Trust and Evidence in an Online Community of Speech and Language Therapists: The Case of iPad Use

Abstract

Mobile touch-screen devices are increasingly being used as part of the daily practices of health practitioners [1,12]. This is particularly so for Speech and Language Therapists (SLTs). There is a wide variety of apps available for use as therapy tools, although there is a scarcity of research examining their efficacy. As a result there has been a growth of online content, namely blogs, where SLTs share their knowledge and experience of using apps as therapy tools, compiling their own resources. We analysed the content of these blogs using a grounded theory approach to gain insights into SLTs' appropriation of both apps and blogs. Our findings indicate tensions surrounding the use of these technologies—tensions that are pervasive across other health care professions and contexts—and develop recommendations to ameliorate these tensions in the design of future apps.

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Trust and Evidence in an Online Community of Speech
and Language Therapists: The Case of iPad Use
Selina Sutton1, John Vines1, Roisin McNaney1, Mary Webster2, and Patrick Olivier1
Culture Lab, 1School of Computing Science / 2Institute of Health and Society
Newcastle University, UK
selinajsutton@gmail.com; {john.vines; r.mcnaney; m.webster; patrick.olivier}@ncl.ac.uk
ABSTRACT
Mobile touch-screen devices are increasingly being used as part of
the daily practices of health practitioners [1,12]. This is
particularly so for Speech and Language Therapists (SLTs). There
is a wide variety of apps available for use as therapy tools,
although there is a scarcity of research examining their efficacy.
As a result there has been a growth of online content, namely
blogs, where SLTs share their knowledge and experience of using
apps as therapy tools, compiling their own resources. We analysed
the content of these blogs using a grounded theory approach to
gain insights into SLTs’ appropriation of both apps and blogs. Our
findings indicate tensions surrounding the use of these
technologies—tensions that are pervasive across other health care
professions and contexts—and develop recommendations to
ameliorate these tensions in the design of future apps.
Categories and Subject Descriptors
H5.m. Information interfaces and presentation (e.g., HCI):
Miscellaneous.
Keywords
Speech and Language Therapy; online knowledge building
communities; grounded theory; apps.
1. INTRODUCTION
SLTs work with clients of all ages who have communication,
eating and drinking difficulties [9]. A range of tools are used to
enhance and facilitate therapy tasks. Traditionally these are paper-
based resources, toys and household objects but they are now
frequently supplemented by digital tools, so much so the topic has
warranted national attention [4,5]. There is little to no literature
reporting how and why SLTs are using these technologies,
however, which can be problematic given the evidence-based
practice that SLTs and most health professions adhere to [7]. In
response to the lack of evidence-based literature on the use of
iPads and apps many therapists have started publically discussing
their use of these devices and the impact they may have upon the
profession’s practices with each other via blogs and social media
(e.g. [3,8,10]). We collected this information as data to help us
develop an understanding of the barriers and opportunities these
technologies present to the SLT profession.
2. DATA COLLECTION
On the 31st December 2012 we performed a systematic search for
blogs written by authors who explicitly identified themselves as
SLTs where apps and iPads were discussed. 92 relevant blogs and
1140 unique posts and comments were identified. Individual posts
and comments were treated as units of data on which a
Summative Content Analysis [6] was performed. Each piece of
data was categorized against a single code, the quantity of each
code counted, and then the distribution of the categorized data
analyzed for patterns or trends for interpretation. Nine codes were
identified, counted and ranked by frequency (Figure 1). As
detailed in Figure 1, ‘Review’ (where SLTs posted written
reviews of App use) was by far the most common category of
content. This illustrated the great importance placed on the
instigation of sharing information and knowledge about these
technologies among this online community of SLTs.
3. GROUNDED THEORY ANALYSIS
In order to examine in more detail the content of the information
and knowledge shared by this online community, we used data
categorized as Review as the basis for a Grounded Theory (GT)
analysis. GT is a method for the systematic analysis of qualitative
data [2]. Open codes are developed by summarising each line of
data. To ensure rigor in our coding system, four independent
coders each coded a random cross-section of the data (10%) as per
the GT approach resulting in 75 unique codes. Discussion among
coders led to these being compressed to 50 codes. Axial codes
[11] that act as themes were then formed by grouping these codes
together. Finally, ‘theory’ is formed—a description of the data
illustrated with excerpts [2]. The GT analysis lead to the
development of four overriding themes, discussed in the below.
Supporting and Changing Practices: There were two opposing
views on what role apps could play. First, there was an
expectation that in the future apps will ‘revolutionise’ practice and
how therapy is provided, fundamentally changing the profession.
This, however, was often strongly argued against as current apps
‘rewards student [for] selecting the right answer’ and not for
communicating. Bloggers supported this argument by highlighting
the importance of there being a facilitator to use the app with a
client: ‘we don't just hand them over and say "here learn this" -
we demonstrate, teach, coach, model & correct as we work
together on an app’. To this end, most bloggers described apps as
‘tools’ in the ‘therapy tool belt’—that they are just one of the
many possible options a SLT has to choose from. This more
common view is also evidenced in the SLTs preference for apps
that are remediations of traditional tools. As the therapeutic effect
of apps have not been researched to date, SLTs are reliant upon
apps that are based upon the traditional tools that have already
been proven to be effective: ‘It has been developed from a system
already in use within SLT clinics […] so we know it works’.
Knowledge: Knowledge building was actively encouraged,
described as a collaborative activity and, therefore, everyone’s
responsibility. Concerns were raised, however, that clients and
families would access the blogs. SLTs were worried that this
might lead to: ‘the easiest solution [...] being chosen in the
absence of qualified advice’ and thus ‘patients could be [...]
choosing their own therapy’. Conducting inappropriate therapy
could be detrimental and so bloggers were aware that the content
posted should be framed carefully so that if it was to be used by
non-SLTs that they do not get a sense that they themselves can
‘become the therapist’. In addition, the information in the blogs is
anecdotal and restricted to be statements of general observations,
often to protect the identities of the patients.
Commoditisation: There is a distinct undertone of financial and
commercial benefit within the data. This is unsurprising as apps

are mass-market consumer products and the private healthcare
context of many of the SLTs mean their blogs are used as a
method of promotion. This causes concern if we consider that the
content of these blogs are informing clinical decision-making:
‘The app world is very Vendor driven – those with the deepest
pockets are getting the most coverage through peer review sites’.
This refers to bloggers reviewing apps if they are provided with a
free example, indicating the app makers who have more resources
available dominate the discussions. It could be argued that app
makers are guiding practice rather than knowledge and evidence.
Integrity: Finally, it is evident that SLTs assess each other’s
conduct. The integrity of the blog and the neutrality of its content
and reviews is highly prioritised by the SLTs if they are to base
decisions upon the information therein. Some blogs consistently
include a ‘Disclosure Statement’ in their reviews to demonstrate
lack of bias. As noted, bloggers often review an app if they are
provided with a free copy which, even if a disclosure is made,
implies the app maker has influence on the blogger’s review.
Interactions perceived to be non-transparent or unprofessional
were highlighted to others even when they occurred outside of the
immediate realm of the online community. For example, an SLT
(who was also an app developer) left a review on the app Store for
their own product. Another blogger recorded this in an entry titled
‘beware of customer reviews’.
4. DISCUSSION
Our findings reveal two overarching concerns that impede the use
of apps and preventing their use being taken further.
4.1 Trust in Technology
While there is overall enthusiasm within the SLT community for
apps to support current practices, content within and across the
blogs suggest there are significant barriers to the technology
transforming practice. It was evident that i) apps are not trusted to
have therapeutic value unless there is an individual facilitating the
patient’s interaction with the device; and ii) the degree of trust in
apps is tightly related to the trust placed in the traditional tools
they are based upon. This illustrates that despite the initial
positives, without evidence of the technology’s worth to SLT
beyond its ability to mimic existing tools, it is difficult to envision
how apps and mobile touch-screen technologies may offer novel
and trustworthy opportunities to improve SLT practice. This
highlights an opportunity to put appropriate supports in place to
minimize the barriers to SLTs collecting and sharing accounts of
app use that contain empirical data and detailed records of clients’
progress through therapy as evidence.
4.2 Trust in Online Knowledge-Building
It is strongly indicated that SLTs’ motivations for collecting
information and knowledge via the blogs is an attempt to evidence
the efficacy of apps in therapy. The trustworthiness of the blogs’
content is restricted by a lack of trust between members of the
online community. This was revealed when ill-conduct is
suspected by members and highlighted to others, resulting in
debate and discussion. The need to appear trustworthy as one
participates in online discussions is important because the
credibility of a blogger’s conduct directly impacts upon the
apparent trustworthiness of the knowledge they share. SLTs who
are attempting to use the knowledge contained in the blog posts
within their practice must assess its neutrality and validity.
Two factors further compound this issue. First, the claims made
on the blogs are not supported by empirical evidence. They are
subjective observations and so a great deal of faith in the
trustworthiness of the information’s source is required from the
reader should this information be used to inform a clinical
decision. Second, much of the information on the blogs is likely to
have been influenced by elements of commoditization, most
notably in that most bloggers receive free products from app
developers in return for reviews. The readers of reviews must
make judgments based upon what the blogger discloses about
their relationship with app developers and publishers, and trust
that this has not influenced the bloggers opinions.
5. DESIGN IMPLICATIONS
We highlight three opportunities to support SLTs in how they
appropriate digital technologies against a lack of evidence-base,
and knowledge is exchanged and shared with peers online.
Supporting independent use: The data highlighted how many
SLTs believed iPads must be used with therapists facilitation. One
of the reasons for this is that SLTs are specialists in providing
explicit feedback to guide clients in their acquisition of
knowledge and skills [7]. Current apps do not provide analogous,
or even any, feedback to clients. In the future it may be feasible
that apps could ‘evolve’ based upon their use. In theory, as the
client uses the app and demonstrates abilities and difficulties the
software could identify, record and analyze this data and then
respond by producing activities and feedback that reflect their
needs. Such a system would need to be regularly monitored by an
SLT to examine progress. Through gradual modification however
an individually tailored package of therapy could be created.
Automatic evidence collection: Apps allowing for independent
use could also be utilized to support SLTs in generating evidence-
bases about apps. Data that has been collected and automatically
analyzed by an app would provide a detailed data set about the
client that is using it and their journey through therapy. Examples
of this data would be the child’s percentage of correct responses
to directions or questions posed by the app during each session of
use. If such data across multiple clients could be collated this
would form the start of an evidence-base detailing the apps
effectiveness on which therapists could base decisions.
Communities of evidence collection: Taking automatic evidence
collection further, multiple therapists could be cooperatively
conducting a research study of the effectiveness of each app in
their everyday practice. A community of therapists cooperatively
assessing an app through SLT practice in the wild could possibly
provide an alternative method with which to conduct research in
SLT. This data could be collated by uploading it to an online
platform—a private online space where SLTs could collect and
analyse empirically evidenced accounts of app use in therapy.
This would support the community’s evolution into a community
of evidence collection and overcome some of the barriers that
blogs pose. Clearly, this system would have to adhere to all
ethical and anonymity guidance as well as be sufficiently secure.
It’s important to note that our suggestions do not call for an end to
traditional, rigorous research methods—rather, we highlight that
in the context of using digital technologies in practice SLTs need
to respond quickly to document their use. This documentation
needs to be sufficient for other SLTs to feel confident in basing
their decisions in practice upon it. As such, our design
implications are likely to be relevant to many health professions
and contexts as digital technologies become more integrated into
their daily practices [1,12,13].
6. ACKNOWLEDGMENTS
This research was funded the SiDE hub at Newcastle University, a
programme grant from the EPSRC.

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8. FIGURES
Figure 1. Summative Content Analysis – categorized blog
entries.