Attitudes is the most important environmental factor for use of powered mobility devices – users’ perspectives

Abstract

Introduction: Different factors in the environment influence the use of powered wheelchairs or powered scooters, i.e. powered mobility devices (PMDs), but there is limited knowledge about how these factors interact and if any factor has a greater impact. According to the ICF the environment consists of five areas.

Aim: To describe users’ experiences of how environmental factors from all ICF areas influence the use of PMDs.

Methods: Descriptive qualitative design including 14 interviews with PMD users, analyzed using inductive qualitative content analysis.

Findings: Use of PMDs means a conditional freedom depending on the interaction of several environmental factors. Regardless of environmental factor the societal attitudes were always present, directly or indirectly, and influenced the participants’ feeling of being included and involved in society. The environmental factors and how they influence PMD use are described in four categories, comprising the following subjects: societal attitudes, the service delivery process, accessibility to the physical environment and financial resources.

Conclusion: The findings show that societal attitudes influence all other factors, directly by others people’s attitudes, or indirectly by how legislation and guidelines are formulated, interpreted and applied. Therefore, a change of societal attitudes seems necessary to increase accessibility and participation for PMD users.

Keywords:

• Powered mobility devices
• environment
• qualitative research
• assistive technology
• powered scooters
• powered wheelchairs

Introduction

Access to a power mobility device (PMD), in this study defined as powered wheelchair or powered scooter, is often crucial for people with reduced mobility as a key to an active life and participation in society [1–3]. Participation can be experienced at different levels, and a commonly used definition distinguishes between to be attendant or to be involved in a life situation [4]. The users of PMDs appear to a great extent to be attendant in society, as PMDs are a common sight in our cities. However, it is less known how involved these users actually feel [2]. This aspect of participation has been sparsely studied. One of the few publications on this subject concludes that users of PMDs feel discriminated against and less involved [5]. A mixed method study shows an overall increased occupational performance after a PMD prescription and also improved quality of life [2]. Most studies into participation among PMD users have been restricted to mobility-related participation [6,7] and show that the physical environment constitutes a major barrier to participation for people who use PMDs [6–12]. However, participation in the meaning being involved requires more than mobility and the use of PMDs and participation in society is probably not only influenced by the physical environment and accessibility, but also by social, attitudinal and political environments [5]. Compared to the more obvious physical environment, the influence of these other parts of the environment on the use of PMDs has been less studied [5,7,8]. For example, the scarcity of knowledge on the influence of the political and the social environment, including attitudes, has been highlighted in a recent scoping review of PMD studies [13]. In addition, legislation and policies differ between countries. In Sweden, the context of this study, it is a civil right to borrow a PMD free of charge with a fee for insurance and new tyres, when required. The prescriber of a PMD is also responsible for customizing the PMD to meet the individual’s needs, for providing information on functionality and for providing training in its use. Furthermore, this responsibility includes regular follow-up and, if necessary, repairs. This procedure is commonly called the “service delivery process”, and is in Sweden regulated by laws and policies [14]. The service delivery process can be viewed as part of the political environment and, as such, influences PMD use. Some comparisons between the service delivery systems of different countries have been made, as well as of users’ satisfaction with the service delivery process [15–17]. However, other aspects of the political environment and its influence on the use of PMDs have been poorly researched. In PMD research some studies have specific focus on scooter models, but commonly both powered wheelchairs and powered scooters are studied together [18]. In this study PMDs are including both powered wheelchairs and scooters.

When studying environmental factors and participation it is important to bear in mind the complex interaction between person, environment and occupation. This interaction is fundamental to occupational therapy and is well described in the PEO model [19]. The aim of a PMD prescription is to compensate for a person’s disability in order to enable occupation in different environments. Factors in the environment can both facilitate and hinder occupational performance and participation in society [20] and are therefore important to study. The concept of environment is complex and there are several definitions. The Model of Human Occupation, MOHO [21], the Canadian Model of Occupational Performance, CMOP [22] and the International Classification of Functioning, Disability and Health, ICF [20] all describe the interaction between humans and the environment in similar ways [23]. These three models all describe the environment as physical, social and political. Thus, when studying the environmental impact on the use of PMDs it is important to move beyond earlier research focusing on a specific environment. Taking the interaction between person, occupation and environment into account it is also reasonable to assume that different environmental factors may interact. Consequently, it is important not to restrict research by focusing on one factor at a time, but to study them all together. It is also important to have an overall perspective on what constitutes an environmental factor. According to ICF the environment can be divided into five different areas; Natural environment, Products & technology, Support & relationships, Attitudes, and Services, systems & policies [20]. Further, the ICF definition not only distinguishes between the social and attitudinal environment but also defines products and technology as an environmental factor. It is also important to take into account that environmental factors are perceived differently by people, either as impeding or facilitating by both their presence and absence. Therefore, to gain a comprehensive picture of how environmental factors influence the use of PMDs the users’ perspective is important to study.

To conclude, many aspects of the environment influence the use of PMDs and many of them have also been studied separately. Some of them, e.g. the physical environment, have been more studied than others. However, taking the important interaction between person, occupation and environment into account as many environmental factors as possible need to be studied together. There could also be meaningful interactions among them and these need to be identified and described in order to gain a deeper understanding of how the environment influences PMD use. To capture these interactions, the PMD user’s own perspective is preferable. This perspective is also invaluable when identifying areas for improvement and enhance accessibility in society for users of PMD. Thus, the aim of this study is to describe users’ experience of how environmental factors from all ICF areas influence the use of PMDs.

Method

A descriptive qualitative design was used and included interviews analyzed using qualitative content analysis with an inductive approach [24]. The study was approved by the Regional Ethics Committee in Uppsala Sweden (Dnr 2012/275).

Participants

The participants were recruited from a center for service and delivery of assistive technology in a county in central Sweden. The inclusion criteria were: aged 20 years or older, have had a PMD for outdoor use for at least one year, and being fluent in Swedish. Purposeful sampling was used to ensure maximum variation of the participants [25]. Prescribers of PMDs were consulted to find potential participants. Men and women of different ages, with different etiology and two main types of PMDs (powered wheelchair or scooter), living in smaller villages or major cities, were sent an information letter and an informed consent form by post. Upon return of the signed informed consent form, the first author (WW) contacted the user by phone to agree a time and place for the interview. The recruitment procedure continued until collected data were both rich and thick [26]. No new information appeared from the last three interviews, and we therefore decided that data saturation was achieved. Fourteen users of PMDs participated (Table1). They represented a broad spectrum in terms of age, sex, etiology and experience of using a PMD. The participants used different PMD models for outdoor use. Some of them had used PMDs since childhood, others had received their first PMD a few years ago. For further description of the participants see Table 1.

Table 1. Characteristics of the participants.

Characteristics
Age (years)
Mean age	50.1
Range	23-78
Sex
Male	6
Female	8
Aetiology (diagnosis ICD-10)
Diseases of nervous system, ICD 6	6
Diseases of musculoskeletal system, ICD 13	3
Injury, acquired amputation, ICD 19	5
Living status
Single	7
Cohabiting	6
Single together with parents	1
Vocational status
Working full time or part time	3
Retired	4
Temporary or permanent disability pension	7
Type of residence
Villa	2
Apartment	9
Other (sheltered housing)	3
Type of PMD
Three-wheeler scooter model	9
Four-wheeler joystick model	5
Experience of using PMDs (years)
Mean experience of using PMD	7.9
Range	2-18
Frequency of using PMD
Daily	11
Weekly	2
Monthly	1
Less than monthly	0
Never	0

Data collection

All interviews were conducted by the first author (WW), who is an occupational therapist experienced in PMDs but with no prior relationship with the participants. The interviews were performed according to the participant’s choice of time and place, either in the participant’s home or at an outpatient clinic at the University Hospital. An interview guide designed by the authors, based on key words incorporating environmental factors from all the five areas in the ICF, was used (Table 2). Although the guide had been used previously in interviews with users of other assistive technology devices [27,28], it was piloted for our purpose on one person using a scooter before data collection commenced. No changes were deemed necessary and the pilot interview was included. The interviews started with demographic questions, an explanation of the study aim and a broad definition of the concept environment. Thereafter, the interview continued with the main question: whether the environment influenced their use of PMDs and, if so, in what way. Most participants narrated spontaneously and very informative about environmental influence and PMD use. The interview guide (Table 2) was used as a checklist and if not all environmental factors were raised spontaneously by the participants probing questions were posed. The interviews lasted 34 to 87 minutes, on average 60 minutes; they were audiotaped and transcribed verbatim.

Table 2. Interview guide.

Main question:

Is the environment influencing your PMD use?

If so, describe in what way, facilitating or impeding?

When do you use your PMD and when do you not use it?

Why is that?

Key words for the interviewer: Design of the PMD Function of the PMD Other technology – e.g. walkers, crutches, elevators, cars Climate and Seasonal variation Outdoor / Indoor environment Transportation – e.g. bus, train, airplane Daylight /darkness Family and friends’ support and attitudes Pets Colleagues’ support and attitudes Societal attitudes and social norms Health professionals and authorities Services, System and Policies, service delivery process

In summary:

Facilitating factors are…

Impeding factors are…

Is there something else in the environment that affects your use of PMD that you wish to add?

Data analyses

Qualitative content analysis with inductive approach was used [24]. All content of the interviews was included as the unit of analysis. The computer program NVivo 10 was used to structure and obtain an overview of data. Initially, the first author (WW) read two of the transcripts thoroughly; first to obtain a sense of the whole, and then to mark parts of the text related to the aim as meaning units. The meaning units were condensed, abstracted and labeled with a code. To ensure credibility of the meaning units and codes, two of the authors (XX and YY) individually read the meaning units from the two transcripts and independently labeled them with codes. In a second step, three of the authors (WW, XX and YY) made joint decisions regarding which parts of the content were related to the aim and agreed on a joint understanding for the coding process. The codes were compared and discussed until consensus was reached. The first author continued the coding process with the rest of the data. Based on their differences and similarities, codes were organized into tentative categories. The tentative categorization was further analyzed by the first author and another author (ZZ). Overall, the authors agreed, and the joint analytic process resulted in four final categories with subcategories. This is an example of the coding process; meaning unit I do not want to be "The guy with the wheelchair.” Instead, I would rather be XXXXXX, the person who I really am, and that is not easy, was condensed to: I do not want to be the guy in the wheelchair, labeled with the code: Others identifying me according to my wheelchair, organized to the sub category: Attitudes and response from other people and the category: To be an individual or an object - the influence of attitudes and response. Finally, the categories were analyzed at a higher level of abstraction to identify the underlying meaning, the latent content, that represented the authors’ interpretation of the overarching theme [24].

Findings

The theme representing the underlying meaning connecting all categories was: ‘Use of PMDs means a conditional freedom depending on societal attitudes’. Conditional refers to that even though all participants experienced that the PMD gave freedom and ability to perform activities in daily life the freedom was fragile and dependent of the interaction of several environmental factors. A prominent common feature in the descriptions were how attitudes played an import role regardless of environmental factor. They were always present, directly or indirectly, and influenced the participants’ feeling of being included and involved in society. As soon as the participants were about to perform an activity it was in the context of the results of other peoples’ attitudes. Directly in interaction with others or indirectly when others’ attitudes have influenced such as the accessibility to stores or how political decisions were interpreted and executed. On individual level, habits and activity patterns influenced how the participants perceived different environmental factors rather than PMD model. Therefore, the matching of right technology to the person’s needs and habits was important for how the participants experienced the environment. The environmental factors, their duality and how they influence the use of PMDs are described below in four categories with underlying subcategories (Table 3).

Table 3. Theme and categories.

Theme	Use of PMD means a conditional freedom depending on societal attitudes
Category	To be an individual or an object - the influence of attitudes and response		To be an active collaborator or a receiver in the service delivery process		To participate in society – the importance of accessibility to the physical environment		To feel worthy and equal as a citizen – the importance of financial resources
Sub category	Attitudes and response from other people	Trying to be invisible or to be in charge, the user’s own attitude	To be involved or not in the choice of PMD	Matching user information and accessibility to store and charge the PMD	Weather and shortcomings of the PMDs influence participation	City planning and public transport influence participation	Laws and policies as bearer of equality concerning costs, support and service	Feeling worthy or not due to financial support or restrictions

To be an individual or an object - the influence of attitudes and response

This category describes how direct attitudes, both from people in society and participants own, makes the participants feel either objectified and marginalized, or in charge of their own life.

Attitudes and response from other people

The potential to be in charge of one’s life is influenced by the attitudes and direct response from people in general, officials, or friends and family. According to the participants, people in general often regard them as a “user of a PMD” instead of seeing them as their own person. The participants experienced that the PMD itself easily removes the focus from themselves as a person, especially when meeting new people, and they disliked being identified according to their assistive technology device.

‘I do not want to be “The guy with the wheelchair.” Instead, I would rather be XXXXXX, the person who I really am.’ (Man J, middle age)

Other participants described that not only new people, but also old friends defined them by their PMD instead of as a person using a PMD.

‘Some say that, hell you can’t drag that thing with you (the scooter) you look like a bloody invalid. You can’t have it. But I am, I say (laughing). So, it’s like, a bit like this with buddies.' (Man L, middle age)

All participants described diverse attitudes towards them as users of PMDs from people in general. Some people are positive, helpful and considerate, while others are more negative. Sometimes ignorance and prejudice from people, such as the supermarkets that only occasionally open the wide checkout through which everyone can exit, or people taking the disabled parking space without permission, or using the bigger fitting rooms intended for the disabled instead of taking the smaller rooms, led to feelings of discrimination among many of the participants. According to most participants, the problem with ignorance and lack of understanding was often reflected in contacts with officials and other professionals, and influenced their potential to be in charge of how they could use their PMD.

‘I was only allowed to go (on the PMD) around the block, so after about two years I said, no, I want to go further. And then he said (the OT): Noo, we can’t risk anything. Then this new girl (another OT) came, and it was no problem. She was great, she said: I can't forbid you. You can go wherever you like. I've seen how you drive, and you're a good driver.’ (Man M, elderly)

The participants experienced that their friends and family are mainly positive to the PMD, although some relatives disliked having the PMD parked indoors.

Trying to be invisible or to be in charge, the user’s own attitude

The participants’ own attitude towards being a user of PMD and how they treat and respond to other people seem to be vital for the feeling of freedom when using a PMD. Several of the participants described initial difficulties accepting themselves as a user of PMD with feelings of embarrassment and being watched by people. This was mostly described as a transient problem; yet many participants expressed how they tried to avoid attention caused by their PMD. They did not want to bother others which resulted in different types of attitudinal strategies. One woman describes her tactic to minimize the inconvenience she thought she caused others:

‘You must have a smile on your face if there is someone in your way or if I need help.' (Woman C, elderly)

The efforts not to bother others resulted in behaviors that limited their freedom, such as avoiding driving in narrow or crowded places, or shopping on Saturdays, or asking their occupational therapist for help with another PMD model or equipment. Others instead described an attitude of being in charge which facilitated their freedom, i.e. they took personal responsibility for both matching the PMD and regular service. They marked their autonomy by avoiding asking others for help. They drove their PMDs everywhere they wanted to go, even inaccessible places, and often they achieved this.

To be an active collaborator or a receiver in the service delivery process

This category describes participants' experience of being able to participate in the service delivery process of PMDs and later their possibilities to use the PMD. Their possibilities to participate is influenced by the prescribers' attitude and engagement to involve them.

To be involved or not in the choice of PMD

The participants’ experiences with the service delivery process differed. Some felt they had great influence and were involved in the choice of PMD as well as the choice of color, which was important for some of them.

‘I was allowed to choose the colour … that was important to me, to choose … if I don’t like my assistive devices, if they don’t look nice, neat and clean, then it doesn’t feel good [to use them]’ (Woman A, young)

Others were not involved in the service delivery process and knew nothing about other models, functions or colors than the one they received. Some participants expressed disappointment with the process.

‘I wasn’t even allowed to choose the colour … I say not even, but for some this is important. To me it is, I mean I would have liked to have the one I tried, it was red. I have a red car. I've always loved red cars and the little red scooter was so cute. Now there is only one standard available …some sort of… green…’ (Woman B, middle age)

Most participants expressed a desire for more information about different models and when new ones were available, something healthcare professionals did not offer on a regular basis.

Overall, the participants felt quite satisfied with their individual match, even though many had received a different model after some years due to mismatching or changed needs. The participants often had to compromise and weigh up a number of pros and cons, i.e. a large PMD with stability and speed or a small PMD that is easy and smooth to drive in confined spaces. Other compromises described were more unusual and appeared to be related to functional solutions.

‘Actually, I wanted an umbrella holder. But that wasn’t available they said, so they fixed this [cup holder] instead. I can keep the umbrella in it when it's closed…' (Woman A, young)

Although most participants were happy with their PMDs, they described areas of improvement in regard to functionality. Many participants desired better matching in terms of the possibility to drive in the forest, increased durability, higher speed and rain protection.

Matching user information and accessibility to store and charge the PMD

All participants had received training before taking their PMD home. The amount of training varied. Some described a “driving school”, including traffic rules and driving lessons both indoors and outdoors. Others test drove the PMD on one occasion only. Some of the participants expressed satisfaction that the amount of training was adapted to their knowledge from driving a car. On the other hand, others experienced a lack of matching to their needs. They felt insecure in traffic and wanted more information than had been provided. Several of the participants also stated that the user information on care and maintenance of the PMDs was not always easy to understand, and there was a lack of adapted information. Different needs were expressed concerning how to get information, some preferring written and others oral information.

‘I did get a manual and I do know how to read … maybe it had been better if someone had told me … I can't take in that much information [in writing].’ (Woman D, middle age)

Accessibility to the storage place was described as crucial for use, and receiving a specially designed garage for the PMD greatly facilitated use. However, for some participants the surrounding environment between the house and the garage was described as a hindrance to accessing the garage. Others were forced to store their PMD in their apartments. This results in dirty wet floors, sometimes deterring them from using the PMD. Many participants also felt that when the PMD was stored indoors the apartment became crowded and difficult to move around in.

To participate in society - the importance of accessibility to the physical environment

This category describes the participants’ different experiences of societal accessibility and mobility related participation, and how this makes the PMD use conditional. The physical environment in this broad perspective includes not only indirect societal attitudes, such as city planning and transportation, but also how different climates influence PMD technology.

Weather and shortcomings of the PMDs influence participation

All participants highlighted the physical environment as a major barrier to their use of the PMD. Some participants drove their PMDs in any weather and season, but for most participants the climate, weather and wind, had a large impact on their use. Rain, snow and wind were described as troublesome, the participants got wet and cold and it was also hard to see and hear the surrounding traffic. Some of the participants avoided going out in snowy weather because they were afraid the PMD would get stuck in snowdrifts.

‘If the snow plough hasn’t been out I have to sit at home, then I can't pick up my daughter from day care.’ (Woman A, young)

Most participants also stated that cold weather decreased the PMD’s battery capacity, which restricted how far they could drive. Some participants had difficulty steering and moving the joystick in cold weather. Conversely, they stated that nice, sunny and warm weather promotes their use of the PMD.

A few participants described that they could drive out into natural terrain, such as the forest, the beach, meadow or lawn. This was something many of the participants really missed, especially those who had previously been able to walk in the forest. They expressed knowledge about PMD models adapted for terrain but stated that they were not available on prescription. Some of the participants therefore wished they could borrow or rent an off-road PMD model when needed.

‘I have the same right to walk in the woods as someone with legs, so to speak. If I want to walk in the woods or pick mushrooms with my family, then I can't. So, actually, I think it should be equal for everyone. Everyone should have the right to have one [PMD off-road model].' (Woman H, middle age)

City planning and public transport influence participation

Accessibility was described as crucial for the participants to participate in activities outside the home, meaning being able both to attend and be involved in society. The city environment facilitated safe driving for all participants. They described asphalted cycle lanes and beveled pavements that enabled easy driving; instead the problem for some was the traffic, such as fast bicycles that show up from ‘nowhere’. All participants found most modern public facilities accessible with a PMD, but older houses and smaller shops were problematic to get in and move around. Other problems were lifts that were too small and the absence of lifts or ramps. For some participants this resulted in feelings of discrimination and stigma.

‘And last time I bought a bracelet, my wife was in the shop and the shop assistant came out with five bracelets for me to look at. Then I had to stand on the pavement to look at those bracelets…it doesn't feel normal at all.’ (Man J, middle age)

Many participants also described grocery shops as problematic. They are crowded and narrow, with food sometimes out of reach, which some participants felt was discriminatory. Accessibility to parking spaces was another problem described by some of the participants. Parking spaces for disabled people were often not designed for PMD users, resulting in too little space to precipitate the ramp.

All participants stated that public transport, e.g. city buses, in general were not adapted to accommodate PMDs. Therefore, most participants used taxis or their own car to transport the PMD. The few participants with experience from trains stated that only certain train carriages on certain departures are adapted to accommodate PMDs, therefore they used their manual wheelchair for trips by train.

To feel worthy and equal as a citizen - the importance of financial resources

This category describes the participants’ different experiences of legislation exercised by society and how that effect their economy, and possibilities to equal participation. Financial resources were not only seen as something practical to get what’s needed. The rules for funding, and how they were interpreted by officials, were also seen as an expression of societal attitudes, i.e., how society valued the participants as citizens.

Laws and policies as bearers of equality - concerning costs, support and service

All participants appreciated the opportunity to borrow a PMD without charge, and expressed that the extra cost of the insurance and electricity was worth every penny. The experiences of support and service from healthcare services were varied. Some participants raised the issue of long waiting times and difficulties getting the PMDs into repair or service, while others shared positive experiences of quick and competent service both in regard to prescription and repairs.

‘I had a flat tire. Then they came, and it didn't take long. And then we have booked an appointment, I have always been there once a year. I usually ask them to check some bolts and do an overall check. It has worked a hundred percent.’ (Woman I, elderly)

Extra costs for the individual user was described as restricting the freedom to use a PMD, such as the extra cost for checking in the PMD at the airport when traveling abroad. Because of this extra cost, many participants choose the manual wheelchair when traveling, which imparts a feeling of dependence as they then need help from others to move around.

Feeling worthy or not due to financial support or restrictions

The participants’ descriptions showed that the authority exercised by society affected their feelings of being a worthy and equal citizen. The experiences of support from authorities split the participants into two groups; those who had been denied financial support and those with good experiences of getting support for adaptations to facilitate use of the PMD.

‘I’ve been given a big car that’s been adapted with a ramp. I drop the ramp and reverse this [PMD] into the car. It's really easy. When I go on holidays, we can bring both this [PMD] and the ordinary wheelchair. It's really great!' (Woman H, middle age)

The policies concerning economic support for adaptations were sometimes perceived as a barrier. Existing solutions might not be appropriate, yet constitute barriers to economic support for further adaptations.

‘But if you have your own garage, then you are not allowed this [specially designed freestanding PMD garage]. My garage is not heated, so I have to take this [the PMD] into the house in winter. And that's very muddy and so on. Because you must not store it below 10 degrees.' (Woman H, middle age)

The participants described different financial resources; some were able to finance their own adaptations if society denied them help, but most did not have the resources. Even a participant that could pay for adaptations described feelings of discrimination and of being less worthy. Insurance companies also caused feelings of discrimination to some of the participants by denying the inclusion of PMDs on insurance policies. Some of the older participants felt less worthy and discriminated by authorities in regard to age. In Sweden persons over the age of 65 are not eligible for financial support for car adaptations, but as the participants stated, people over 65 still is dependent of a car to be able to independently participate in society.

Discussion

This study shows that the use of PMD is influenced by several environmental factors with direct, or indirect, attitudes as a common characteristic. Interestingly, it is apparent that the less researched environmental factor “attitudes” has the greatest influence on all the other environmental factors. Attitudes influence both the prescription of the PMD, the actual use of the PMD, and thereby also the occupational performance and participation for the person using a PMD. The social attitudes are either direct responses from others people, or indirect consequences from how legislation and guidelines are formulated, interpreted and applied. How the participants perceived the environment were also dependent on habits and occupational patterns, meaning that what they wanted or needed to do influenced their perceptions. These findings strengthen the theoretical approach in the PEO model, which emphasizes the interaction between person, environment and occupation [19] but also that people can experience the influence of the environment differently [20]. This means that the participants willingness and habits to perform different activities in combination with how well their PMD is matched to their needs influence how they perceive different environmental factors. For example, a small PMD scooter model is perfect for a person who likes shopping but useless for a person who likes walks in the forest. Another aspect is that habits and occupational patterns change over time. For example, PMD users with congenital disabilities may over the years adapt their habits to what is doable with their PMD. They may therefore experience less barriers in the environment than PMD users with acquired disabilities. To investigate this was not within the scope of this study but could be an area for future research.

Similar to other studies [5,29,30], our findings show that using a PMD means freedom but that this is a conditional, fragile freedom because it depends on the nature of the surrounding environment. This is in line with the recent meta-synthesis that also highlights the duality in PMD use, and that this duality is based on the interaction with the environment [30]. However, in these studies mainly one or two environmental factors at a time where studied, the physical environment and the social environment. Our findings generate additional knowledge about the interaction between multiple environmental factors and how the interaction influences PMD use in a broad perspective. Further, our findings show that attitudes in society, directly or indirectly, can constitute barriers for the participants in this study. Feelings of discrimination due to directs attitudes from a wider population is in line with earlier studies [5,7,8]. The participants in our study felt that discrimination in society was a result of people’s ignorance, lack of respect or lack of knowledge about PMD use. To improve knowledge of the needs of PMD users in the city environment, city planning needs to involve the people who use PMDs and should include user organizations and healthcare professionals.

As in most Northern European countries, the users of PMD in this study are satisfied with a service delivery system that enables them to borrow a PMD for free [15–17]. Our findings also show that the service delivery process affects the actual use of a PMD. This is not unexpected. However, what is less expected is the importance of the attitude of the prescriber. This strongly influences the matching process, and, consequently, the use of the PMD. Perfect matching requires a sensitive and competent prescriber, who also involves the user in the matching process. Our findings show that the interaction between PMD user and prescriber could be improved, and the importance of the individual’s opportunity to be active and involved in the prescription process is highlighted. The importance of involvement is supported by earlier studies on assistive technology devices [5,31,32]. Our study also highlights the participants’ differing abilities and power of initiative. One conclusion could be that the prescriber must take responsibility for inviting the user into the process and cannot assume that the user will take the initiative. Moreover, our findings show that the possibility of complying with the individual’s own choice is essential for a successful matching experience. Participants in this study expressed their dislike of using a PMD that was the wrong color, and which did not look attractive, and this impacted their use. Similar results have been shown in earlier research [33–35]. Meeting the PMD users’ needs may be challenging for the national budget, although a higher number of satisfied users would hopefully lead to increased use of prescribed PMDs and improved societal participation. Attempts have been made to measure the benefit and costs of PMD prescriptions in a small pilot study by evaluating the users’ occupational performance, societal participation and life satisfaction. These three factors appeared to improve for satisfied users of PMDs. The use of PMDs also appears to be beneficial for the user’s personal financial situation and for the national economy [36]. A more recent study showed that PMD prescriptions might be cost effective although a useful valuation of time savings is lacking [37]. Hence, further studies on the costs and benefits of PMD use are necessary.

The physical environment is the most researched environmental factor, and in line with previous research, our findings show that the physical environment has a major impact on use of PMDs [6–12,38,39]. Our findings show that users of PMD have difficulties to enter shops, restaurants, public places, beaches and forests, which make them feel discriminated. A new Swedish Act against discrimination was passed in 2015 [40]. Hopefully, in the near future, the Act will lead to improved accessibility and participation in society for PMD users. Therefore, the Act’s eventual impact on physical environment could be an area of future research.

As in most societies, people with financial resources are able to afford advantages. Our study shows that PMD users with financial resources solved their transportation or storage problems, while less well-off users needed to rely on contributions (or grants) from their local communities. This inequality influence to what degree different participants felt that the political environment had an impact on their use of PMD. Our findings also show that PMD users over 65 years of age feel discriminated against by legislation that prevents them from participating in society. Discrimination against the elderly is also common in other countries [41]. Additionally, users of PMDs of all ages have previously declared that the authorities, rules and regulations do not sufficiently support the use of PMDs [39]. Thus, the political environment, in this case, laws and policies regarding financial support strongly influence accessibility in society and participation for PMD users. It could be considered that everyone should have a right to access his or her PMD, e.g. by being provided with a garage in which to store and charge the PMD so it can be used in any season. In our study, participants reported problems during the winter, when they are forced to store a dirty PMD in a cramped apartment. This statement is an example of the theme of this study. The freedom provided by using a PMD is conditional and, as an example, depends on the weather and the laws that hinder the adaptation of the individual’s physical environment (by providing a garage). Another aspect is how laws are interpreted and the attitude of officials. To promote the use of PMDs and thereby the user’s potential to participate in society, politicians and officials need to increase their understanding of the use of PMDs. They must promote PMD users and their potential to fully participate, meaning, to be both attendant and involved in their life situation, within all societal environments.

Methodological considerations

In this study an inductive approach was used that strengthens credibility through the possibility of gathering thick descriptions and new information and to ensure that all data are accounted for. Another method could have been to use a deductive approach with the ICF definition of environmental factors as a grid in the analysis. However, such a deductive approach might increase the risk of missing valuable data outside the grid and therefore negatively affect the credibility of the findings. To strengthen the dependability of the study, an interview guide that had previously been successfully used in two studies on environmental factors and assistive devices was used [27,28]. Before using it in this context, it was piloted. The interview guide was based on key words incorporating environmental factors from the ICF definition of environment. This enabled us to capture many different aspects of the environment in the interviews, which also strengthened the credibility of this study. However, during the analysis it was a challenge to see beyond the ICF definitions and concepts, which might have been a possible disadvantage, although overall, the positive aspects of using the ICF definition outweigh any slight disadvantages. Furthermore, the use of quotations strengthens the confirmability and, in addition, the varied sample may also strengthen the credibility of the results [24]. However, it is a challenge to translate quotes from an original language and avoid misinterpretations; therefore, a professional translator has been involved. Further, to strengthen the credibility all analyses were made in the original language [42]. To enhance the readers’ opportunity to judge transferability, efforts were made to describe the participants in as detailed manner as possible, as well as the methods used [43]. The varied sample of both men and women of different ages with differing etiology and using different types of PMDs also gives strength to transferability. The aspect of participants using different types of PMDs was not analyzed since this was not a comparative study. It might be that the experiences of participants with scooter models who are able to walk a short distance differed from those of the participants with joystick models who always use a PMD. However, the overall impression of the interviews was that most experiences were common to the users of the various PMD models. The main differences were due to the person's will’ and habits, and how well the technology had been matched to the person's needs.

Conclusion

The findings show that societal attitudes influence all other environmental factors, directly by others people’s attitudes, or indirectly by how legislation and guidelines are formulated, interpreted and applied. Thus, a change of societal attitudes seems necessary in order to increase accessibility and participation for users of PMDs. Society needs to increase its understanding of the barriers to which PMD users face on a daily basis. One way might be to increase the involvement of PMD users in various aspects of society, e.g. legislation, news surveillance, social media, film and television. Additionally, the prescriber’s attitude is crucial to optimal PMD use. In order to accommodate all individuals, the prescribers need to be more aware of their responsibility to involve the user in the service delivery process for PMDs.

Acknowledgements

The authors would like to thank the prescribers and the Centre for service and delivery of assistive technology in Region Örebro County for their contribution in the data collection.

Disclosure statement

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This research was funded by the Uppsala–Örebro Regional Research Council and the Research Committee of Örebro County Council, Sweden.