1. Introduction
More than one billion people in the world live with some form of disability and its prevalence is steadily growing [
1]. It is well recognized, especially after the implementation of the International Classification of Functioning, Disability and Health (ICF), that the end goal of rehabilitation is to preserve or improve participation [
2].
Mobility devices reduce the impact of disability and add dignity to the human being enhancing human rights by promoting functionality and social inclusion [
3]. The concept of participation in persons using mobility device is also based on several areas of ICF [
4]. The 2006 “United Nations Convention on the rights of persons with disabilities” and the “2008 Word Health Organization guidelines on the provision of wheelchairs in less resourced settings” respectively express the responsibility of governments to ensure access to personal mobility options as well as the need for mobility device training [
3]. Thus, prescribing and using a wheelchair in less resourceful settings is a clinical and civilizational challenge [
5,
6].
Assistive products and technologies hold promise for partially or completely mitigating the impacts of impairments and enhancing work participation when appropriate products and technologies are available, when they are properly prescribed and fitted, when the person receives proper training in their use and appropriate follow-up, and when societal and environmental barriers are limited [
7]. It is important to objectively identify those barriers and facilitators that interact with mobility during social participation [
8], as social participation could be linked with morbidity and quality of life [
9]. Several studies showed the benefits of the assistive technologies (AT), particularly if they contribute to enhancing participation of adults with mobility problems, as well as on psychosocial condition [
10,
11].
Getting a wheelchair is a complex event with various repercussions on individuals, particularly on social roles, promoting the possibility of “doing” activities of daily life and increasing interactions with external environments [
8,
12]. Powered wheelchairs (PW) in particular seem to improve daily routines, ability to engage in mobility related activities and social participation, and increasing peoples’ independence, safety and self-esteem [
9,
13]. PW improve autonomy in activities of daily living of the persons with disability [
14,
15]. Moreover, it seems that the transition from a manual wheelchair (MW) to a PW increased the occupational performance, competence, adaptability and self-esteem of persons with severe disabilities [
16].
However, a large number of persons with disabilities are reluctant to use the PW, which makes the integration process important in promoting autonomy and significant to their participation [
17]. When matching individuals with appropriate assistive technologies, it is important to understand the complexity of factors that must be optimized to enhance their performance and satisfaction, since it can influence its abandonment or underuse [
18]. Selecting, designing, or modifying the correct assistive device for an individual and providing training in its use, as well as appropriate follow-up, are complex but necessary elements for maximizing function among users of assistive products and technologies [
7].
Thus, we tried to understand the impact of the AT on peoples’ participation profiles, in order to improve the quality of services, based on their needs and preferences. The aim of this study was to analyze the relationship between the psychosocial impact of PW, users’ satisfaction and social participation profiles.
2. Methods
A cross-sectional study was designed, using a convenience sample of 30 persons with disabilities recruited by doctors and physiotherapists external to the study in the outpatient clinic of the Physical and Rehabilitation Medicine Department of the Coimbra University Hospital Centre (CHUC) and in the inpatient and outpatient clinics of two other institutions whose patients were PW users, respectively, the Cerebral Palsy Association of Coimbra and the Occupational Activities Centre of São Silvestre. The study was approved by the CHUC Ethic Commission (number CHUC-054-17).
Inclusion criteria were age between 18 and 64 years old, ability to understand written and spoken Portuguese language and using the current PW for at least one year and four hours per day. All individuals voluntarily gave their informed consent to participate in the study.
Measures adopted to evaluate the impact of assistive devices, namely the PW, regarding the psychosocial factors, satisfaction and social participation profile of a person with disabilities must be suitable for use in a particular cultural and specific language context [
19].
Data were collected face to face between May and October of 2017 by a trained junior researcher, who had never been in contact with the patients previously. Participants responded to the Portuguese version of Quebec User Evaluation of Satisfaction with Assistive Technology, version 2.0 (QUEST) [
20,
21]; the Portuguese version of Psychosocial Impact of Assistive Devices Scale (P-PIADS) [
22] and the Activities and Participation Profile Related to Mobility (PAPM) [
23], in addition to demographic, clinical and PW related questions.
The QUEST 2.0 is a 12-item questionnaire whose purpose is to evaluate the users’ satisfaction with his/her assistive device (regarding its dimensions, weight, ease of adjustment, safety, durability, ease of use, comfort and effectiveness) and the related services (specifically, delivery, repairs and servicing, professional services and follow-up services). The participant rates his/her satisfaction regarding each of the 12 items using a scale of 1 to 5 and, afterwards, chooses the 3 items he/she considers to be the most important ones [
21].
The PIADS is a 26-item, self-report questionnaire that evaluates the effects of an assistive device on the functional independence, well-being and quality of life. It assesses psychosocial factors which includes both factors within the individual and other factors attributable to the environment that affect the psychological adjustment of persons with disabilities. PIADS comprises 3 subscales, specifically, competence, adaptability and self-esteem. The competence subscale, composed of 12 items, is related to the perceived impact of the AT on the users’ competence, performance and productivity. The adaptability subscale, with 6 items, assesses the persons’ eagerness to try new challenges and take risks and his/her ability to take advantage of opportunities, thus evaluating the enabling aspects of the AT regarding participation. Finally, the self-esteem subscale, composed of 8 items, measures the perceived impact of the AT on self-confidence and emotional well-being. For each item, a score is attributed ranging from −3 (maximum negative impact) to +3 (maximum positive impact). The midpoint, zero, indicates no perceived impact. For every item, the impact of the current AT, which in this specific study is always a PW, is being compared to either the previous AT used by the participant or to not using an AT at all, depending on the participant’s previous situation [
24].
The PAPM is an 18-item scale designed to measure the social participation of community dwelling adults. It assesses the difficulties experienced by individuals in performing daily life activities that may be conditioned by mobility and related to social interactions and relations, education, employment, money management and social and community life. For each item, the participant attributes a score ranging from zero (no limitation/restriction) to four (complete limitation/restriction), except for the activities that do not apply to the individual’s life (NA), which are not rated. As a result, an individual’s participation profile is obtained [
23].
In addition, the participants replied to a form comprising demographic, clinical and AT related questions. The demographic information consisted of age, gender and occupation (before and after starting to use the current PW). Clinically, the participants were questioned about their medical condition and the time of its onset. Regarding the AT, the questions included time since adoption of the current PW and hours of use per day.
Descriptive and inferential statistics were conducted, using the software “IBM SPSS Statistics for Macintosh, Version 23.0 (IBM Corp., Armonk, NY, USA)”. Correlations between QUEST (total and subscales), P-PIADS (total and subscales), PAPM, age, time since onset of medical condition and time since adoption of the current PW were carried out through Pearson’s Coefficient. Differences between groups, specifically, between who had a MW as the previous AT compared to those who had a different PW and between who had received training with the PW compared to those who had not, were evaluated using Student´s t-test for independent samples. Groups were compared in terms of the scores obtained in each of the scales and subscales. Cross-tabulation was used to describe the relationship between the previous AT and whether they had received training with the current PW. Descriptive statistics were used to describe the results of QUEST, P-PIADS and PAPM and respective subscales, as well as other demographic, clinical and AT related data. Testing for normality was executed using a Kolmogorov-Smirnov test. In inferential statistics, the reference p value used was < 0.05.
4. Discussion
According to our findings, social participation does not seem to be associated to the psychosocial impact of the PW, similar to what was demonstrated by Buning, Angelo and Schmeler, who found no significant relationship between the psychosocial impact of powered mobility devices and the users’ occupational performance [
16]. Contrarily, a study by Martins and collaborators demonstrated a relation between the higher psychosocial impact scores and the better performance in social participation, regarding different types of AT [
10]. The fact that there was no correlation between the psychosocial impact and participation profile might mean that they had such severe physical limitations that, despite the positive psychosocial impact of the PW, it is not enough to attenuate these limitations and to improve performance in the activities of the daily living and social roles.
Furthermore, a higher satisfaction was linked to a better participation profile, which had also been previously shown concerning MW users [
25,
26]. On the other hand, another study did not find any correlation between wheelchair user’s satisfaction and participation [
27]. Historically, people with disabilities, as end users, have been missing in product development. At minimum, a knowledge of people with disabilities is needed. Often this means people with disabilities must be directly and pervasively involved in all phases of the product lifecycle, from idea generation to outcomes measurement [
28].
In this study, younger individuals had the worst participation profile. This can be explained by the particular characteristics of these participants—they are diagnosed with cerebral palsy, with severe limitations since birth, which also explains why younger users had been using their PW for a longer period of time compared to older ones, which their medical conditions, in general, had a later onset. A previous study had found no relation between age and participation profile [
10]. It is important to take into consideration that the PAPM scores may be influenced by the fact that the participants only attribute a score to the activities they consider to be significant to them, choosing “not applicable” for the others [
23]. These activities that were considered unimportant may, in fact, be the ones they perform with more difficulties. However, once this questionnaire is a self-reported measure, we interpret the results as the perception of people with disability.
Moreover, our findings suggest a positive psychosocial impact of PW in competence, adaptability and self-esteem, as it was also previously shown by Buning, Angelo and Schmeler regarding PMD [
16,
29]. Likewise, other studies showed benefits associated with PW use, namely increased independence [
16,
30], well-being [
14] and social participation [
11,
29]. There was no evidence of negative impact of the AT due to stigmatization, as suggested in other studies [
31,
32], since the self-esteem level is about the same as competency and adaptability. There was no relationship between the psychosocial impact of the PW and users’ age, which indicates that the AT could be beneficial at any age, making sense to be prescribed through the lifespan, also shown by Martins and collaborators [
10].
On a different note, the transition from a MW to a PW seems to have a greater psychosocial impact than from a PW to a new one. Buning, Angelo and Schmeler had previously shown that this transition increased the competence, adaptability and self-esteem of severely impaired persons, as well as their occupational performance [
16]. Nevertheless, we cannot ignore the fact that, in our study, only eight of the participants had a previous MW whereas more than twice this number (twenty participants) had already a PW, which may have had some influence on the results. This also applies to the comparison of the participation profiles, which suggest that there was a better performance among the first group. This is easily understandable considering that those who only required a PW recently, compared to the participants on the second group who had been handling a transition to a PW long time ago due to stronger limitations and, therefore, exhibit a worse participation profile.
Considering the training with the current PW, it seems it has been provided preferably to the ones who had a worse participation profile, eventually as a possible attempt to improve it. There was a tendency for better adaptability among users who received training, which suggests efficiency and value of the training. A study by Mountain and collaborators demonstrated that stroke patients who received formal PW training improved their PW skills to a significantly greater extent than participants who did not [
33]. Nevertheless, a study by Fehr, Langbein and Skaar showed that 10% of the PW users who received training found it impossible or extremely difficult to use their PW for activities of daily living [
17], while another study by Martins and collaborators showed no differences in terms of participation profile or psychosocial impact of diverse AT between those who did and did not receive training [
10]. Besides this, the ones who benefited from the training seemed to appreciate this help that was provided, considering their satisfaction relative to the services. If a bigger investment was made to provide training to the PW users, there could possibly be a more positive impact of these AT in the long term. Future studies are needed to support or oppose this hypothesis.
Considering this positive psychosocial impact of the PW, and according to the World Health Organization’s definition of Quality of Life (QoL)—“[a]n individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept affected in a complex way by the person’s physical health, psychological state, personal beliefs, social relationships and their relationship to salient features of their environment” [
34]—we can infer that the PW increase the QoL of the persons with disabilities, as was also shown by previous studies [
15,
35]. Accordingly, Chan and Chan demonstrated a relation between wheelchair users’ social participation and QoL [
27].
Concerning the limitations of this study, most of them were presented earlier in this discussion section and were mainly related with sample selection bias and metric instrument restrains. There were some data access constrains, which did not allow us to obtain a larger sample, more representative of the target population. The sample engaged individuals with complex and heterogeneous impairments which better represents this study target population. However, this obviously represents an expected and controlled evaluation bias. We tried to use simple but more superficial measures of evaluating psychosocial impact, satisfaction and participation, collected by the researcher, in order to include representative patients with mild cognitive impairments.
The present study allows researchers and clinicians to better understand the PW users’ opinion about the impact of AT on their lives and, also, about the services provided, which may help to improve the quality of such services and the characteristics of the PW, according to preferences and needs. These improvements may, in turn, lead to a more positive impact of the PW on persons with disabilities’ lives, facilitating their interaction with the surrounding environment, promoting their social participation and, consequently, improving their QoL. Successful assistive technology product interventions are complex and include much more than the simple selection of the right product. Assistive technology product use is highly context sensitive in terms of the person with disabilities’ environment. As a field, we have much to study and develop around assistive technology product interventions from a global perspective [
28].