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Table 4 Statements and the ratings given to each statement in subsequent rounds

From: Stakeholder consensus for decision making in eye-gaze control technology for children, adolescents and adults with cerebral palsy service provision: findings from a Delphi study

Statements identified in Round 1a

Round 2 b

% of respondents

Round 3 b

% of respondents

Critical importance

Important

Not critical

Critical importance

Important

Not critical

Question 1: What is unique about eye-gaze control technology as an access method?

 For the person

[1.3.1.a] it can be suitable if they have severe motor disabilities which limits voluntary gross and fine motor control

87.9

10.3

1.7

92.7

7.3

0.0

[1.2.1.b] it can be a fast, efficient and accurate direct access method to the computer as well as to communication software

67.2 d

29.3

3.4

82.9

17.1

0.0

it can provide the opportunity to communicate spontaneous, novel words quickly and efficiently

69.0

24.1

6.9

   

it can be fatiguing

44.8

37.9

17.2

   

[1.3.1.c] it can be reliant on seating and positioning

74.1

15.5

10.3

82.9

17.1

0.0

[1.3.1.d] it may require careful set up and positioning prior to use

79.3

17.2

3.4

85.4

14.6

0.0

[1.3.1.e] it may be difficult to use outdoors due to bright sunlight

57.4 d

35.2

7.4

79.5

17.9

2.6

 For the person’s support network

it can be hard to demonstrate/model how to use the device in a clear way

43.1 d

44.8

12.1

63.4

31.7

4.9

Question 2: What information should be considered as part of an eye-gaze control technology assessment before a trial?

 Ability to visually attend to the screen

[2.3.1.a] vision (acuity)

74.1

20.7

5.2

78.0

19.5

2.4

[2.3.1.b] visual motor (eye movements)

86.0

10.5

3.5

87.8

9.8

2.4

[2.3.1.c] visual perceptual skills

76.8

16.1

7.1

77.5

17.5

5.0

 Ability to show understanding

cognition

41.1

42.9

16.1

   

understanding of cause and effect

46.6

32.8

20.7

   

attention

50.0

43.1

6.9

   

concentration

44.8

48.3

6.9

   

memory

24.1

62.1

13.8

   

communicative intent

49.1

42.1

8.8

   

existing communication methods

43.6

38.2

18.2

   

understanding of language

39.3

42.9

17.9

   

 General health issues

physical health

24.6

59.6

15.8

   

medications

33.9

41.1

25.0

   

fatigue

50.0

41.4

8.6

   

pain

36.2

51.7

12.1

   

hearing

29.3

39.7

31.0

   

 Motor ability

head control

55.2 d

37.9

6.9

58.5

34.1

7.3

[2.3.2.a] positioning

84.5

15.5

0.0

80.5

17.1

2.4

 Drive, ambitions and experiences

motivation

62.1

31.0

6.9

   

personal preferences

53.6

35.7

10.7

   

personal goals

47.4

36.8

15.8

   

previous trials or use of technology and the outcomes

28.1

49.1

22.8

   

interest in technology

24.1

41.4

34.5

   

Question 2a: The following information about the person’s environment and support network should be considered as part of an eye-gaze control technology assessment before a trial.

 In the environment

lighting levels in settings where the device will be used

50.9

45.6

3.5

   

what other technology the device might need to interface with

52.6

45.6

1.8

   

[2.3.3.a] the need to mount the device, and if so, how

86.2

13.8

0.0

85.4

14.6

0.0

[2.3.3.b] whether the technology will need to be moved between settings

74.1

22.4

3.4

77.5

20.0

2.5

 The support network

their expectations

58.6

36.2

5.2

   

[2.3.4.a] their need for support and training

89.5

10.5

0.0

90.2

9.8

0.0

[2.3.4.b] who the key people are that will coordinate the implementation the upcoming trial

90.9

9.1

0.0

92.7

7.3

0.0

[2.3.4.c] their ability to borrow or rent one or more devices to trial for a sufficient period of time

72.7

16.4

10.9

70.0

22.5

7.5

[2.3.4.d] their availability to support access, use and/or teach the person to use their device

87.7

12.3

0.0

87.8

12.2

0.0

their knowledge of the application process for any available funding

45.5

41.8

12.7

   

Question 2b: The following information about the technical aspects of eye gaze-control technology should be considered as part of an assessment before a trial.

 The eye-gaze control technology system

[2.3.5.a] ability to be used with different light levels or outside

45.6 d

45.6

8.8

57.5 d

37.5

5.0

battery life of computer/speech generating device interfacing with the eye-gaze control technology camera

64.3 d

32.1

3.6

62.5

37.5

0.0

memory of computer/speech generating device interfacing with the eye-gaze control technology camera

50.9

41.5

7.5

   

[2.3.5.b] portability

65.5 d

31.0

3.4

73.2

26.8

0.0

[2.3.5.c] ease of set up

70.7

27.6

1.7

78.0

22.0

0.0

options for methods of calibration

67.3 d

30.9

1.8

63.4

31.7

4.9

compatibility with other hardware and software

63.2

31.6

5.3

   

[2.3.5.d] connectivity with the computer/speech generating device interfacing with the eye-gaze control technology camera using WiFi, Bluetooth and InfraRed

65.4 d

30.8

3.8

71.8

25.6

2.6

screen size of computer/speech generating device interfacing with the eye-gaze control technology camera

57.9

42.1

0.0

   

volume of computer/speech generating device interfacing with the eye-gaze control technology camera

53.6

42.9

3.6

   

weight of computer/speech generating device interfacing with the eye-gaze control technology camera

49.1

45.6

5.3

   

 The device and its flexibility to respond to the person’s ability

[2.3.6.a] hold deliberate fixations (dwell time)

82.1

16.1

1.8

85.4

12.2

2.4

[2.3.6.b] calibrate

77.2

19.3

3.5

80.5

17.1

2.4

activate sleep mode and move between programs, once the device is set up

49.1

41.5

9.4

   

[2.3.6.c] use vision despite limitations (vision in only one eye, vision out of the corner of the eye, shifting dominance of the eyes)

83.3

16.7

0.0

100

0.0

0.0

Question 3: The following factors should inform decision making when carrying out a trial

 The person’s

health and well-being to enable consistent participation in trial

54.4

38.6

7.0

   

motivation

68.4

26.3

5.3

   

[3.3.1.a] preferences

71.7

26.4

1.9

72.5

27.5

0.0

[3.3.1.b] goals for the trial, jointly established with the person, their family and clinician

82.5

17.5

0.0

87.5

12.5

0.0

[3.3.1.c] seating and positioning equipment are adequate to meet their needs

93.0

7.0

0.0

90.2

9.8

0.0

 The person’s support network, specifically their

ability to be flexible in responding when a person’s skills advance or their abilities decline

63.2

33.3

3.5

   

strategies to minimise the person’s fatigue

64.3

35.7

0.0

   

[3.3.2.a]. attitudes

82.5

12.3

5.3

85.4

12.2

2.4

[3.3.2.b] training needs (the person’s support network needs to be comfortable in implementing the trial, operating the device, using and modifying software, and using communication partner strategies)

98.2

1.8

0.0

87.8

9.8

2.4

[3.3.2.c] input and feedback (family, carers, teachers, employers and others in the settings in which the device is trialled)

91.2

7.0

1.8

90.0

7.5

2.5

[3.3.2.d] ability to provide regular and sufficient time to practise

89.5

10.5

0.0

95.1

4.9

0.0

[3.3.2.e] access to local therapists to support the device trial

84.2

14.0

1.8

80.5

19.5

0.0

[3.3.2.f] access to staff who are experienced with using and teaching eye-gaze control technology and are motivated and engaged in an ongoing way to fully support the person and their support network with the device trials

78.9

17.5

3.5

85.4

14.6

0.0

 The person’s environment

settings in which a person will use a device

66.1

32.1

1.8

   

[3.3.3.a] appropriate space which is large enough to accommodate the device and mountings, and which will support use of device (e.g., quiet)

70.4

27.8

1.9

73.2

24.4

2.4

[3.3.3.b] mounting options (e.g., wheelchair, table or floor mounting)

76.8

23.2

0.0

75.6

22.0

2.4

portability of the device

68.5 d

24.1

7.4

73.2

26.8

0.0

[3.3.3.c] access to low-tech AAC for periods when using eye-gaze devices is not possible or practical

78.0

18.0

4.0

78.0

19.5

2.4

[3.3.3.d] customisation of the device, for example, the on-screen cell size

88.9

11.1

0.0

90.0

10.0

0.0

[3.3.3.e] reliability of the eye-gaze control system

96.4

3.6

0.0

100.0

0.0

0.0

[3.3.3.f] features of the system, such as screen size, on-switch location and accessibility, battery life, size and weight, ease of installation and set up

75.0

25.0

0.0

85.4

12.2

2.4

[3.3.3.g] fun and motivating activities which are intuitive to use; appropriate to the goals, abilities and interests of the person; and have varying levels to enable progression

85.7

14.3

0.0

87.8

12.2

0.0

[3.3.3.h] sufficient time is necessary to properly consider all the variables that might impact on the outcome of the trial

80.4

19.6

0.0

92.7

7.3

0.0

[3.3.3.i] if trialling more than one system, uniform trial conditions are required to enable equal comparisons

65.5 d

34.5

0.0

73.2

26.8

0.0

[3.3.3.j] funding to hire or rent devices, fund staff for trials and purchase a device if appropriate

66.7 d

24.1

9.3

75.7

16.2

8.1

[3.3.3.k] keeping up to date with the latest information on eye-gaze research and technology developments

75.0

23.2

1.8

78.0

19.5

2.4

 The procedures in place

ongoing monitoring to record progress and outcomes

77.2

19.3

3.5

68.3

31.7

0.0

 

[3.3.4.a] building on user’s abilities, skills, development and progress

82.5

17.5

0.0

87.8

12.2

0.0

 

[3.3.4.b] a plan for the device trial, with clearly outlined roles and responsibilities

80.4

19.6

0.0

82.9

17.1

0.0

Question 4a: When selecting activities and resources that are useful for the person and their support network to learn to use the eye-gaze control technology effectively, the following should be considered.

 Games and activities

commercially available in skill building software and which drives practise and monitors progress

58.5

35.8

5.7

   

a range of engaging activities controlling their surroundings such as music and TV

53.7

38.9

7.4

   

low-tech form (e.g., E-Tran frame)

50.0

37.0

13.0

   

 Educational activities to achieve

literacy

52.8 d

35.8

11.3

50

37.5

12.5

vocabulary

71.7

24.5

3.8

65.0

30.0

5.0

general learning activities

60.4

35.8

3.8

   

Resources

online resources, for example, training videos, blogs and e-learning

53.7

38.9

7.4

   

[4.3.1.a] guidelines for the assessment of eye pointing

68.5 d

25.9

5.6

74.4

23.1

2.6

Question 4b: Information to consider when learning how to use the eye-gaze control technology - Practising using the technology to learn to use it effectively

 The person’s practise should take place

[4.3.2.a] in regular, frequent sessions, please specify:

82.0

16.0

2.0

92.7

7.3

0.0

daily

64.2

34.0

1.9

   

[4.3.2.b] in short sessions, to reduce the effects of fatigue, please specify:

72.5

23.5

3.9

85.4

14.6

0.0

in addition, the person’s support network (communication partners)

[4.3.3.a] should receive regular training and support

79.2

18.9

1.9

92.7

7.3

0.0

Question 4c: When recommending practise and support when learning how to use the eye-gaze control technology, the following should be considered

 The person should

[4.3.4.a] start by focusing on skills (e.g., cause and effect, targeting, dwell) through activities or games

57.7 d

38.5

3.8

82.9

14.6

2.4

be provided training in technical aspects of the device

36.0

44.0

20.0

   

[4.3.4.b] be supported by professionals who will guide direction and identify areas to work on

88.5

11.5

0.0

95.1

4.9

0.0

[4.3.4.c] receive face-to-face support in the their usual settings

80.4

17.6

2.0

85.4

14.6

0.0

[4.3.4.d] be provided with clear modelling/demonstration and direction

88.2

11.8

0.0

97.5

2.5

0.0

[4.3.4.e] have an individualised practise plan

71.2

25.0

3.8

80.5

19.5

0.0

[4.3.4.f] have practise embedded in their current routines

84.6

15.4

0.0

95.1

4.9

0.0

 The support network to should receive

[4.3.5.a] training in technical aspects of the device

76.9

21.2

1.9

85.4

12.2

2.4

[4.3.5.b] timely technical support in person / by phone / online

88.5

11.5

0.0

92.7

7.3

0.0

[4.3.5.c] support from multiple professionals (Speech Language Therapist/Speech pathologist, Occupational Therapist, Physiotherapist/ Physical Therapist, Psychologist, Assistive Technology consultant, Education Professional)

80.8

19.2

0.0

87.8

12.2

0.0

face-to-face support in their usual settings

63.5

32.7

3.8

   

Question 5: When and how often should use of eye-gaze control technology be reviewed?

 During the initial stages - while learning to use the system, review should take place

daily

18.4

32.7

49.0

   

weekly

57.1

32.7

10.2

   

monthly

68.1

23.4

8.5

   

every 3 months/once a school semester (term)

50.0

25.0

25.0

   

6-monthly

43.8

29.2

27.1

   

annually

53.2

21.3

25.5

   

[5.3.1.a] as required or requested

83.7

10.2

6.1

90.2

9.8

0.0

 During the intermediate stages - while mastering the system, review should take place

daily

12.5

29.2

58.3

   

weekly

24.0

38.0

38.0

   

monthly

43.8

31.3

25.0

   

every 3 months/once a school semester (term)

61.7

19.1

19.1

   

6-monthly

52.2

19.6

28.3

   

annually

53.2

19.1

27.7

   

[5.3.2.a] as required or requested

85.7

6.1

8.2

90.2

9.8

0.0

 During the latter stages - once use of the system is mastered, review should take place

daily

4.3

10.6

85.1

   

weekly

6.4

10.6

83.0

   

monthly

20.8

22.9

56.3

   

every 3 months/once a school semester (term)

28.6

32.7

38.8

   

6-monthly

56.3 d

25.0

18.8

56.1

34.1

9.8

annually

68.8 d

22.9

8.3

64.1

28.2

7.7

[5.3.3.a] as required or requested

91.8

4.1

4.1

87.8

9.8

2.4

Question 6: Recommendations for measuring the outcomes of eye-gaze control technology

 Goal attainment

[6.3.1.a] reports from the person and their support network

91.8

6.1

2.0

87.8

12.2

0.0

[6.3.1.b] observation by professionals

83.7

14.3

2.0

87.8

9.8

2.4

Canadian Occupational Performance Measure (COPM)

34.5

34.5

31.0

   

Goal Attainment Scaling (GAS)

56.8 d

29.7

13.5

58.3

41.7

0.0

 Satisfaction

[6.3.2.a] reports from the person and their support network

91.8

8.2

0.0

97.6

2.4

0.0

[6.3.2.b] observation by professional

75.5

20.4

4.1

78.0

19.5

2.4

Quebec User Evaluation of Satisfaction with assistive Technology (QUEST)

26.1

47.8

26.1

   

 Functional independence, well-being and quality of life

[6.3.3.a] reports from the person and their support network

85.7

14.3

0.0

97.6

2.4

0.0

[6.3.3.b] observation by professional

75.5

22.4

2.0

87.8

12.2

0.0

the Family Impact of Assistive Technology Scale for Augmentative and Alternative Communication (FIAT-AAC)

37.5 d

33.3

29.2

59.3

40.7

0.0

the Therapy Outcome Measure – AAC (TOM-AAC)

41.4

37.9

20.7

59.3

40.7

0.0

 Communication

[6.3.4.a] reports from the person and their support network

93.9

6.1

0.0

95.1

4.9

0.0

[6.3.4.b] observation by professional

85.7

14.3

0.0

87.8

12.2

0.0

C.O.D.E.S Framework

34.8

43.5

21.7

   

Communication Matrix

35.7

42.9

21.4

   

Dynamic AAC Goals Grid-2 (DAGG-2)

33.3

45.8

20.8

   

standardised and norm-based language and communication assessments carried out by a speech and language therapist to monitor progress over time

39.0

43.9

17.1

   

the Pragmatics Profile for People who use AAC

22.6

54.8

22.6

   

the AAC Profile™ – A Continuum of Learning

32.1

50.0

17.9

   

 Eye-gaze skills

[6.3.5.a] reports from the person and their support network

81.6

18.4

0.0

95.1

4.9

0.0

[6.3.5.b] observation by professional

83.7

16.3

0.0

95.1

4.9

0.0

measures of speed

27.7

61.7

10.6

   

recordings of concentration times

23.4

59.6

23.4

   

Inclusive EyeGaze Learning Curves

12.5

43.8

43.8

   

in-house produced check-list of operational skills

30.0

52.5

17.5

   

pre and post games to evaluate progress

33.3

44.4

22.2

   

Tobii Dynavox Eye Gaze Pathways

18.8

37.5

43.8

   

 Determining classifications

Communication Function Classification Scale

43.8

37.5

18.8

   

Functional Communication Classification System

37.0

40.7

22.2

   

Eye Pointing Classification Scale

41.4

41.4

17.2

   

Question 7: Funding an eye-gaze control technology system - the following criteria could be considered to inform a supplier, purchaser or funding body of the need for eye-gaze control technology

 The procedures in place

[7.3.1.a] recommendations from professionals based on evidence collected during a trial of devices

89.4

10.6

0.0

92.7

4.9

2.4

[7.3.1.b] the application meets the criteria of the supplier, purchaser or funding body

82.2

15.6

2.2

87.2

12.8

0.0

the preferred device offers value for money when compared with other options

60.9

28.3

10.9

   

trials of devices were carried out over a reasonable period of time (e.g., 1 to 3 months)

61.7

27.7

10.6

   

 Outcomes for the person

[7.3.2.a] enables them to engage in play, leisure and recreation activities

83.0

17.0

0.0

82.9

17.1

0.0

[7.3.2.b] enables them to participate in learning, study and education

85.1

14.9

0.0

92.7

7.3

0.0

[7.3.2.c] enables them to participate in employment and volunteer roles

78.3

19.6

2.2

82.9

14.6

2.4

[7.3.2.d] enables access to a computer and other technology

73.3

24.4

2.2

78.0

22.0

0.0

[7.3.2.e] enables them to control their environment

71.7

23.9

4.3

78.0

22.0

0.0

enables them to move around in the environment

47.8

43.5

8.7

   

[7.3.2.f] increases their ability to communicate

93.6

6.4

0.0

97.6

2.4

0.0

[7.3.2.g] enhances their quality of life and well-being

93.6

6.4

0.0

95.1

4.9

0.0

[7.3.2.h] facilitates their social interaction

93.6

6.4

0.0

97.6

2.4

0.0

is the only form of access method is suitable

40.0

33.3

26.7

   

enhances their posture

23.3

53.5

23.3

   

enhances their personal comfort

40.5

42.9

16.7

   

was trialled, and can be used, in a variety of settings

65.2

32.6

2.2

   

demonstrates that they are motivated to use the device

67.4

23.9

8.7

   

[7.3.2.i] demonstrates that they are satisfied with the device

69.6

19.6

10.9

73.2

24.4

2.4

[7.3.2.j] demonstrates that their goals were achieved

69.6

21.7

8.7

73.2

24.4

2.4

[7.3.2.k] demonstrates necessary skills and abilities to operate eye-gaze control technology, for example, eye-pointing, dwell on a target on screen, language and cognition

71.1

20.0

8.9

70.7

26.8

2.4

demonstrated that they will benefit from eye-gaze control technology for a significant period of time

59.6

25.5

14.9

   

 The person’s support network capacity

[7.3.3.a] availability of professional staff to provide support

83.0

12.8

4.3

90.2

9.8

0.0

[7.3.3.b] availability to provide support at home, school and other settings

76.6

19.1

4.3

90.2

9.8

0.0

Question 8: Preparing for eye-gaze control technology when it is not currently the right choice

 For the person

[8.3.1.a] ensure optimal seating, positioning and head support

91.7

8.3

0.0

92.5

7.5

0.0

arrange for an eye control assessment

59.6

36.2

4.3

   

arrange for a vision assessment

64.6

25.0

10.4

   

arrange for a cognitive or developmental abilities assessment

40.4

42.6

17.0

   

support skill development such as visual attention, eye pointing, gaze shifting and gaze tracking

65.2

32.6

2.2

   

support the person’s understanding of cause and effect

62.5

35.4

2.1

   

[8.3.1.b] build the person’s confidence in communicating

79.2

20.8

0.0

87.5

12.5

0.0

[8.3.1.c] encourage the person to use their eyes for making choices

81.3

18.8

0.0

82.5

17.5

0.0

 The person’s support network capacity

[8.3.1.d] provide practise using low tech options, accessed by eye gaze, to develop communication and language

77.1

18.8

4.2

77.5

20.0

2.5

provide practise with lower cost/free software and hardware

36.2

42.6

21.3

   

provide practise with commercially available software to train and develop eye-gaze skills

39.6

43.8

16.7

   

encourage the person in turn-taking

45.7

47.8

6.5

   

[8.3.1.e] establish clear goals

75.0

25.0

0.0

77.5

22.5

0.0

[8.3.2.a] ensure that all stakeholders keep working together

85.4

14.6

0.0

92.5

7.5

0.0

support engagement with other users and support networks

55.3

40.4

4.3

   

[8.3.2.b] support communication partners to assist people in building the skills to use eye-gaze control technology

87.2

12.8

0.0

92.3

7.7

0.0

[8.3.2.c] maintain knowledge of research and development in eye-gaze control technology

70.2

25.5

4.3

70.0

30.0

0.0

  1. a All 200 original items identified in Round 1
  2. b Items were retained after Rounds 2 and 3 if they were rated 7–9 (critical to include) by ≥70% of respondents and 1–3 (not critical to include) by < 15% of respondents. Shaded cells in Round 3 columns mean the item did not progress to round 3
  3. c Items in boldface text are the 94 numbered consensus statements remaining after Round 3 and which will form the basis for clinical guidelines
  4. d Items that consumers identified as priorities and which were not identified by the whole sample