Understanding the Global Challenges to Accessing Appropriate Wheelchairs: Position Paper

Theories, models and frameworks to understand barriers to the provision of mobility-assistive technologies: a scoping review

OBJECTIVES

There is strong evidence that mobility-assistive technologies improve occupational performance, social participation, educational and employment access and overall quality of life in people with disabilities. However, people with disabilities still face barriers in accessing mobility products and related services. This review aims to summarise and synthesise: (1) theories, models and frameworks that have been used to understand mobility-assistive technology access, (2) determinants of access and (3) gaps in knowledge.

DESIGN

A scoping review using the five-step framework by Arksey and O'Malley.

DATA SOURCES

We searched the MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and SCOPUS databases for publications published between 2000 and 2024. We searched for articles published up to 20 March 2024.

ELIGIBILITY CRITERIA

We included English-published literature in peer-reviewed journals that reported (a) barriers to the provision of mobility-assistive technologies, (b) including at least one theory, model or framework and (c) between 2000 and 2024.

DATA EXTRACTION AND SYNTHESIS

We extracted the study characteristics, theories, models, framework usage, research recommendations, key findings on mobility-assistive technology barriers and theoretical propositions. We conduct a theoretical synthesis guided by Turner's approach.

RESULTS

We included 18 articles that used 8 theories, models and frameworks, synthesised into 9 propositions. The synthesised theory emphasises that mobility is essential for human flourishing, and that certain health conditions may impose restrictions on mobility. This impact can be alleviated by two direct determinants: (1) the provision of suitable services and (2) their comprehensive provision. Policies and costs influence these services indirectly. Environmental and personal factors also affect the use of these services. Ineffectively addressing these determinants can limit access to mobility-assistive technologies and subsequent disabilities.

CONCLUSION

Our synthetic model describes the logic of providing evidence-based mobility-assistive technologies, and we identify the determinants of access that can act as targets for future work to improve the provision of mobility-assistive technologies.

Outcomes in occupational therapy students' preparation for wheelchair skills training provision

While wheelchair skills training has demonstrated highly effective outcomes for wheelchair users, prevalence of receiving comprehensive skills training is low. Studies demonstrate a wheelchair skills "bootcamp" significantly improves occupational therapy students' capacity to demonstrate wheelchair skill performance; however, how bootcamps impact students' self-efficacy to deliver skills training in future clinical practice is unclear. This study explored a large dataset collected from nine successive student cohorts attending a structured wheelchair skills bootcamp at a single site. Bootcamps were 4-4.5 hours in duration and content was based on the Wheelchair Skills Program. Mean improvement in skill capacity was 34.8% (95% CI 33.5; 36.1) and wheelchair self-efficacy improved by 28.7% (95% CI 27.3; 30.1). Post-bootcamp self-efficacy scores for Assessment (80.9%), Training (78.5%), Spotting (87.4%), and Documentation (70.4%) all improved by 30-40%. Mandatory bootcamps had lower baseline scores but similar post-bootcamp and change scores as voluntary ones. Cohorts during the COVID-19 pandemic had significantly lower baseline scores for wheelchair skill capacity and confidence as well as self-efficacy with assessment, but significantly larger improvements post-bootcamp. An experiential bootcamp is effective across a wide range of occupational therapy student cohorts in preparing them to deliver wheelchair skills training in future clinical practice.

A cross-sectional survey investigating wheelchair skills training in Ireland

PURPOSE

Wheelchair skills trainings are a vital aspect wheelchair provision yet are arguably overlooked and extent to which training is provided in the Irish context is highly variable. The primary aim of this study was to quantify whether a need exists to further develop wheelchair skills training in Ireland.

METHODS

A cross sectional survey was conducted using SurveyMonkeyTM. Irish health professionals involved in wheelchair service delivery were asked how they offer wheelchair skills trainings and what components of wheelchair skills they train. To collect qualitative information, questions also explored how health professionals would like training to develop.

RESULTS

Consensus among respondents was that training is often provided to new users (n = 91, 89%), however, it is limited to mostly transfers and simple mobility techniques. Further, it was reported that advanced mobility skills are sometimes (n = 81, 51%) or never taught (n = 81, 21%). The respondent's confidence instructing various skills corresponded with the frequency of instruction. The responses captured a shared interest in developing standardised training programs and the development of continued education training in the area.

CONCLUSION

The findings from this study reinforce that a present need exists to further develop wheelchair skills training in Ireland, with the aim of improving Irish wheelchair service providers' knowledge and confidence in advanced wheelchair skills needed to mobilise and perform activities of daily living.IMPLICATIONS FOR REHABILITATIONCurrent clinical practice in Irish wheelchair service delivery includes basic wheelchair skills training, whereas training in advanced skills needed for improved independent mobility is highly variable.This study raises awareness that health professionals seek formal education and training in wheelchair skills to improve their knowledge and confidence in providing wheelchair skills training.There is a need to develop wheelchair skills training opportunities, both as a requirement for stakeholders involved in wheelchair provision and to address an unmet need for wheelchair users.

Effects of the WHO 8-step wheelchair-service-delivery process on wheelchair users in El Salvador: a cohort study

PURPOSE

To test the hypotheses that, after the delivery of manual wheelchairs following the WHO 8-step service-delivery process, wheelchair-related health and quality of life, wheelchair skills, wheelchair use, and poverty probability would improve; and that the number of wheelchair repairs required, adverse events, caregiver burden, and the level of assistance provided would decrease.

METHODS

This was a longitudinal, prospective within-subject study including 247 manual wheelchair users, and 119 caregivers, in El Salvador who received a wheelchair following the WHO 8-step process as well as maintenance reminders. Outcome measurements were performed via structured questionnaires and dataloggers at the initial assessment, at wheelchair delivery, and at 3- and 6-month follow-up.

RESULTS

Significant improvements in wheelchair-related health indicators (all with p < 0.004) and quality of life (p = 0.001), and a significant reduction in national and "extreme" poverty probability (p = 0.004 and p = 0.012) were observed by six months. Wheelchair use significantly decreased (p = 0.011 and p = 0.035) and wheelchair skills increased (p = 0.009). Caregiver burden did not change (p = 0.226) but the number of activities of daily living (ADLs) that required no assistance significantly increased (p = 0.001) by three months and those who required complete assistance decreased (p = 0.001). No changes were observed in wheelchair repairs (p = 0.967) and breakdowns over time with new wheelchairs.

CONCLUSIONS

Wheelchair service delivery using the WHO 8-step process on manual wheelchair users in El Salvador has positive effects on health and quality of life, wheelchair skills, caregiver assistance levels, and poverty. Further research is needed to determine the relative contributions of the intervention components.Implications for RehabilitationProviding manual wheelchairs using the 8-step process of the WHO has benefits on health and quality of life, wheelchair skills, caregiver assistance levels, and poverty.The WHO 8-steps service delivery process for manual wheelchairs can be used in less-resourced settings.

Impact of seating and mobility services for individuals with disabilities in Peru

The purpose of this study is to critically analyze the perceived impact of seating and mobility services, provided by occupational therapists using an ISL model, from the perspective of the recipients of services in Peru. A quantitative, cross-sectional survey design was implemented using a survey that was developed based on areas of occupation outlined by the OTPF-4, translated into Spanish, and administered by an in-country partner via SurveyMonkey. More than 85% of respondents (n = 133) indicated they "agree" or "strongly agree" that receiving services had an overall positive impact on their life, ability to complete ADLs, social interaction, community mobility and participation, overall health, and sense of confidence and well-being; responses were generally "neutral" regarding impact on employment and education. The results support the potential of collaborative ISL, specific to the provision of seating and mobility, to improve occupational performance from the perspective of service recipients in Peru.

A Goal-Directed Program for Wheelchair Use for Children and Young People with Cerebral Palsy in Uganda: An Explorative Intervention Study

In this exploratory study, we investigate whether goal-directed intervention for wheelchairs can increase the activities of daily living for children and young people with cerebral palsy (CP) when implemented in rural Uganda. Thirty-two children and young people with CP (aged 3–18 years) participated in a home-visit intervention program, which included donating wheelchairs and setting individual goals. Goal achievement, frequency of wheelchair use, condition of wheelchairs, and caregivers’ perspectives were collected by interviews at 6–10 month after the start of intervention and the after three years. Our result show that most wheelchairs were in good condition and frequently used after 6–10 month with 83% goal achievement (132/158 goals; mean 4.3 (range 0–7). The caregivers reported several advantages (e.g., the child being happier) and few disadvantages (e.g., poor design and durability). At the three-year follow-up, only eleven wheelchairs were still used by 23 available participants (seven deceased and two moved). The children achieved 60% of their goals (32/53 goals mean 2.9; range 1–5). This demonstrates that the goal-directed intervention program for wheelchairs can be successfully implemented in a low-income setting with a high rate of goal achievement and frequent wheelchair use, facilitating participation. However, maintenance services are crucial to obtain sustainable results.

Potential ethical problems in the creation of open educational resources through virtual spaces in academia

The concept of open educational resources (OER) is an emerging phenomenon that encourages modern teaching and learning in the higher education sector. Although many institutions are promoting the adoption and creation of OER, they are still lacking in the policies and development guidelines related to the creation. This could perpetrate the potential ethical problems that affect the development of OER. This study aimed to find out ethical procedures and peer-review processes associated with the adoption and development of OER. A qualitative approach was used to gather data from OER developers in the academic space. Structuration theory was considered the main theoretical underpinning of this study. The commonly used big data virtual spaces for OER, such as social media and learning management systems (LMS), were identified. The study articulates three major causalities of OER's ethical problems, as follows: non-compliance to openness, transactional purchases of OER, non-incentives for developers. Also, the scholars' ideas and OER outputs cannot be undermined; however, there is a need for a peer-review process in the creation of OER. Institutions are expected to formulate the standards and requirements to be followed in the creation of OER because OER contributes to the rising of big data in the education domains. The study recommends that OER be developed for a specific purpose and aligned with the specific subject content, and the resource must be precise and peer reviewed for quality measures.

Wheelchair service provision education for healthcare professional students, healthcare personnel and educators across low- to high-resourced settings: a scoping review

PURPOSE

This review aimed to collate and summarize available research literature about wheelchair service provision education available to healthcare professional students, healthcare personnel and educators across low- to high-resourced settings.

METHODS

The Joanna Briggs Institute methodological steps for scoping reviews were followed. Included studies were mainly sourced from Medline, Embase, CINAHL, Scopus, Academic Search Complete and ProQuest. Independent title, abstract and full-text screening with defined inclusion and exclusion criteria was performed. All screening and extraction were performed independently by two authors. A thematic approach was used to synthesize results. Data extracted from included studies were charted according to a template that we created. The study quality was also appraised.

RESULTS

A total of 25 articles were included (11, 36% from high-income settings) with 12 (48%) observational studies and 13 (52%) experimental studies. The literature addressed three main topics: (1) assessing wheelchair service provision knowledge, (2) implementing training interventions using in-person, online and/or hybrid learning approaches and (3) describing current wheelchair service provision education globally. The most frequently reported training programs used were the Wheelchair Skills Program and the World Health Organization Wheelchair Service Training Package - Basic Level.

CONCLUSION

Limited information has been published about the integration of wheelchair content into the curricula of professional rehabilitation programs. Efforts to build international partnerships, improve the quality and currency of training programs and build resources that can assist educators in the integration of wheelchair-related content into professional rehabilitation programs should be prioritized.Implications for RehabilitationThis is the first review that examined and synthesized the current state of wheelchair service provision education for rehabilitation students and personnel across low- to high-income countries.Findings from this review indicate that there is limited information about the integration of wheelchair-related content into professional rehabilitation programs.Efforts to build international partnerships, standardize wheelchair service provision content and evaluation and integrate training into professional rehabilitation programs worldwide should be prioritized.

Wheelchair service provision education in Canadian occupational therapy programs

Occupational therapists in Canada play a central role in wheelchair service provision. Inadequate entry-to-practice professional education has been identified as a major concern in the delivery of wheelchair related services. The goal of this study was to describe the current education provided in Canadian occupational therapy programs and to map this content against the recommended WHO 8-step wheelchair service provision process. The study used a descriptive cross-sectional online survey design. Educators were recruited from accredited occupational therapy programs in Canada. Participants completed a short sociodemographic questionnaire and a survey with 97 closed- and open-ended questions regarding the wheelchair service provision education provided in their curriculum. Survey data was then mapped according to the WHO 8-step wheelchair service provision process. Twenty-nine educators from all Canadian occupational therapy programs (n = 14) were enrolled. Most participants (55.2%) were full-time faculty members that had been teaching in occupational therapy programs for an average time of 10.9 years. All programs covered at least 4 of the WHO recommended steps, but only 5 programs covered all steps. Assessment and Prescription steps were covered in every program while the Referral & Appointment, Funding & Ordering, Fitting and User Training steps were covered in most programs. The pedagogic approach, the amount of time dedicated to wheelchair-related content, and the type of evaluation used varied greatly between programs. This study is the first to provide a detailed description of wheelchair service provision education across all Canadian occupational therapy programs according to the WHO 8 steps and provides a foundation for collaborative efforts to promote best practice in entry-to-practice professional education.

An exploratory analysis of global trends in wheelchair service provision knowledge across different demographic variables: 2017-2020

OBJECTIVE

To explore global trends in manual wheelchair service provision knowledge across geographic, professional, and socioeconomic domains.

DESIGN

A secondary analysis of a dataset from the International Society of Wheelchair Professionals' Wheelchair Service Provision Basic Knowledge Test was conducted.

SETTING

The dataset included test takers from around the world and was extracted from Test.com and International Society of Wheelchair Professionals' Wheelchair International Network.

PARTICIPANTS

2,467 unique test takers from 86 countries.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

International Society of Wheelchair Professionals' Wheelchair Service Provision Basic Knowledge Test.

RESULTS

We identified significant inverse associations between pass rate and the following variables: education (high school and some college), test taker motivation (required by academic program or employer), and country income setting (low and middle). There were significant positive associations between pass rate and the following variables: training received (offered by Mobility India or 'other NGO'), and age group served (early childhood).

CONCLUSION

Global wheelchair knowledge trends related to key variables such as training, occupation, and income setting have been preliminarily explored. Future work includes further validation of the primary outcome measure and recruitment of a larger sample size to further explore significant associations between additional test taker variables.