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Models of Practice. Lecture 7. A successful outcome begins with choosing the most appropriate AT for a person. How can we best do that?.

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Models of practice

A successful outcome begins with choosing the most appropriate AT for a person. How can we best do that?

Models of practice

  • Assistive technology is designed to provide functional benefits and to facilitate participation for a person with a disability (World Health Organization, 2002).

  • However, research shows that there is a high level of device abandonment, even with what appears to be a well matched device (M. J. Scherer & Craddock, 2002).

  • Studies on device abandonment, often explained by inefficient assessments and intervention processes (Judge, 2002; M. J. Scherer & Craddock, 2002), have led to the development of assistive technology specific outcome measures to evaluate the satisfaction and effectiveness of a device.

  • There is a lack of evidence- based procedures that are specific to assistive technology provision.

Models of practice

  • Although the International Classification of Functioning (ICF) was not specifically developed to guide assistive technology assessment, the literature shows that it lends itself as a descriptive model for the assistive technology assessment process.

  • ICF captures the complex aspects of the impact of assistive technology and its service delivery process and can assist the professional in decision-making (Bernd, Van Der Pijl, & De Witte, 2009).

Models of practice

  • When assistive technology is successful, it reduces or removes barriers, to allow the person to take part in activities (Jutai, Fuhrer, Demers, Scherer, & DeRuyter, 2005).

  • The ICF checklist assists the service provider to elicits what capabilities and limitations the user’s experience in activities and participation related domains.

  • Examples of relevant domains are: learning and applying knowledge; speaking; getting around inside and outside the home; self-care; interpersonal relationships; and social life etc

Models of practice

Matching people with assistive technology is complex because people’s expectations of and reactions to technologies are complex. Reactions are highly


Scherer M. J. (2005). Assistive technology in

education for students who are hard of hearing or deaf. Handbook of special education technology research and practice. Knowledge by Design. (2005). Whitefish Bay, WI.

Models of practice

Sometimes the evaluation people’s expectations of and reactions to technologies are complex. Reactions are highly

is driven by a request for a

specific piece of equipment.

In these instances, the focus

is on the equipment, and

the student’s problem is

not identified.

Kurtz J. (2003). Assistive technology in schools: how do we make it work? OT Practice. Aug 18; 8 (15), 16-20.

Atd selection framework
ATD Selection Framework people’s expectations of and reactions to technologies are complex. Reactions are highly

Environmental Factors 

Cultural and Financial Priorities

Legislation & Policy

Attitudes of Key Others

Personal Factors

AT Decision-Making

and Device Selection


* Family/Friends & Significant Others

* Financial


Trialling, Use and Realization of Benefit

Assessment of

Functional ATD Need

 (‘Objective Need’)

Knowledge and Information




Assessment of

ATD Predisposition

(‘Subjective Need’)

Personal Preferences and Priorities

Scherer, M., Jutai, J., Fuhrer, M., Demers, L. & DeRuyter, F. (2007). A framework for modeling the selection of assistive technology devices (ATDs). Disability and Rehabilitation: Assistive Technology, 2(1), 1-8.

Purpose of outcomes measurement
Purpose of Outcomes measurement people’s expectations of and reactions to technologies are complex. Reactions are highly

Ensure good outcomes for individuals

Provide evidence for successful practices

Augment AT knowledge base

Document need to funding and policy makers

Consumer c entered o utcome m easurement
Consumer- people’s expectations of and reactions to technologies are complex. Reactions are highlyCentered Outcome Measurement

to make informed choices

to monitor how well solutions meet their goals, preference and ongoing requirements

to enable them to direct the process in order to optimize their utilization on the solution.

An integratedapproach which utilizes a range of mechanisms to provide consumers with adequate information

Models of practice

Context people’s expectations of and reactions to technologies are complex. Reactions are highly



Functioning & Disability

Body Functions &


Activities &


Models of practice

QOL people’s expectations of and reactions to technologies are complex. Reactions are highly

Models of practice

Individual people’s expectations of and reactions to technologies are complex. Reactions are highly

Influences on Activities & Participation





  • Milieu

  • Policies and mandates

  • Financial/funding

  • Provider knowledge

  • Attitudes of others



  • Individual Predisposition

  • Resources and knowledge

  • Personal perspectives, priorities

  • Prior experiences

  • Expectations



  • Outcomes

  • Degree of AT use

  • Perceived benefit/gain from


  • Subjjective well-being/quality of life

Models of practice

It is no longer sufficient to show we have improved a person’s functioning. We must show we have enhanced


Challenges to evaluating outcomes
Challenges to Evaluating Outcomes person’s functioning. We must show we have enhanced

•AT is often provided as part of a number of interventions and it is therefore difficult to ascertain the degree to which the AT is responsible for the outcome

•Difficult to define the expected outcomes

•Consumer diversity and individualization makes comparisons difficult

We know what to measure but how with what tools
We know what to measure, but how? With what tools? person’s functioning. We must show we have enhanced

  • PIADS for assessing the increase in the user’s sense of competence, self-esteem and adaptability

  • QUEST for assessing the person’s satisfaction with the device

  • MPT for assessing person-technology fit -- how well the device matches the needs, characteristics, preferences and expectations of the person -- and enhances participation

  • Plus others that were designed to address AT

PIADS person’s functioning. We must show we have enhanced

  • 26 self-report items on a 7-point scale ranging from decreases (-3) to increases (+3). Items are: competence, happiness, independence, adequacy, confusion, efficiency, self esteem, productivity, security, frustration, usefulness, self confidence, expertise, skillfulness, well-being, capability, quality of life, performance, sense of power, sense of control, embarrassment, willingness to take chances, eagerness to try new things, ability to participate, adapt to activities of daily living and take advantage of opportunities.

  • 3 scales, competence, self-esteem and adaptability

Jutai J & Day H. (2002). Psychosocial Impact of Assistive Device Scale (PIADS). Technology and Disability, 14, 107-111].

PIADS person’s functioning. We must show we have enhanced

+ Good psychometric properties after a slow start (contact lens and eyeglasses use)

  • Quality of life is assessed with only 1 item and a separate items exists for well-being

  • Some items lack face validity regarding impact on AT use

  • Consumers report difficulty in distinguishing power and control

QUEST person’s functioning. We must show we have enhanced

  • 12 self-report items on a 5-point scale ranging from not at all satisfied (1) to very satisfied (5). Items are: Dimensions, weight, adjustment, safety, durability, ease of use, comfort, effectiveness, service delivery, repairs & servicing, professional services, and follow-up

  • 2 scales: Device and Service

Demers, L., Weiss-Lambrou, R., & Ska, R. (1997). Quebec User Evaluation of Satisfaction with assistive Technology (QUEST): A new outcome measure. In S. Sprigle (Ed.), Proceedings of the RESNA 97 Annual Conference (pp. 94-96). Arlington (VA): RESNA Press.

Models of practice

  • The only evidence based assistive technology specific model, developed to match the ICF and its checklist found in the literature, is the Matching Person and Technology (MPT) model

  • Bernd, et al., 2009;

  • Karlsson, P (2006) ICF: A Guide to Assistive Technology Decision-making University of Western Sydney

Matching person with technology
Matching Person with Technology developed to match the ICF and its checklist found in the literature, is the Matching Person and Technology (MPT) model

  • The MPT model explores assistive technology use and perceived quality of life/participation of predetermined assistive technology users and non-users. The foundation of the instrument is the user and their environments. It assists the assessment process as a collaborative decision-making tool designed to determine the most appropriate assistive technology solution for a given individual. Separate instrument for children and adults

  • Mapped on ICF

  • Several instruments make up the MPT assessment package with versions of each to be completed by the consumer and by the service provider. Depending on what is been assessed each scale can be used independently They include:

Mpt assessment instruments
MPT assessment instruments developed to match the ICF and its checklist found in the literature, is the Matching Person and Technology (MPT) model

  • The Survey of Technology Use (SOTU)

  • The Assistive Technology Device Predisposition Assessment (ATD PA)

  • The Workplace Technology Predisposition Assessment (WPPA)

  • The Health Care Technology Predisposition Assessment (HCT PA)

  • The Educational Technology Predisposition Assessment (ET PA)

Models of practice
IMPT developed to match the ICF and its checklist found in the literature, is the Matching Person and Technology (MPT) model

  • The MPT was modified and re-validated for an Irish audience – Irish Matching Person with Technology

  • Impact of Assistive Technology on the quality of Life and participation, student self-esteem and autonomy of students (Craddock 2002)

  • Expanded to include subset on QOL & participation

  • 45 students assessed using the IMPT, longitudinal study, pre and post

Mpt impt
MPT (IMPT) developed to match the ICF and its checklist found in the literature, is the Matching Person and Technology (MPT) model

  • Environment – Educational Environment Subscale

  • Technology – Educational Technology Subscale

  • User-Capability

  • Quality of Life

  • Self-evaluation

  • Educational Goal

  • Additional information, transport, family support etc

Mpt impt models
MPT & IMPT models developed to match the ICF and its checklist found in the literature, is the Matching Person and Technology (MPT) model

  • It was developed to address the environment, the person and the technology, factors that need to be considered when evaluating a person’s need for assistive technology

  • The MPT supports a collaborative partnership between the service providers and the user

Models of practice

  • The Assistive Technology Device Predisposition Assessment consumer form (ATD PA), a part of the MPT assessment battery, is compatible with ICF and measures the impact of technology using the ICF domains.

  • The ATD PA items ask the user to rate their predisposition to using the assistive technology that is being considered, to better match technology with the person and therefore minimize device abandonment. ATD PA is developed for adults

Models of practice
IMPT consumer form (ATD PA), a part of the MPT assessment battery, is compatible with ICF and measures the impact of technology using the ICF domains.

  • Pre-test was used to capture the stage of technology experience, their quality of life, their degree of support and level of self-esteem before the assistive technology was introduced.

  • Post-test was used to measure these qualities after the client has used the technology for two years, in order to investigate if assistive technology had made a difference

Mpt specifically the atd pa
MPT (Specifically the ATD PA) consumer form (ATD PA), a part of the MPT assessment battery, is compatible with ICF and measures the impact of technology using the ICF domains.

  • It has 66 self-report items on a 5-point scale and yes/no questions, all mapped to the ICF

  • 4 scales: Functional capabilities, Subjective well-being, personal factors, and person-device match with each item mapped to the ICF

Scherer, M.J. (1989). The Assistive Technology Device Predisposition Assessment (ATD PA) Consumer Form. Webster, NY: The Institute for Matching Person & Technology, Inc.

Functional abilities
Functional Abilities consumer form (ATD PA), a part of the MPT assessment battery, is compatible with ICF and measures the impact of technology using the ICF domains.

ATDPA Section A: Abilities ICF Classification: Body Functions (b)


1. Seeingb210 Seeing functions

2. Hearingb230 Hearing functions

3. Speechb3 Voice and speech functions

4. Understanding,rememberingb144 Memory; b164 higher level cognitive

functions; b1670 reception of language

5. Physical strength/staminab730, b735, b740 Muscle functions

6. Lower body useb760 Control of voluntary movement functions

7. Grasping and use of fingersb760 Control of voluntary movement functions

8. Upper body useb760 Control of voluntary movement functions

9. Mobilityb770 Gait pattern functions

Subjective well being
Subjective Well-Being consumer form (ATD PA), a part of the MPT assessment battery, is compatible with ICF and measures the impact of technology using the ICF domains.

ATDPA Section B. Well-Being, QOL ICF Classification: Activities & Participation (d)


10. Personal care, household activitiesd5 Self-care; d630, d640 Household tasks

11. Physical comfort & well-beingb280 (pain)

12. Overall healthb4, b5, b6, b8

13. Freedom to go wherever desiredd4 Mobility; d460 Moving around in different locations, d470, Using transportation; d475 Driving

14. Participation in desired activitiesd2 General tasks & demands; d9 Community, social &

civic life

15. Educational attainmentd810-d839 Education

16. Employment status/potentiald840-d859 Work and employment

17. Family relationshipsd760, e310 Family relationships

18. Close, intimate relationshipsd770 Intimate relationships, e320Friends

19. Autonomy, self-determinationd177 Making decisions

20. Fitting in, belongingd7 Interpersonal interactions, d910 Community life

21. Emotional well-beingb152 Emotional functions;d240 Handling stress and

other psychological demands

Person factors
Person Factors consumer form (ATD PA), a part of the MPT assessment battery, is compatible with ICF and measures the impact of technology using the ICF domains.

ATDPA Section C: Psychosocial factors ICF Classification: Contextual Factors


Attitudes and support from family, Support from family (e310, 410),

friendsSupport from friends (e320,420)

Temperament Personal, Temperament & personality (b126)

Mood Emotional functions (b152)

Autonomy and self-determination Making decisions(d177), Higher cognitive functions (b164), Attitudes (e4)

Self-esteem Personal, Emotional functions (b152)

Readiness for technology use Incentive to act (b1301), Forming an opinion


Characteristics of the at device
Characteristics of the AT Device consumer form (ATD PA), a part of the MPT assessment battery, is compatible with ICF and measures the impact of technology using the ICF domains.

ATDPA Section D. Device MatchICF: Products & Technology Matching (e115-e145)


Help achieve goals General tasks and demands (d2)

Improve QOL All Activities & Participation (d), Energy (b130), Sleep (b134),

Emotional functions (b152)

Knows how to use Learning and applying knowledge (d1), Support (training) from

health professionals (e355)

Secure with use Psychomotor function (b147), Emotional functions (b152)

Fits with routine Carrying out daily routine (d230)

Capabilities for use Specific mental functions (b140-bb180), Neuromusculoskeletal &

movement –related functions (b7)

Supports for use Support and relationships (e3)

Will physically fit Moving around using equipment (d465), Domestic life (d6), Community life (d910), etc.

Comfort – family Emotional function (b152), family attitudes (e410)

Comfort – friends Emotional function (b152), friends attitudes (e420)

Comfort - school/work Emotional function (b152), peer attitudes (e425)

Comfort - communityEmotional function (b152), stranger attitudes (e445)

Mpt specifically the atd pa1
MPT (Specifically the ATD PA) consumer form (ATD PA), a part of the MPT assessment battery, is compatible with ICF and measures the impact of technology using the ICF domains.

+ Good psychometric properties. Predictive of a match.

+ Useful when evaluating a person’s device expectations and realization of benefit with a specific device.

+ Computerized scoring and interpretations available

– Requires a commitment of at least 45 minutes to complete (longer if other forms are also used such as History of Support use) and to involving the consumer in the process

– Many professionals are uncomfortable with asking consumers personal questions.

More information on consumer at experiences and the other measures
More information on consumer AT experiences and the other measures

de Jonge, D., Scherer, M & Rodger, S. (2006)

Assistive Technology in the WorkplaceSt Louis, Mosby.

Scherer, M. J. (2005). Living in the State of Stuck: How Assistive Technology Impacts the Lives of People with Disabilities, Fourth Edition. Cambridge, MA: Brookline Books.

Models of practice
COPM measures

  • Canadian Occupational Performance Measure is an individualized evaluation tool

  • uses a semi-structured interview to assist consumers to identify specific problems in occupational performance areas such as self-care, productivity and leisure

  • The importance of each problem is then rated on a scale of 1 (not important) to 10 (very important). Then, the client rates current level of performance and satisfaction with their performance on scales of 1(unable to perform, not satisfied) to 10 (able to perform, extremely satisfied).

Models of practice
COPM measures

+ Allows the client to reassess their performance on the identified tasks at various intervals

+ Very individualized

– Requires considerable time

– Not focused on AT

Models of practice
IPPA measures

  • Individualized Prioritised Problem Assessment (IPPA) is an interview similar to format of COPM.

  • clients identify problems and rate the importance and degree of difficulty experienced in carrying out an activity on a 7-point scale (1= no importance at all, not at all difficult, 7=most important, too difficult to perform activity).

  • Provides a list of daily activities similar to activities listed in the ICF. Asks the AT user to rate how the AT has addressed each problem on a 5-point scale with –2 being much less than expected and +2 being much more than expected.

Models of practice
IPPA measures

+ Enables issues to be prioritised and the baseline performance to then be compared with performance following acquisition of the device

– Assesses activities and not participation

– Requires consumers to be able to identify their problems

– Has not been used extensively in outcome studies.

Scai siva cost analysis instrument
SCAI (SIVA Cost Analysis Instrument) measures

  • Designed to help clinicans estimate the economic aspects of AT provision

  • Using SCAI involved 3 steps – describing the objectives of the AT programme

  • Establishing the sequence and timing of interventions

  • Compiling cost for each AT solution

Models of practice
SCAI measures

  • The social cost is the main indicator of the economic significance of the AT solution

  • Alternative solutions must compared in terms of their social cost

  • Not a decision making tool, informative which adds to clinical assessment to make clinicans and users aware of economic consequences

Models of practice
SCAI measures

At paradox andrich renzo cost analysis of at portale siva
AT paradox – measures Andrich, Renzo Cost analysis of AT, Portale Siva

Other measures
Other Measures measures

COMPASS is a software program to measures computer performance (input, navigation and output). Provides quantitative data regarding reaction time, typing speed, number of errors.

The Siva Cost Analysis Instrument (SCAI) detail/compares costs of technology interventions.

Assessment of Life Habits (LIFE-H) questionnaire available in two forms: a 69- item screening tool to identify areas of life where participation in limited and a 240-item in-depth assessment across 12 domains: nutrition, residence, responsibility, fitness, personal care, communication, interpersonal relations, mobility, community, education, employment and recreation.

Other measures of participation have been developed for wheelchair users, community activities (AM-PAC/PM-PAC is not an AT outcome measure),

Few functioning everyday in a wheelchair
FEW Functioning Everyday in a Wheelchair measures

  • Functional Evaluation in a Wheelchair (FEW)

  • ICF coded

  • Designed as a tool to measure basic wheelchair use including such items as ability to reach form the wheelchair

  • Includes a mix of body function, activity and participation and environmental elements

  • Difficult measure to classify because all items are multi-barreled, eg respondents asked to rate their agreement with following statement “The size, fit, postural support and functional features of my wheelchair – response is on a 7 point scale

Wheelchair outcomes measurment whom
Wheelchair outcomes Measurment (WHoM) measures

  • Based on the ICF

  • Uses items nominated and weighted by the client

  • Rater solicits information that is participation focused

  • Captures the satisfaction with performance of activities or participation when using a wheelchair

At the end of the day
At the end of the day…. measures

  • A variety of processes and measures are used to address AT outcomes. Thus, it is imperative that you know your consumers and what will work best for them!

  • As important as choice in quality measures is their appropriate use

    • Know what you want to measure, and not want to measure (competence, functioning, satisfaction participation)

    • Determine how much time you want to devote to outcomes assessment

    • Know how specific or general you want to be

      • IPPA vs. QUEST

Evidence based practice
Evidence Based Practice measures

Evidence based practice is how Clinicians/researchers objectively provide evidence through scientific means on the outcome (positive and/or negative) of their intervention/s with their client group/s

Health service executive
Health Service Executive measures

Why we need evidence based Practice.

  • To eliminate poor/unnecessary practice and promote good practice.

  • To promote evidence based medicine.

  • To increase the accountability of services in line with the key principles of the Health Strategy, "Quality and Fairness” (2001)

  • To develop means to evaluate services.

  • To empower consumers and involve them in service evaluation and planning.

  • To evaluate new services.

  • To inform priority setting and resource allocation.

  • To help set, monitor and improve standards of care.

  • To develop and share research

Hiqa hrb
HIQA & HRB measures

  • The HSE through the Health Information and Quality Authority (HIQA) is responsible for making sure that the resources in our health services are used in a way that ensures the best outcome for the patient or service user.

  • They intend to do this by assessing the clinical and cost effectiveness of the medicines, devices, diagnostics, and health promotion used across the health system.

  • The Health Research Board (HRB) is the lead agency in Ireland supporting and funding health research. They provide funding, maintain health information systems and conduct research linked to national health priorities.

Models of practice
HSE measures

  • The outcomes of these assessments will allow the HIQA to support the Minister for Health & Children to make informed decisions on the desirability and effectiveness of investing in new therapies, drugs, equipment or health promotion activities.

  • HIQA will also advise on the rationale for continuing with existing practices to ensure that people are not being treated with outdated therapies, drugs or procedures.

Evidence based practice ebp
Evidence Based Practice (EBP) measures

  • Where has this come from?

  • This movement emerged first in the health sciences in response to the demand for more accountability in professional practice

  • The goal of EBP is to bridge the knowledge gap between research and practice by providing guidelines based on the best available evidence from research

  • In the fields of EBP, methods have been developed, called “systematic reviews,” that insure that searches are thorough and reliable. Archives of systematic reviews have been developed that can be used as key resources for EBP.

Evidence based practice ebp1
Evidence Based Practice (EBP) measures

  • The Cochrane Library (health sciences) and the Campbell Collaborative (social sciences) are organizations devoted to supporting the development of EBP. Each maintains an archive of systematic reviews and has specific guidelines for conducting a review for their archive.

  • The National Center for Dissemination of Rehabilitation Research has published several concise articles describing the concept of systematic reviews and started an archive of systematic reviews in rehabilitation science

The cochrane collaboration
The Cochrane Collaboration measures

  • The Health Research Board have paid national subscription to make the Cochrane Database available to all clinicians/researchers in Ireland

  • 5000 scientific papers published daily

  • Clearing house for international evidence based practice

  • Information on evidence based practice

  • Improving healthcare decision-making globally, through systematic reviews of the effects of healthcare interventions

Measuring outcomes
Measuring Outcomes measures

  • Quality of life indicators are now generally considered reliable measures to evaluate services, rather than merely questioning users as to their degree of satisfaction.

  • Traditionally the services received were considered as the standard for establishing social validity eg client surveys, waiting lists as opposed to establishing the success of intervention for the client’s needs etc

Assistive technology outcomes
Assistive Technology Outcomes measures

  • Clinical Result

  • Functional Status

  • Quality of Life

  • Consumer Satisfaction

  • Cost Factors

    DeRuyter 1998

Perspectives of different stakeholders importance of various outcome dimensions deruyter 98

Clinical result measures

Functional status

Quality of Life

Consumer Satisfaction

Cost Factors

























Perspectives of Different Stakeholders: Importance of Various Outcome DimensionsDeRuyter 98

Outcomes based research
Outcomes based research measures

  • When choosing an instrument, careful consideration must be given to validity and reliability.

  • If the instrument is considered to be invalid or unreliable, the research is worthless

  • Validity refers to the degree to which a study accurately reflects or assesses the specific concept that the researcher is attempting to measure.

  • reliability is concerned with the accuracy of the actual measuring instrument or procedure, validity is concerned with the study's success at measuring

  • In validating an instrument, certain criteria must assessed through repeated testing

Validity reliability
Validity & Reliability measures

  • Validity is key to effective research,

  • In qualitative data validity might be addressed through the honesty, dept, richness and scope of the data achieved, the participants approached, the researcher’s objectiveness

  • Quantitative data validity is addressed through careful sampling, appropriate instrumentation and appropriate statistical analysis

Measurement tools
Measurement Tools measures

  • There are many standardised instruments available to clinicians

  • Assistive technology outcome measurement is commonly associated with a number of conceptual domains, including: device usability, user satisfaction, quality of life, social role participation, functional level and cost.

  • Most instruments focus on one or more of the above domains to measure a specific type of outcome of the application of assistive technology. The challenge for clinicians is in identifying the most appropriate tools for their clients and service.

Outcomes based measurement
Outcomes based measurement measures

  • A analysis of existing measurement tools should cover conceptual, reliability, validity and practical considerations

  • Comprehensive reviews have been undertaken using the ICF

  • Older instruments which focus on the construct of handicap may not fully capture the full scope of the concept of participation

Appraisal of instruments
Appraisal of Instruments measures

  • Conceptual comparisons can be classified according to the ICF, Cieza et al have proposed a process

  • Each measure can be classified in terms of whether it measures activity or participation or both eg items such as mobility, self care and domestic life could be deemed as activity. Items that assess interpersonal interactions, community, social life etc are deemed as participation

Outcomes based research1
Outcomes based research measures

  • As the prescription process becomes more complicated and Health departments begin to demand evidence to support the need for equipment, outcome measurement is becoming necessary

  • Attempting to decide on an appropriate measure, researchers and clinicians must choose from an increasing array of potential instruments

Outcomes measurement
Outcomes measurement measures

  • Provision of the right system is essential to reduce not only monetary cost but also person related cost

  • Garber et al found that 31% of their sample discontinued using their wheelchairs because the devices no longer met their needs

  • Kittel et al found that failure to consider important lifestyle issues was identified as primary factor leading to wheelchair abandonment

  • Many studies have documented abandonment due to mismatch of device

At system for education nz

AT System for Education NZ measures