated to include teaching and administrative responsibilities (See Fig. 2). In his role as a teacher, the tasks he needed to carry out were teaching instruments, teaching music theories (topics), overseeing student projects and participating in student advisory committees. He rated his level of productivity at a 4 (“productive”) for these tasks. His administrative roles included being in charge of a musical instrument recycling club and engaging in negotiations with contracts for the school staff. Here again, Peter identified himself as “productive” (4).
Assistive technology plays a vital role in every aspect of Peter’s job. He utilizes a Smartboard combined with an electronic pen as the most important tool to fulfill all his teaching roles. The board is specifically necessary and time efficient, as his wheelchair does not allow him to maneuver parallel to the smart board. His ratings of the Smartboard and electronic pen on the USAT questionnaire were the same for all the tasks involved in teaching. He rated his skills for the using the tool be “adequate” as well as the level of support offered by the tool for the tasks. When probed further in the interview, he stated being unsure if he is using the most recent version/model of the Smartboard and doubted if he was using it most optimally without undergoing any training. In addition, he realized that he lacks the knowledge of other technologies that may be more beneficial to him. He rated the accommodation provided by the school for the use of the SmartBoard only to be “somewhat adequate” (3) and attributed it to the fact that the school did not proactively seek and provide accommodations unless requested by him. He does not feel that the SmartBoard is the most effective tool as the children cannot touch or interact with it. He believes that if a more expensive device is needed, it would not be granted.
For fulfilling his administrative duties in managing the recycling club and contract negotiations, Peter needs to rely on his modified mini-van for travel and a power wheelchair and wheelchair lift for mobility. He rated these AT devices as “very adequate” (5) in supporting his job tasks. He also rated his skills in using these devices as “very adequate”. However, he expressed concerns with the level of accommodations provided towards use of his power wheelchair and mini-van and rated them to be only “somewhat adequate.” At his school, most of the doors require scan cards and are not equipped with electric buttons, which makes it impossible for him to pass through both ways independently. He stated “the front doors are locked with a scanning key card which reads my ID but they put it at shoulder level so I can’t reach it with my arm strength problems. Kids need to scan it and open the door.” Overall, it seems that Peter is performing his job quite well, but as reflected in his ratings on productivity, there are areas that could be further optimized with some training and physical accessibility.
Erin
As stated before, Erin works as a referral counselor in an office for disability services. Her work involves three roles: Providing client support, managing client records, and information dissemination. Within the role of client support, her tasks include communicating with clients via email, doing research and finding information over the internet, attending and initiating phone calls, and working at the frontdesk.
As displayed in Fig. 3, Erin describes herself as “very productive” (5) in managing email and doing research over the internet. She identified a left-handed (adapted) mouse and an adapted pull-out keyboard as the two AT devices that provided access to the computer. She rated her skills as very adequate in using both devices to operate her computer. Accordingly, the devices were also rated as “very adequate (5)” in supporting the demands of the tasks. The accommodations such as the space, layout and workstation for using the devices were described as “adequate” (4). Due to her hearing impairment, Erin requires an amplified headset for attending to phone calls. She rates the headset as “very adequate” in addressing this task, as well as her skills and accommodations in using the device. However, for working at the front desk, she rates the headset as only “somewhat adequate”. She attributes the inadequacy to the awkward set up of her portable laptop at her front desk and also considers her skills to be “somewhat adequate” in such a situation.
In her role with management of records, Erin rates her task of entering information into database as “very productive” and managing fax and mail as “productive”. She considers a left-handed mouse and a pull out keyboard to be the assistive devices that enable her use of the computer for data entry. She rates both her skills and the support provided by these devices as “very adequate” and the level of accommodation for use of these devices to be “adequate.” A step stool is being used by Erin as an AT devices for physical access to the fax machine and mail boxes.
As a disability advocate, Erin conducts presentations and on many occasions needs to travel out of office to external sites. She uses a hearing aid and a power wheelchair during the presentations. However, she describes herself as “somewhat productive” while presenting because of the seating layout for the audience. She reported that sometimes the attendees who are seated in the back cannot see her because of her short stature. To this end, she expressed the need for an adjustable seating height in her wheelchair. She also reported problems in mobility due to difficulties in access to buildings and instability in her wheelchair when weight is carried- “If I have to put on a backpack, it will tip back due to the poor alignment.” Also to note, her hearing aid (rated as “somewhat adequate”) was felt to lack adequate clarity and sound localization to pick up on conversation across the room.
Kate
Kate’s job as an information and referral coordinator involves two roles: Communication and administrative responsibilities (See Fig. 4). She communicates with clients by taking calls and conveying information to them in real time by accessing her computer. She also needs to contact her agency’s care coordinators via phone. To compensate for her legal blindness during communication, she uses a closed caption television to magnify written materials, a Zoom Text software program to magnify her computer screen, and JAWS screen reader program for text-to-speech feature on her computer. Overall, Kate describes herself as being “very productive” with the task of taking calls. She finds the support provided by the CCTV, her skills for operating the CCTV and accommodation provided for the device to be “very adequate.” However, she rates the JAWS program (as well as her skills for using it) as only “somewhat adequate” because according to her the program is “very frustrating”, as it “bounces around”, and at times reads out the wrong information on the computer. She reported the accommodation for using JAWs to be also “somewhat adequate” as she could benefit from a more recent edition of software and associated training. The ZoomText program for screen magnification and the skills for using it was rated as “adequate” by her although she did mention that only small portions of the screen can only be viewed by her at any given time thereby compromising the efficiency of her task. For contacting care coordinators, she uses a phone modified with high contrast stickers on buttons. She considers this adaptation to be only “somewhat adequate” for her skills and task needs as she could benefit from an adapted phone with a high contrast key pad and enlarged keys.
In fulfilling her administrative duties, Kate performs the tasks of supervision, sorting mailings, and documentation of client records. For the supervision and mailing, she uses the CCTV for reviewing documents and mail and finds the device and the provided accommodation to be “very adequate.” For documenting client records, she uses a large print keyboard for data entry. She reports the large keyboard and her skills to be “very adequate” for the task although it must be noted that the problems already outlined with ZoomText and Jaws exist while she reviews the entered information on the computer.
Tim
Tim, who experiences quadriplegia, works as the director of family services at a community development center. His single, yet important, role here can be described as management of programs with assigned tasks of fund raising, drafting reports and working with children. As reported in Fig. 5, he rates himself as “productive” in fund raising and reporting, and considers his work with children to be “very productive.”
To contact potential donors, Tim uses an adapted phone that he operates using a mouth stick. While he rates the adapted phone as “very adequate” in the support it provides and his skills in interacting with it, his rating for the mouth stick was only “somewhat adequate” as it was much slower for him to dial the phone. Although he feels a voice-activated phone could have been provided, he was comfortable using his mouth stick. In preparing reports, he stated the adapted phone to be “very adequate” and the mouth stick to be “adequate” for typing. For working with children, Tim identified his mouth stick and power wheelchair as the AT devices that supported this task. Regarding the mouth stick, he stated “working with kids while helping with homework using the mouth stick is challenging. I can write on paper but I can’t write on the white board.” Consequently, he rated it as only “somewhat adequate” for the task, despite his skills and accommodation being “very adequate.” In using his power wheelchair to travel for community events, Tim rated his skills as “very adequate” and wheelchair as “adequate”. However, the accommodation was rated as “somewhat adequate” due to problems in transportation availability. As quoted here-“The biggest challenge is finding transportation. I have to rely on others to drive me. I have to plan ahead and there is no impromptu traveling”.
Sarah
Sarah’s position as a customer associate at a rehabilitation equipment facility involves customer support that requires answering and directing phone calls. In addition, she has administrative duties including sending and receiving faxes and electronic record keeping. Her phone communication with the customers is enabled using a headset and an assisted dialing program on her computer. As seen in Fig. 6, she considers her task as “productive” and rates the headset as “very adequate” in meeting her needs. However, she rates her skills in using the computer as “somewhat adequate” as she experiences difficulty in controlling and navigating the phone menu on her screen.
Sarah perceived the task of managing the faxes to be “very productive” and rated her skills and accommodations provided to be “very adequate”. The fax machine which was connected via her computer was however rated as “somewhat adequate” because of its lack of reliability. In many instances this computer-linked fax machine had broken down and she found the regular fax machine to be challenging to operate. She also identified her power wheelchair as “very adequate,” as well as the accommodation (the space) needed for maneuvering around the fax machine. For filing records electronically, Sarah rated her task performance as “very productive.” She considers the computer and the accommodation as “very adequate” for performing this task.
Discussion
Assistive technology is one of the most important components and predictors of employment for individuals with disabilities (Marini, Lee, Chan, Chapin, & Romero, 2008; Pack & Szirony, 2009; Rumrill, Fraser, & Johnson, 2013). Nevertheless, evaluating the integration and role of AT devices in workplace has generally been complicated by the intricacies of the employee’s disabilities, nature of the job, task demands and involved accommodations. Researchers in the field of vocational rehabilitation have advocated for a multi-step heuristic evaluation process for integration of AT in workplace with preliminary emphasis on the job demands (Langton & Ramseur, 2001) and the individual “situation” of the employee including impairment, functional limitation, and experiences (Gamble, Dowler & Orslene, 2006). In preliminary research, the introduction of AT following a detailed analysis of work has yielded positive outcomes in efficiency and productivity (Hartmann, 2009).
This research study demonstrated a systematic framework and streamlined approach to comprehensively examine the usability and implementation of work-related AT devices. Five case scenarios were used to demonstrate the application of the USAT-Workplace. The employees were in their prime working age ranging from 34 to 45 and experienced varying neuromuscular and sensory impairments. The context of their jobs, their roles, and task requirements also varied. A variety of simple and inexpensive to sophisticated high-cost AT devices were being used to fulfill their work roles. Collectively, the employees were successful in performing their job tasks. Their overall perceptions of productivity were high and their critical accommodation needs seemed to have been met by the employer. As shown in previous research (Hedrick et al., 2006), the employees expressed satisfaction and appreciation for their AT for its role in their work. However, some common concerns with the integration and use of AT devices were evident.
At the basic level, the employees may be further benefitted by improved knowledge and skills pertaining to the AT devices they were using. The evaluation framework demonstrated that the employees were at times unaware about recent technological developments and the existence of newer versions or models of AT devices that were potentially available. It was also evident that further training, specifically pertaining to computer access AT, could enhance their work productivity. In synchrony with past research, individualized training and learning support for AT devices is a key strategy to enhance the employee productivity at work (De Jonge & Rodger, 2006). In some instances, the employees seemed to rely on older computer-based AT, needed periodical software updates, and were experiencing compatibility issues. Issues with accommodations centered mostly on the physical environment. Workplace mobility was limited by inaccessible buildings and unreliable accessibility equipment. Also, simple alterations in existing accommodations such as placement of door openers (in the case of Peter) and changes in audience seating layout (in the case of Erin) could have had a positive impact on the employee’s work.
Taken individually, each employee in this study presented with a unique set of strengths as well as barriers that illustrated the implementation and practical usage of workplace AT. Conducting evaluations using the USAT framework allows identification of the day-to-day barriers and thereby informs the employee as well as the employer about strategies and remedies to bring to place. Specific to this study, the participants appreciated the interview structure that allowed them to outline their tasks and systematically focus on the AT devices, skills and accommodations inherent in performing the tasks. In applying the framework, it is illogical at the outset to merely evaluate AT devices in isolation without considering the vocational context and repertoire of tasks. Evidently, there were many instances in the case scenarios wherein the support rendered by the same AT device varied on different tasks.
Recent research shows that AT equipment is provided to employees with disabilities at workplace “much more readily” than other accommodations such as work schedule modifications (Rumrill et al., 2013, pg-89). However, historically, AT when provided as accommodations has predominantly been low-cost (Inge, et al., 2000) and the strong tendency among employers to limit the AT that are easy to procure and implement still continue (Rumrill, et al 2013). Therefore, it is essential to recognize if in fact the job roles demand the use of high-tech and high-cost AT and to justify and document that need through a formal evaluation.
The USAT-Workplace framework is designed for use by professionals in the field of vocational rehabilitation including rehabilitation counselors, job coaches and AT service providers. It is applicable to all employees with disabilities who are currently employed, seeking new jobs, or returning to a job following disability. The framework also provides directions to the employer regarding AT devices, training and level of accommodations required by an employee with disability relative to the job tasks and priorities. Although the framework is designed for self-evaluation of AT devices by the employee, it would also be crucial to involve the employer to verify convergence in views as well as to determine resource allocation and the feasibility of implementing improvements.
Limitations
The objective of this study was to demonstrate the application of an evaluation framework with a small cohort of employees with disabilities. It should be noted that the gathered data was primarily qualitative and the illustrated quantitative ratings from the pilot questionnaire are included to complement the qualitative data. The quantitative ratings are not amenable for cross comparison of the employees’ AT experiences and due to the small sample size and sample variability, generalizability in the findings may be limited. Also, the evaluation questionnaire is not yet operational. Importantly, the framework was applied to highlight the use of AT in an employee’s current status at work. It should ideally be tested in a situation of job entry or return to work.
Conclusion
Future work should be directed towards validating and testing the framework with a large sample of employees with disabilities. Specifically, analysis of causal pathways among the AT device use, the employee skills, the accommodations provided and productivity would validate the dynamic interaction depicted in the framework. Concurrently, the development of a practical evaluation tool for use in vocational rehabilitation settings is warranted. The tool development should involve the expertise of professionals in the vocational rehabilitation community and psychometric studies through a large sample of employees. More importantly, the developed tool needs to be tested in a vocational rehabilitation context and interventions introduced to determine increases in AT related work productivity.
Footnotes
Acknowledgments
This article is dedicated to the memory of Thad Mandsager for his contribution to this research. Funding for the study was provided by the Hamel Center for Research at the University of New Hampshire. Special thanks to all participants for their time and valuable insights.