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

Abstract

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 REHABILITATION

• Providing 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.

Keywords:

• Manual wheelchairs
• WHO 8-step
• outcome measures
• service delivery
• training
• low- and middle-income countries

Acknowledgments

The authors thank the personnel of Momentum Wheels for Humanity (formerly UCP Wheels for Humanity) and the University of Pittsburgh, the data collectors from the University of El Salvador, and the personnel of each service delivery centre in El Salvador. The authors declare that this manuscript is original, has not been published before and is not currently being considered for publication elsewhere.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

All data files of this study are publicly available from the OPEN-ICPSR (Inter-university Consortium for Political and Social Research) database at https://doi.org/10.3886/E173201V1.

Additional information

Funding

The study was supported with a grant from Google.org [grant #322068] which was awarded to United Cerebral Palsy - Wheels for Humanity (UCPW). Additional funding to support the drafting of this manuscript by the University of Pittsburgh staff was provided by the support of the American People through the United States Agency for International Development (USAID). The contents of this manuscript are the sole responsibility of authors and do not necessarily reflect the review of Google.org, USAID or the United States Government.

Notes on contributors

Yasmin Garcia-Mendez

Yasmin Garcia-Mendez is the Technical Advisor of Momentum Wheels for Humanity. She earned her BS in Biomedical Engineering at the Universidad Iberoamericana in Mexico City and a MS in Rehabilitation Science at the University of Pittsburgh, PA, USA. Her research interests are in the areas of in assistive technology, public health, and regulation.

Megan D’Innocenzo

Megan D’Innocenzo earned her BS in Exercise Science from Slippery Rock University and her MS in Health, Physical Activity and Chronic Disease, with a concentration in statistics, from the University of Pittsburgh. Her research interests are in the areas of in rehabilitation technology, public health, and statistical analysis.

Jonathan Pearlman

Jonathan Pearlman is an Associate Professor and Chair of the Department of Rehabilitation Science and Technology. Pearlman earned his BS and MS in mechanical engineering at UC Berkeley and Cornell University, respectively. Pearlman completed his PhD work in Rehabilitation Science and Technology at the University of Pittsburgh in 2007, with an emphasis on assistive technology design and transfer to developing countries. His research interests are in the areas of participatory action design, assistive technology transfer methods, and new product development.

Stephanie Vásquez-Gabela

Stephanie Vásquez Gabela serves as Clinical and Research Manager at the University of Pittsburgh and as a Rehabilitation Engineer at the UPMC-Center for Assistive Technology. Stephanie holds a BS in Mechatronics Engineering and a MS in Rehabilitation Science & Technology. She is involved in projects on wheelchair testing and standards. She is interested in public policy for rehabilitation and access to Assistive Technology in low- and middle-income countries.

Perth Rosen

Perth Rosen is Senior Advisor to Momentum Wheels for Humanity and international development consultant. Rosen earned a degree in International Development from UC Boulder in 2000 and a Master in Advanced International Relations from the University of Queensland in 2008. She specializes in health security and health equity and between 2016-2022 led programming that increased access to rehabilitation and assistive technology in low-and-middle income countries.

Maria-Virginia Rodriguez-Funes

Maria-Virginia Rodriguez-Funes is the Quality Officer at the National Hospital Rosales in El Salvador. She was the Clinical Research Coordinator at the Faculty of Medicine in the University of El Salvador at the time of the study. She earned her MD at the Universidad Evangélica de El Salvador and a Master in Public Health at the Universidad Centroamericana José Simeón Cañas, El Salvador. She is a member of the Red Bioetica Latinoamericana UNESCO.

R. Lee Kirby

R. Lee Kirby received his MD degree from Dalhousie University in Halifax, Nova Scotia, Canada. His specialty training in Physical Medicine and Rehabilitation was carried out at the University of Washington in Seattle, Washington, USA, at Dalhousie University and at Stoke Mandeville Hospital in England. He is a Professor in the Division of Physical Medicine and Rehabilitation in the Department of Medicine at Dalhousie University with a cross-appointment in Community Health and Epidemiology. His primary research interest is the safety and performance of wheelchairs. He has held research grants from several national and international funding bodies. He has authored or co-authored 2 books and 175 papers in peer-reviewed journals. He heads the team that developed the Wheelchair Skills Program, a low-tech, high-impact training program that is relevant for both more- and less-resourced settings.

Anand Mhatre

Anand Mhatre is an Assistant Professor in the Department of Occupational Therapy at the Ohio State University. He has a PhD and post doctorate in Rehabilitation Science, a master’s degree in manufacturing systems engineering and a bachelor’s degree in mechanical engineering. Dr. Mhatre’s work focuses on technology development, standards development, user testing and technology transfer. He has taught undergraduate and graduate students product design in health science and engineering schools. He serves as an active member of the ISO committee for wheelchair standards and CLASP Product Advisory Council for global mobility aids procurement, among several other committees.