Automated Vehicles: Future Initiatives for Occupational Therapy Practitioners and Driver Rehabilitation Specialists.

This article addresses a critically important topic for the occupational therapy (OT) profession and driver rehabilitation specialists (DRS), related to the introduction and deployment of personal and public automated vehicles (AVs); and discusses the current and corresponding changing roles for these professionals. Within this commentary, we provide an overview of the relevant literature on AV regulations, policy, and legislation in North America, the various levels of AV technology, and inclusive and universal design principles to consider in AV deployment for people with disabilities. The role of the OT practitioner and DRS is described within the context of the person-environment-occupation-performance model, and within the guidelines of the Association for Driver Rehabilitation Specialists and the American Occupational Therapy Association. The article concludes with considerations for an extended clinical agenda, a new research agenda, and a call for action to OT practitioners and DRS, as well as to educators, certification bodies, professional organizations, and collaborators.

Automated Vehicles: Future Initiatives for Occupational Therapy Practitioners and Driver Rehabilitation SpecialistsThis article discusses a critical practice and scientific area for occupational therapy (OT) practitioners and driver rehabilitation specialists (DRS), namely the deployment of automated vehicles (AVs) in North America and its effect on the OT profession. The article situates driving, including driving AVs, within the context of a credible OT model, discusses the current and changing roles of the OT practitioner and DRS, stipulates the rules and regulations for AVs in North America, expounds on the different levels of AV technology and potential implications, requirements for accessible AVs for people with disabilities, and highlights guidelines from professional organizations pertaining driving as a practice area. The article concludes by suggesting new directions for clinical practice and research, and it calls on OT practitioners, DRS, educators, certification organizations, and collaborators to take action.

An Examination of Two Diverse Communities: Residents' Transportation Behaviors, Challenges, and Opportunities.

The Smart Cities Collaborative aims to mitigate transportation challenges and inequities with new approaches and technologies (e.g., ridesharing). Therefore, assessing community transportation needs is essential. The team explored the travel behaviors, challenges, and/or opportunities among low- and high-socioeconomic status (SES) communities. Using Community-Based Participatory Research principles, four focus groups were conducted to investigate residents' behaviors and experiences with transportation availability, accessibility, affordability, acceptability, and adaptability. Focus groups were recorded, transcribed, and verified before thematic and content data analysis. Participants with low SES (n = 11) discussed user-friendliness, uncleanliness, and bus accessibility challenges. Comparatively, the participants with high SES (n = 12) discussed traffic congestion and parking. Both communities had concerns about safety and limited bus services and routes. Alternatively, opportunities included a convenient fixed-route shuttle. All groups stated the bus fare was affordable unless multiple fares or rideshare were needed. Findings provide valuable insight when developing equitable transportation recommendations.

Does in-vehicle automation help individuals with Parkinson's disease? A preliminary analysis.

Introduction: PD is a progressive neurodegenerative disorder that affects, according to the ICF, body systems (cognitive, visual, and motor), and functions (e.g., decreased executive functions, decreased visual acuity, impaired contrast sensitivity, decreased coordination)-all which impact driving performance, an instrumental activity of daily living in the domain of "Activity" and "Participation" according to the ICF. Although there is strong evidence of impaired driving performance in PD, few studies have explored the real-world benefits of in-vehicle automation technologies, such as in-vehicle information systems (IVIS) and advanced driver assistance systems (ADAS), for drivers with PD. These technologies hold potential to alleviate driving impairments, reduce errors, and improve overall performance, allowing individuals with PD to maintain their mobility and independence more safely and for longer periods. This preliminary study aimed to fill the gap in the literature by examining the impact of IVIS and ADAS on driving safety, as indicated by the number of driving errors made by people with PD in an on-road study. Methods: Forty-five adults with diagnosed PD drove a 2019 Toyota Camry equipped with IVIS and ADAS features (Toyota Safety Sense 2.0) on a route containing highway and suburban roads. Participants drove half of the route with the IVIS and ADAS systems activated and the other half with the systems deactivated. Results: The results suggest that systems that assume control of the driving task, such as adaptive cruise control, were most effective in reducing driving errors. Furthermore, individual differences in cognitive abilities, particularly memory, were significantly correlated with the total number of driving errors when the systems were deactivated, but no significant correlations were present when the systems were activated. Physical capability factors, such as rigidity and bradykinesia, were not significantly correlated with driving error. Discussion: Taken together, these results show that in-vehicle driver automation systems can benefit drivers with PD and diminish the impact of individual differences in driver cognitive ability.

Simulated Driving Errors: Indicators of Real-World Driving Events in Returning Combat Veterans.

Motor vehicle crashes is a leading cause of death for Veterans. We quantified the efficacy of an Occupational Therapy Driving Intervention (OT-DI) and a Traffic Safety Education (TSE) intervention on real-world driving in combat Veterans. Via a randomized trial, we assessed 42 Veterans' fitness-to-drive abilities using a CDS-250 driving simulator and driving records, to determine differences in simulated driving and real-world events pre- and post-interventions. The OT-DI group (vs. TSE) had fewer over-speeding errors (p < .001) and total number of driving errors (p = .002) post-intervention. At Post-Test 2, the OT-DI (vs. TSE) had a reduction in real-world speeding (p = .05). While statistically not significant, both interventions showed reductions in real-world speeding, number of violations (OT-DI: 23% and TSE: 46% decrease) and crashes (OT-DI: 25% and TSE: 50% decrease). Veterans showed early evidence of efficacy in improving their real-world fitness-to-drive abilities via an OT-DI and TSE intervention.

RCT protocol for driving performance in people with Parkinson's using autonomous in-vehicle technologies.

Introduction: Driving is an essential facilitator of independence, community participation, and quality of life. Drivers with Parkinson's Disease (PD) make more driving errors and fail on-road evaluations more than healthy controls. In-vehicle technologies may mitigate PD-related driving impairments and associated driving errors. Establishing a rigorous study protocol will increase the internal validity and the transparency of the scientific work. Methods: We present a protocol to assess the efficacy of autonomous in-vehicle technologies (Level 1) on the driving performance of drivers with PD via a randomized crossover design with random allocation. Drivers with a PD diagnosis based on established clinical criteria (N = 105), referred by neurologists, are exposed to two driving conditions (technology activated or not) on a standardized road course as they drove a 2019 Toyota Camry. The researchers collected demographic, clinical, on-road data observational and kinematic, and video data to understand several primary outcome variables, i.e., number of speeding, lane maintenance, signaling, and total driving errors. Discussion: The protocol may enhance participant adherence, decrease attrition, provide early and accurate identification of eligible participants, ensure data integrity, and improve the study flow. One limitation is that the protocol may change due to unforeseen circumstances and assumptions upon implementation. A strength is that the protocol ensures the study team executes the planned research in a systematic and consistent way.Following, adapting, and refining the protocol will enhance the scientific investigation to quantify the nuances of driving among those with PD in the era of automated in-vehicle technologies. Trial registration: ClinicalTrials.gov NCT04660500.

Rater-Reliability of Assessing Driving Errors with a DriveSafety 250 Simulator.

This study aimed to establish inter-rater reliability among three raters while training new driver rehabilitation specialists to correctly identify driving errors on a DriveSafety 250 driving simulator. Five participants completed adaptation, residential and suburban, and city and highway scenarios. Intraclass correlation coefficients indicated scores between .623-.877 (p = .003-.122) for the total driving errors recorded in the two scenario drives with rater agreement initially ranging between 7-8%. When analyzing the data for types of driving errors, the intraclass correlation coefficients ranged from .556-.973 (p < .05) and rater agreement between 15-100%. Through proper training and strategy development, raters reached 100% consensus on all aspects of inter-rater reliability while assessing driving errors.

Home modifications and repurposing: perspectives on the accessibility, affordability, and attractiveness.

PURPOSE: Society has progressed in universal design guidelines and assistive devices for individuals with disabilities yet challenges due to affordability and attractiveness concerns remain to incorporate them into existing residences. Repurposing (i.e., replacing or adapting problematic fixtures or spaces, with others not originally intended for that purpose) may be the action to address the concerns of consumers. The purpose of this study was to elicit information on problems and solutions regarding home modifications and identify ways that consumers and professionals implement repurposing, that residents deemed accessible, affordable, and attractive. METHODS: This convergent parallel design study consisted of focus groups who rated images of repurposed spaces. The focus groups included consumers with functional mobility and visual limitations (n = 8); and professionals who devised or recommended home modifications (n = 8). Participants reviewed three images of home modification solutions and completed a Likert-scale rating based on accessibility and attractiveness. RESULTS: Focus group data indicated that high contrast, heights of fixtures, doors, and flooring - all pose threats to accessibility in the home. Consumers placed more value on attractiveness than professionals. Participants were aware and receptive to repurposing as a home modification technique but focused their discussion on adaptations. CONCLUSION: Overall, adoption and implementation of home modifications promote accessibility, but professionals need to consider individualized needs and preferences, before suggesting modifications.IMPLICATIONS FOR REHABILITATIONRepurposing existing spaces, features, and fixtures can serve as a method of home modification.Consumer home modification recommendations are perceived to be more effective when collaboratively and individually developed with professionals.Data gathered through focus groups can be valuable for informing practice and research in home modifications.

Predicting Autonomous Shuttle Acceptance in Older Drivers Based on Technology Readiness/Use/Barriers, Life Space, Driving Habits, and Cognition.

Shared autonomous vehicle services (i. e., automated shuttles, AS) are being deployed globally and may improve older adults (>65 years old) mobility, independence, and participation in the community. However, AS must be user friendly and provide safety benefits if older drivers are to accept and adopt this technology. Current potential barriers to their acceptance of AS include a lack of trust in the systems and hesitation to adopt emerging technology. Technology readiness, perceived ease of use, perceived barriers, and intention to use the technology, are particularly important constructs to consider in older adults' acceptance and adoption practices of AS. Likewise, person factors, i.e., age, life space mobility, driving habits, and cognition predict driving safety among older drivers. However, we are not sure if and how these factors may also predict older adults' intention to use the AS. In the current study, we examined responses from 104 older drivers (M age = 74.3, SD age = 5.9) who completed the Automated Vehicle User Perception Survey (AVUPS) before and after riding in an on-road automated shuttle (EasyMile EZ10). The study participants also provided information through the Technology Readiness Index, Technology Acceptance Measure, Life Space Questionnaire, Driving Habits Questionnaire, Trail-making Test Part A and Part B (TMT A and TMT B). Older drivers' age, cognitive scores (i.e., TMT B), driving habits (i.e., crashes and/or citations, exposure, and difficulty of driving) and life space (i.e., how far older adults venture from their primary dwelling) were entered into four models to predict their acceptance of AVs-operationalized according to the subscales (i.e., intention to use, perceived barriers, and well-being) and the total acceptance score of the AVUPS. Next, a partial least squares structural equation model (PLS-SEM) elucidated the relationships between, technology readiness, perceived ease of use, barriers to AV acceptance, life space, crashes and/or citations, driving exposure, driving difficulty, cognition, and intention to use AS. The regression models indicated that neither age nor cognition (TMT B) significantly predicted older drivers' perceptions of AVs; but their self-reported driving difficulty (p = 0.019) predicted their intention to use AVs: R 2 = 6.18%, F (2,101) = 4.554, p = 0.040. Therefore, intention to use was the dependent variable in the subsequent PLS-SEM. Findings from the PLS-SEM (R 2 = 0.467) indicated the only statistically significant predictors of intention to use were technology readiness (ß = 0.247, CI = 0.087-0.411) and barriers to AV acceptance (ß = -0.504, CI = 0.285-0.692). These novel findings provide evidence suggesting that technology readiness and barriers must be better understood if older drivers are to accept and adopt AS.

A Social-Ecological Approach to Identify Facilitators and Barriers of Home Modifications.

Aging individuals may face difficulty with independently navigating and interacting with their home environment. Evidence-based interventions promoting home modifications are needed to support aging-in-place across the lifespan. This study identified the facilitators and barriers to implementing home modifications from the perspectives of residents and professionals (N = 16). Guided by a social-ecological model, researchers utilized directed content analysis of focus group interviews. While participants discussed facilitators and barriers mainly on the individual level, factors were presented at the relationship, community, and societal level of the model. Overall, the findings suggest a potential for targeted interventions on all levels of the model to promote adoption of home modifications.

Fidelity of a Traffic Safety Education Intervention for Combat Veterans.

Equipoise, feasibility, and fidelity were studied for the control condition of an occupational therapy driving intervention in a randomized controlled trial. We ranked equipoise and feasibility of six traffic safety education methods and created an implementation fidelity competency checklist. Education method selection was informed using the proportion of concordant ranks analysis while literature and a peer review informed competency checklist development. A proctored-online course delivery had the highest rater agreement (equipoise = .96 [.87-1.00]; feasibility = .99 [.97-1.00]). Implementation fidelity was supported by a 19-component training and evaluation checklist. This study supports promoting the scientific rigor of the RCT via - equipoise, feasibility, and implementation fidelity.

Driving errors that predict simulated rear-end collisions in drivers with multiple sclerosis.

OBJECTIVE: Drivers with Multiple Sclerosis (MS) may have an increased crash risk. However, the driving performance deficits that contribute to crashes are not fully understood. Based on the extant literature, adjustment to stimuli errors indicate failing an on-road assessment. This study examines whether adjustment to stimuli errors can detect the occurrence of collisions in a driving simulator in drivers with MS. METHODS: As part of a quasi-experiment, 38 participants with MS and 21 participants without MS completed visual-cognitive and driving simulator assessments, which also recorded their adjustment to stimuli maneuvers. We quantified participants' adjustment to stimuli maneuvers via initial pedal reaction time (seconds), time to collision (seconds), mean speed (meters per second), and the occurrence of rear-end collisions (collide vs. did not collide) when a simulated vehicle cut across the lane in front of them. RESULTS: Logistic regression analyses indicated that, compared to drivers without MS, those with MS had a shorter time to collision (OR= .04, p= .001, 95% CI= [.006, .27]) and a faster mean speed (OR= 1.32, p= .04, 95% CI= [1.01, 1.74]) which increased the odds of experiencing a rear-end collision. Receiver operating characteristic curve analyses indicated that, for MS and control groups, time to collision (MS group = AUC= .94, p<.0001, Control group = AUC= .86, p<.0001) and mean speed (MS group = AUC= .76, p=.005, Control group = AUC = .78, p= .005) differentiated between participants who collided vs. did not collide. For drivers with MS, a time to collision of ≤1.81 seconds (85% sensitivity, 100% specificity, 15% error rate), and a mean speed of ≥7.83 meters per second (77% sensitivity, 76% specificity, 47% error rate) predicted the occurrence of collisions with the lowest error rate. CONCLUSIONS: During a driving simulator assessment, adjustment to stimuli errors predicted the occurrence of rear-end collisions in drivers with MS (vs. without MS). Driving assessors may target scenarios that measure participants' adjustment to stimuli, via time to collision and mean speed, to make decisions about their visual-cognitive deficits and driving performance.

Clinical predictors of driving simulator performance in drivers with multiple sclerosis.

BACKGROUND: Drivers with multiple sclerosis (MS) may experience visual-cognitive impairment that affects their fitness to drive. Due to limitations associated with the on-road assessment, an alternative assessment that measures driving performance is warranted. Whether clinical indicators of on-road outcomes can also predict driving performance outcomes on a driving simulator are not fully understood. OBJECTIVE: This study examined if deficits in immediate verbal/auditory recall (California Verbal Learning Test-Second Edition; CVLT2-IR) and/or slower divided attention (Useful Field of View™; UFOV2) predicted deficits in operational, tactical, or strategic maneuvers assessed on a driving simulator, in drivers with and without MS. METHODS: Participants completed the CVLT2-IR, UFOV2, and a driving simulator assessment of operational, tactical, and strategic maneuvers. RESULTS: Deficits in immediate verbal/auditory recall and slower divided attention predicted adjustment to stimuli errors, pertaining to tactical maneuvers only, in 36 drivers with MS (vs 20 drivers without MS; F(3, 51) = 6.1, p = 0.001, R2 = 0.3, Radj2=0.2). CONCLUSION: The CVLT2-IR and UFOV2 capture the visual and verbal/auditory recall, processing speed, and divided attention required to appropriately adjust to stimuli in a simulated driving environment. Clinicians may use the CVLT2-IR and UFOV2 as precursors to driving performance deficits in drivers with MS.

Construct Validity and Test-Retest Reliability of the Automated Vehicle User Perception Survey.

Fully automated vehicles (AVs) hold promise toward providing numerous societal benefits including reducing road fatalities. However, we are uncertain about how individuals' perceptions will influence their ability to accept and adopt AVs. The 28-item Automated Vehicle User Perception Survey (AVUPS) is a visual analog scale that was previously constructed, with established face and content validity, to assess individuals' perceptions of AVs. In this study, we examined construct validity, via exploratory factor analysis and subsequent Mokken scale analyses. Next, internal consistency was assessed via Cronbach's alpha (α) and 2-week test-retest reliability was assessed via Spearman's rho (ρ) and intraclass correlation coefficient (ICC). The Mokken scale analyses resulted in a refined 20-item AVUPS and three Mokken subscales assessing specific domains of adults' perceptions of AVs: (a) Intention to use; (b) perceived barriers; and (c) well-being. The Mokken scale analysis showed that all item-coefficients of homogeneity (H) exceeded 0.3, indicating that the items reflect a single latent variable. The AVUPS indicated a strong Mokken scale (H scale = 0.51) with excellent internal consistency (α = 0.95) and test-retest reliability (ρ = 0.76, ICC = 0.95). Similarly, the three Mokken subscales ranged from moderate to strong (range H scale = 0.47-0.66) and had excellent internal consistency (range α = 0.84-0.94) and test-retest reliability (range ICC = 0.84-0.93). The AVUPS and three Mokken subscales of AV acceptance were validated in a moderate sample size (N = 312) of adults living in the United States. Two-week test-retest reliability was established using a subset of Amazon Mechanical Turk participants (N = 84). The AVUPS, or any combination of the three subscales, can be used to validly and reliably assess adults' perceptions before and after being exposed to AVs. The AVUPS can be used to quantify adults' acceptance of fully AVs.

Driving Outside the Wire: Examining Factors Impacting Veterans' Postdeployment Driving.

Combat Veterans (CVs) deployed to Iraq or Afghanistan experience driving difficulty, based on medical conditions and/or deployment exposures, elevating their risk of motor vehicle crash-related injury or death. To address grounded theory rigor and incorporate constructs such as the Person Environment Occupation Performance model, we revised the Hannold et al. (2013) conceptual framework. We conducted two focus groups with seven CVs. Conceptual framework revisions were based on an iterative process and thematic analysis. We elicited CVs' perspectives on deployment training, driving pre- and postdeployment, strategies, and intervention preferences. Personal, environmental, and task factors underpinned CVs' driving. Participants described triggers (e.g., stressful stimuli), use of environmental (e.g., car controls) or personal (e.g., avoiding traffic) strategies, and outcomes of appropriate or risky driving. Findings illustrated CVs' driving difficulty and informed development of a Veteran-centric driving intervention. Improving driving fitness has implications for Veterans' participation and community integration.

Insufficient sleep and fitness to drive in shift workers: A systematic literature review.

BACKGROUND: Insufficient sleep, <6.5 h per night, majorly affects shift workers, placing them at higher risk for motor vehicle crash related injury or fatality. While systematic reviews (SLRs) examine the effects of insufficient sleep and driving, to date, no SLR focuses on driver fitness or performance in shift workers. OBJECTIVES: Determine the class of evidence (Class I-highest to Class IV-lowest), and level of confidence (Level A-high, to Level U-insufficient) in the determinants of driver fitness and performance in shift workers. Next, consider evidence-based recommendations for clinical practice, research, and policy. METHODS: A protocol was registered on PROSPERO (#CRD42018052905) using an established SLR methodology: a comprehensive electronic database search, study selection, data extraction, critical appraisal, analysis, and interpretation using published guidelines. RESULTS: Searches identified 1226 unique records with 11(2 on-road, 9 simulator) meeting final inclusion criteria. Class III to IV evidence identified that exposure to overnight shift work possibly predicts (Level C confidence) drivers at risk for adverse on-road outcomes and likely predicts (Level B) drivers at risk for adverse driving simulator outcomes. Higher ratings of subjective sleepiness and extended time driving possibly predict (Level C) drivers at risk for adverse driving simulator outcomes. CONCLUSIONS: This study demonstrates a low to moderate level of confidence in the determinants of driving in shift workers. A critical need exists for gold-standard on-road assessments integrating complex driving environments representative of real-world demands, targeting tactical and strategic outcomes in a broad spectrum of shift workers.

Clinical Utility of the DriveFocus™ Intervention on Young Drivers With and Without Experience.

Introduction: The DriveFocus™ intervention addresses the ability of young drivers to detect and respond to critical roadway information. DriveFocus is an interactive video-based tablet application that teaches users how to detect and prioritize critical roadway items. However, young drivers with and without experience may respond differently to the intervention. Objectives: We compared the simulated driving performance of two 17 year-old licensed drivers with (novice) and without (learner) driving experience, after three (post-test 1) and six (post-test 2) intervention sessions. Methods: We collected clinical, driving performance (number of visual scanning, adjustment to stimuli, and total driving errors) and acceptability data. Results: The learner driver made more visual scanning, adjustment to stimuli and total errors when compared to the novice. Both participants exhibited a decrease in both types and number of driving errors from baseline to post-test 2 and the learner also made less driving errors at post-test 1. Both participants rated the perceived ease of use of the intervention favorably. Conclusions: This study lays the foundation to examine the impact of the DriveFocus™ intervention among novice and more experienced young drivers.

An Integrative Review on Teen Distracted Driving for Model Program Development.

Distracted driving, especially driver inattention, is associated with high levels of crash-related fatalities and injury. Teen novice drivers are one of the groups most likely to drive distracted and to suffer its consequences. Teens have a higher risk of engaging in texting or secondary tasks, e.g., eating while driving. Distracted driving interventions to date aim to improve teen and societal safety, but few have achieved effectiveness. A need exists for effective evidence-based distracted driving interventions. We used an integrative review to identify rigorous evidence, and inform the development of a teen distracted driving educational intervention. This five-step review included: identifying the research problem; collecting literature; evaluating literature; synthesizing data; and presenting results. We searched 6 databases, identifying 185 articles. Following three rounds of inclusion screening (title, abstract, and full-text), captured according to a PRISMA flow chart, 17 studies met inclusion. We categorized these studies, conducted in the U.S., as five intervention types that used approaches including presentations, videos or instructional programs, education or training programs, driving simulator training, in-vehicle monitoring or feedback, and integrated programs. Study designs included randomized controlled trials pre-post, quasi-experimental, and experimental designs with prospective longitudinal cohorts. The studies were heterogeneous in design, intervention and outcome. However, three core themes emerged across studies: i.e., hazard awareness, hazard mitigation and attention maintenance are primary critically necessary skills to prevent distracted driving; engaging a parent or adult as a partner in the intervention process from classroom to car contributed to the effectiveness of the intervention; and leveraging technology in training enhanced the effectiveness of the intervention. Study limitations pertained to a focus on short-term effects; sampling distributions that did not account for gender, age, race, and/or ethnicity; types of interventions; and bias. The limitations affect the generalizability of included study findings and, potentially, the review findings, as they may not apply to populations or contexts outside those synopsized. Strengths included our team's expertise in conducting evidence-based reviews, support of a health science librarian, and use of international review guidelines. As an outcome, we are applying findings of the integrated review to develop a computer-based training addressing teen distracted driving.

Corrigendum: Construction and Validation of the 21 Item Fitness-to-Drive Screening Measure Short-Form.

[This corrects the article DOI: 10.3389/fpubh.2018.00339.].