In this section, we first use a thematic analysis of our interviews to characterize the different ways that care ecosystems collaborate and work. (We connect here with the theme of “Collaboration Approaches.”) Next, we focus on identifying how the different types of collaborations impacted care (connecting with the theme of “User Perspectives and Experiences”), uncovering exactly how some ecosystems managed to provide better care than others. (Here, we connect with the themes of “Identity” and “Collaboration Approaches.”) We finish by presenting concrete features that ecosystems have in place to provide quality care for recipients. (In this part, we connect with the themes of “Structural Support,” “Collaboration Approaches,” and “Maker Culture.”)
4.1 The Importance of Ecosystem Structure in Supporting Follow-up
Prior work has established the risks of abandonment with upper-limb prosthetics [
20], some suggesting the importance of “follow-up” care in the volunteering context (e.g., Reference [
101]). Our interviews highlighted the range of challenges that follow-up must address, such as fixing broken assistive devices, adjusting the device to better fit the recipient, or even providing recipients with physical therapy that helps them to better use their devices. Ecosystem processes strongly impacted abandonment. Some participants had lengthy and detailed processes for providing follow-up. In contrast, for others, it was completely missing from their ecosystem, and they did not seem to know how to implement these care activities. Participants M1, M2, M4, M5, M6, R4, R5, R6, R7, R8, R9, R10, R11, R13, R14, R15, R16, C1, C2, C4, C5, and C6 reported being in ecosystems where follow-up was provided to recipients, while M3, M7, M8, M9, C3, R1, R2, R3, and R12 reported being in ecosystems where follow-up was rare. In situations where follow-up was lacking, the recipient experience was negatively impacted. For example, R1, R2, and R12, all came from ecosystems with limited maker-clinician interactions and no follow-up. They all reported that the original 3D printed assistive device they had received from their ecosystem was unusable, likely because the lack of follow-up meant that their devices were never improved or better tailored to them. For example:
“…it's been a year since the first inception of receiving the hand [3D printed AT] and it's kind of been just sitting in her box not doing anything… [the device] doesn't feel good, doesn't work well…” R2, USA.
The lack of fit is a well-known reason for abandonment [
20]. Compare this to R8, a recipient who received follow-up from a clinician, who taught her best practices for using her AT:
“Once the device is ready [i.e., once makers have finished fabricating the 3D printed assistive device], they call us back. We pick it [the device] up and set up a schedule for therapies [with clinicians] so we can learn how to use the device….” R8, Mexico.
At the time of our study, R8 had been using her device for over two years. Similar results were found for recipients R4, R5, R6, R7, R8, R9, R10, R11, R13, R14, R15, and R16—all part of ecosystems, where clinicians worked closely with makers to provide follow-up that included therapeutic support. All reported using their devices for over two years at the time of the study.
4.1.1 Multi-Stakeholder Collaboration Fosters Follow-Up.
In ecosystems that provide follow-up, all had collaborations between clinicians, makers, and recipients, with clinicians often leading the effort. For example, M2 describes how his ecosystem involved clinicians from the start, and they were the key decision makers:
“…the first step is that we [his team of makers] ask [recipients] two things. First: do you have a doctor? If he has a doctor, we schedule a meeting with this doctor…and we ask this doctor, who knows about the case and the patient, to evaluate the devices and based on that to say what is the device we need to create for the kid [recipient]. So, we [the makers] do not choose, also the recipient does not choose. The doctor is the one who will tell us what needs to be printed…. If the kid doesn't have a doctor…we try to find a doctor near the city…and we approach this doctor…and ask him to help this person with his evaluation. So, the doctor is the first step…” M2, Brazil.
Having a setup where clinicians interact closely with makers likely helped cover makers’ knowledge gaps in medical topics, while helping to deliver better devices and interactions for recipients (including follow-up). In ecosystems where clinicians worked closely with makers and recipients, it was easier for all stakeholders to share their specialized knowledge to provide follow-up and ensure quality experiences for recipients. Participants M1, M2, M4, M5, M6, R4, R5, R6, R7, R8, R9, R10, R11, R13, R14, R15, R16, C1, C2, C4, C5, and C6 expressed that within their ecosystems, all three stakeholders had sustained interactions with each other, helping to provide follow-up and appropriate AT design for recipients. The following maker from e-NABLE, M5, shared how in his ecosystem, makers, clinicians, and recipients worked together to deliver quality care and follow-up:
“…the engineer [maker] is responsible for the design work and the modifications that need to be done on the printers and the design software. But the prosthetic technician [medical maker] gives him [the maker] ideas on how he can edit the designs […] we have another occupational therapist [clinician] who lives in New Delhi, who guides the doctor [clinician] on all the training [the ‘training’ here refers to the follow-up training that is given to the recipient to help the recipient learn how to use the 3D printed device], on like what kind of trainings he [the doctor] should be giving […] We also ask the beneficiaries [recipients] for ideas just like how we asked [recipient] what works better.” M5, India.
Another benefit we observed of maker/clinician collaborations was having follow-up that quantified how assistive devices were used by their recipients. For instance, M6, a maker who developed 3D printed AT within a private company, worked closely with a clinician who developed a follow-up protocol for measuring the way that recipients used their assistive devices. M6 explained how this follow-up protocol used evidence-based medicine practices to decide the best way to care for individual patients [
114]:
“…so, I am friends with [name changed], a hacker who is at the School of Medicine. One of his goals for the last years has been improving evidence capture. He's also developed one of the more recent novel upper extremity outcome [assessment] protocols. To me it's important to be using upper extremity outcome assessments for my designs….” M6, USA.
Such data can help define strategic design modifications and identify the ideal medical care for recipients.
4.1.2 Lack of Collaborations with Clinicians may Increase Risk.
Clinicians who came from ecosystems, where they had limited interactions with makers, shared concerns regarding makers’ medical knowledge gaps. C3 came from an ecosystem, where clinicians and makers rarely collaborated. As a retired hand therapist, she observed the following:
“The most glaring one [issue] that I saw was on the prosthetic [3D printed assistive device] that they handed out. It [the 3D printed AT] was very poorly fitted on the residual stump [limb of the recipient] and in order to correct this the [leader in the ecosystem] tried to remediate this by tightening the straps really really tight on the gauntlet [a part of the 3D printed assistive device]. But this would not be suitable because to [a clinician] it would be causing pain for the recipient and it could also lead to nerve compression if it was left on too long.” C3, USA.
Fit was a major concern for C3. She believed that the makers in her ecosystem did NOT fully account for the medical needs of recipients in their designs, nor in their interactions with recipients.
4.2 Maker Acculturement: Adoption and Spread
Our interviews exposed how several recipients and clinicians also self-identified as makers. These crossover participants had the advantage of directly addressing some of the challenges associated with providing/using the devices themselves.
4.2.1 From Clinician to Medical Maker.
In the ecosystems where clinicians actively collaborated with makers, the clinicians tended to take a more active role in the fabrication process, with some of these clinicians transitioning to the role of being “medical makers” (i.e., clinicians who are also makers [
74]):
“…we have a prosthetic technician. So, he [a medical maker] assesses the hands and he modifies the hands [3D printed AT]. He tells us what tools to use and when we have a challenging beneficiary [a recipient with a medical condition which requires a new or adapted AT design], he gives us ideas on how we can modify the design….” C2, India.
Such “medical makers” had the advantage of more easily providing follow-up, which could include customizing or fixing devices to better address the medical needs of the recipients. Another advantage was that these clinicians were able to more easily collaborate with makers, because they had access to a shared design language.
4.2.2 Recipient Makers: A Growth Mindset.
Similar to clinicians, the recipients of 3D printed AT can be exposed to makers and their cultures [
1]. Almost all our recipients (R1, R2, R3, R4, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16) expressed that they identified on some level with the values of the maker's culture, such as “doing things by oneself,” “sharing knowledge,” and having a “growth mindset” (referring to the belief that a person's capacities and talents can be improved over time) [
66]. Note that “identifying with the maker culture” does not mean that these recipients necessarily participated in the fabrication and direct modification of the devices. Identifying with the maker culture and adopting the mindset of finding value in its related growth helped the recipients to view their devices as something that was not yet finished. They viewed their devices as a “work-in-progress” that was not perfect but could be improved:
“[I] couldn't hold a spoon [with the device], could grip, but not eat with it. Went to the dollar store. Tried Velcro, PVC pipe. I would put the Velcro on the hand and on the end of that PVC pipe. And I'd put the fork inside that PVC, and that worked quite well at first but it just wasn't strong enough. Then got magnets. Oh and the magnets worked so well. Got bar magnets and good glue and I glued the magnet to the palm of the hand [3D printed AT].” R1, USA.
Figure
3 illustrates an example of the maker activities that R1 conducted to modify his 3D printed assistive hand so he could ensure being able to eat with the device.
“… the device [3D printed assistive device] is a great way to induce: a growth mindset… I saw the device [3D printed assistive device] as a prototype, something that needed to be changed and edited…” R3, USA.
This notion of identifying with the growth mindset and hence seeing their devices as something to be improved over time led some recipients to decide to directly address the challenges of follow-up by taking part in maker activities. These activities were a way through which recipients could take direct action to fix and improve their devices themselves. Recipients R3, R7, R10, R13, R14, R15, and R16 also shared that identifying with the maker culture helped them view their disability and the related care they sought, as something that could be improved over time. The growth mindset of the maker culture helped the recipients view the activities they could do with their limbs as something to be improved over time. Identifying with the growth mindset also helped these recipients value their therapies more, as shared by R10:
“…I am doing my extensions [therapy exercises] all the time. While I'm watching TV, chatting with family or just relaxing I'm always doing my extensions [therapy exercises]. But all the time I've spent [on the therapy exercises] has been advantageous. I've improved a lot…I am never going to stop [doing the therapy exercises] till I get it [3D printed assistive device] to work like the hand I had….” R10, Chile.
4.2.3 A Maker Family/Community.
The recipients’ membership in a care network extended also to their families. For example, R1, R3, and R9 all reported that their families engaged in making with them:
“…It is usually the women, like my mom or other moms who become makers to help their kids….” R9, Mexico.
The recipients who reported having their families involved in the making process were primarily those recipients who self-identified as makers. (Overall, these recipients not only adopted the maker culture, but they also actively participated in the design and fabrication of 3D printed devices.) Having family members who identified as makers helped them invest more time in fixing and improving their devices. R3, an e-NABLE recipient, built their 3D printed AT with their father. Although their 3D printed device was not perfect, the fact that a parent had helped build the device motivated them to want to invest more time in improving their device, as it had become an activity they could do together:
“…My dad and I built the hand [the 3D printed assistive device] together. The first version [of the device] hurt a lot. It was a prototype, and there was always something that needed to be changed and edited. But because my dad and I made it together, it was a project we wanted to finish… Part of it was that it was fun to make changes and make them together….” R3, USA.
Within these bonding activities, some recipients also reported benefiting from their connections with other recipients. R1, R3, R7, R9–R11, R13—R16 described that they practiced “knowledge sharing” to learn from each other about new care techniques. Some of these care techniques included “new rehabilitation exercises,” “ways to psychologically deal with limb loss,” “how to do by themselves certain activities,” “which 3D printed material was best for specific devices,” or even “how to get better medical insurance that would cover the costs associated with their 3D printed devices”:
“…We [group of recipients] show up and just share how we do things with our hands [3D printed assistive devices]. One same activity is done differently by each person… It's about learning together new ways to live, new ways to live with our new hands [3D printed AT]….” R7, Mexico.
“…part of my goal [on an online forum from his ecosystem] is having open discussions about what's working, for each of us, and what's not working. How did you get the insurance company to pay [i.e., cover the costs of a private company fabricating the device and providing follow-up]?…” R16, USA.
These knowledge-sharing activities took place primarily within online forums or physical meetups (e.g., convention centers or casual in-person reunions). Recipients shared that they were invited through their ecosystems to join these social gatherings. The social gatherings also helped for emotional support:
“I see people…[recipients in the social gatherings of his ecosystem]…who say: ‘I have to go to surgery tomorrow!’ and I'm like, ‘Just take what I'm saying and put in your heart and keep it there, you're going to be okay and you will adapt and you're going to be a better person’…” R14, USA.
4.3 Ecosystem Services
To better understand the role of the overall ecosystem in fostering success, we explored the ecosystem services that may have helped foster follow-up.
4.3.1 Preparatory Work.
One unusual aspect of some ecosystems was the degree of preparatory work fostered. Unlike U.S. maker communities that emphasize rapid production [
48], some ecosystems and recipients studied valued a slower approach to designing successful AT. For example, R5, a recipient who lost her hand in an accident, shared how she had one-on-one follow-up sessions to plan how her device would be modified to better fit her needs:
“…These sessions [one-on-one sessions with her medical maker] have helped me to start to craft with my doctor my ideal device… My ideal device is one that will help me to re-establish the image I had about myself before the accident and with the same functionalities that I had before.” R5, Mexico.
The ability to address aesthetic goals and custom needs is one advantage of 3D printed AT, since it leverages a volunteer maker network willing and able to take the time to customize the look of the designs, as well as prioritize different functionalities. These consequences help the device to be used long-term, something that may be harder to address in more traditional clinical settings [
111]. Furthermore, engaging recipients (and makers) in such an iteration provides an opportunity for learning maker values as well as human-centered design skills. Together, this fosters identification with and adoption of those values and skills.
4.3.2 Establishment of Formal Collaborations.
We found that ecosystems with sustained follow-up have established formal collaborations among the different stakeholders. It is known that having formal collaborations can help avoid uncertainties between the different stakeholders long term [
55]. Therefore, the integration of formal agreements likely facilitates the sustained participation of all stakeholders and helps to ensure follow-up with input from makers, recipients, and clinicians. Our interviewees discussed how these formal agreements took the form of insurance policies (R11, R13, R14, R15, R16, M1, M6, and C4) or officially signed documents (R4, R5, R6, R7, R8, R9, R10, M2, M4, M5, C1, C2, C5, and C6). C6 shared how his ecosystem had an official agreement between local government hospitals and universities (which had e-NABLE chapters). The agreement detailed how the different stakeholders would interact to produce 3D printed assistive devices and provide quality experiences to recipients:
“…we had to go to the doctor who is the director of [government clinics in a region of Mexico]… [This doctor] signed off on the project, and he was going to be responsible for overseeing that the devices did not have any side effects on patients…we also had to get professors [from universities with e-NABLE chapters] to sign off that they would help with the 3D printing….” C6, Mexico.
Similarly, M2, who came from an ecosystem with follow-up and sustained participation from all stakeholders, reported that in his ecosystem, the makers did not produce devices if they did not first receive a signed and certified letter from clinicians, detailing their agreement to help recipients, as well as showcase proof of the required abilities and knowledge to support recipients:
“Here, we [makers] only donate the device if the physiotherapist [clinician] sends us the prosthetic prescription with signature and professional registration number [indicating the clinician is trained] … [clinicians] register as volunteers and are trained to know how to prescribe the devices….” M2, Brazil.
These formal collaborations were missing from the ecosystems that did not provide follow-up. M3, M7, M8, M9, C3, C4, R1, R2, R3, and R12 described how the different stakeholders only interacted “casually” in their ecosystems. M8 shared how he only sometimes “casually” connected with clinicians through forums. But no formal collaborations had been established:
“In terms of medical professionals [clinicians], I haven't worked directly with a lot of medical professionals. There have been a few prosthetists [clinicians] that have worked with us [his ecosystem] just through the online community. And my interactions with them have been mostly just through those online, you know communications…” M8, USA.
4.3.3 Securing Funding for Collaborations.
Another strategy found in the ecosystems with follow-up was that some “secured funding” to ensure that certain collaborations took place. The funding was to cover the participation costs of clinicians (R11, R13, R14, R15, R16, M1, M6, C4, C2, C5, M5, and M4), makers (R11, R13, R14, R15, R16, M1, M6, C2, C4, and C5), or even recipients (M5, C1, C2, C5, and C6). C2 shared how, in her ecosystem, they had raised funds to cover the participation costs of all stakeholders to facilitate their participation. This was especially important in the case of recipients who often lacked the resources to travel to their follow-up:
“…So we raise funds and no one is volunteering [for the follow-up], we employed them all […] some of them [recipients] didn't come initially [to the follow-up] because they didn't have the money. [Recipients are] really, really poor so what [the ecosystem] started to do is that…we pay their transport and give [recipients] a meal so that they come to us. So that motivates [recipients] to come…” C2, India.
Funding to support participation was missing from those ecosystems that lacked follow-up; however, not all of the ecosystems with follow-up implemented monetary payments. This was particularly true for our interviewees from Brazil, who were able to secure resources to cover participation costs. But these resources were not directly translated into monetary compensations, as they felt it could demotivate participation. Therefore, this ecosystem made a point of not giving anyone monetary payments:
“…One of the basis of the work is that all volunteers, even the doctors, need to do the work free of charge […] the best way to get people to stop doing what they like is paying them to do it. Imagine you like to paint and you do it for free, because you like it. So, I start paying you one dollar for each painting; with time, you will think that your work is not being valued and you will want to receive more for it. So when we come to volunteer work, the idea is to engage the volunteer in other ways that don't involve money….” M2, Brazil.
It was interesting to observe that this particular ecosystem avoided, in general, any type of monetary transaction. The resources they donated were supplies and materials to fabricate the assistive devices:
“…We avoid using money in every part of the process […] we also do not accept donations in money. Only donations of raw material and equipment used to create the devices….” M2, Brazil.
SUMMARY OF RESULTS: We present some of the key findings from our results:
•
Providing follow-up to recipients was a key challenge that ecosystems faced (with some ecosystems never able to provide sustained follow-up).
•
Ecosystems with multi-stakeholder collaborations tended to produce better care, in terms of device adoption and reported recipient experiences.
•
The exposure of the maker culture to recipients and clinicians had positive care outcomes (in terms of recipient satisfaction and device usage).
•
To involve multiple stakeholders, ecosystems adopted different strategies for motivating participation, such as creating formal collaborations around stakeholder involvement and securing funding to cover the participation costs, when needed.