According to Borg, Larsson and Ö stergren (2011:165), assistive technology, which includes wheelchairs, ‘has been a missing bridge along the road to human rights and development … for many people, particularly in low-income countries’. The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) (UN 2006) specifically refers to the provision of assistive technology in five articles (Borg et al. 2011), with Article 20 focusing on personal mobility (UN 2006). For people with no or limited ability to walk, wheelchairs can enhance function and independence and may open opportunities for work and leisure which otherwise might have been impossible. Within a rights-based paradigm, wheelchairs are therefore essential tools in the promotion of user autonomy, dignity, freedom, inclusion and participation (Borg et al. 2011).

Function in a wheelchair is, however, dependent on a complex interaction between user characteristics, activities and social roles, the environment, wheelchair features as well as user assessment and training (Routhier et al. 2003). Thus wheelchairs should be appropriate to the users’ functional, environmental, posture support and durability needs (Pearlman et al. 2008; WHO 2008). Comprehensive rehabilitation and wheelchair services, as well as trained personnel are instrumental in providing appropriate wheelchairs and achieving right-based outcomes (WHO 2008).

Persons with mobility impairments in Southern Africa have limited access to appropriate wheelchairs and wheelchair services (Eide & Ø derud 2009; Eide et al. 2011; Visagie, Scheffler & Schneider 2013) with demand surpassing supply. Donor organisations often attempt to fill this void by donating wheelchairs in bulk, mostly basic folding and basic non-folding frame designs as shown in the examples in Figure 1.

The basic folding frame design is essentially for temporary or low active indoor use. Apart from height adjustable footplates, it lacks adjustability to optimise fit, posture support and function and is not appropriate for active use in less resourced settings (Eide & Ø derud 2009; Mukherjee & Samanta 2005; Pearlman et al. 2008; Toro et al. 2012). The non-folding wheelchair has a solid seat system, offers no adjustability and has a similar ergonomic design and thus shortcomings as the basic folding frame wheelchair (Mukherjee & Samanta 2005). Despite the limited gains in function and independence offered by these wheelchairs as described by Shore and Juillerat (2012), the limitations of these designs fuel the longstanding and ongoing debate on whether 'something is better than nothing’ (Pearlman et al. 2008; Rotary International 2014; WHO 2006).

In January 2012 the Comprehensive Mobility Support Project (CMSP) was implemented in Zimbabwe by the Jairos Jiri Association in partnership with Christian Blind Mission (CBM) and the Ministry of Health and Child Welfare (MOHCW n.d.). Financial support was provided by USAID. The aim of the project was to improve the quality of life of persons with mobility impairments in Zimbabwe by developing capacity and providing appropriate comprehensive wheelchair services. This paper presents baseline data collected during the CMSP and aims to add to the debate on whether any wheelchair is better than no wheelchair by describing satisfaction with wheelchairs, wheelchair services and wheelchair function of a group of Zimbabwean wheelchair users of primarily basic folding and rigid frame wheelchairs.

Zimbabwe is a landlocked country in Southern Africa covering 390 757 km². It is divided into 10 provinces of which two, Bulawayo and Harare, are cities with provincial status (Figure 2). Zimbabwe has a population of 13 million with a population density of 33 persons per square kilometre. Sixty-seven percent of the population live in rural areas. The life expectancy at birth is 38 years. Approximately 6% of the population live with a disability, of these 35.9% have difficulty moving and might require a wheelchair (ZIMSTAT 2013).

The majority of Zimbabweans are dependent on public healthcare provided by the MOHCW, complemented by non-governmental organisations and a small private sector (MOHCW n.d.). Rehabilitation services are provided by occupational and physiotherapists in urban centres, as well as rehabilitation technicians who are the primary providers in rural areas at the district hospitals and community-based rehabilitation (CBR) programmes. Rehabilitation technicians outnumber therapists at a ratio of approximately 2:1 (Personal communication with Medical Rehabilitation Practitioners’ Council of Zimbabwe, 09/04/2015). A situational analysis by the CMSP team found that Zimbabwe had no policy on wheelchair service provision and that wheelchair services were fragmented and poorly integrated in rehabilitation services. Limited numbers of wheelchairs were provided by hospitals as part of rehabilitation services, or purchased directly from retail shops. However, many wheelchairs were donated by non-governmental organisations, churches and politicians without any clinical or follow-up support services.

The study comprised a descriptive design with a quantitative and qualitative phase and is part of a larger mixed method descriptive study with a pre-test post-test component. A sequential explanatory strategy where qualitative data were collected after quantitative data in order to explore and contextualise quantitative findings through the experiences and perceptions of individual participants (Kroll, Neri & Miller 2005) was used. The larger study commenced in October 2013 and was completed in May 2014. This paper focuses on wheelchair users’ experiences prior to the implementation of the Comprehensive Mobility Support Project (CMSP) in 16 clinics. Data presented in this paper were collected between 30 October 2013 and 28 February 2014 at the 16 clinics in the Zimbabwean provinces of Harare, Mashonaland East, Matabeleland South, Bulawayo and Masvingo where the CMSP was to be implemented.

Although more than 60% of wheelchair users agreed that the wheelchair contributed to specific functions such as reaching and doing tasks at different heights, carrying out daily routines and personal care tasks as well as doing transfers, less than 50% agreed that it allowed them appropriate indoor and outdoor mobility (FEW scores). This finding was echoed in the respective adult and child QUEST items rating on satisfaction with wheelchair performance, namely effectiveness (Figure 3) and meeting user needs (Fig 4), where only 31% of adults and 39.4% of children were satisfied. Most everyday tasks, although performed in various settings, do not require much mobility in the wheelchair, and just being able to sit might assist in performing the tasks. Shore and Juillerat (2012) reported similar improvements in function with a basic non-folding wheelchair for users from Vietnam, India and Chile, whilst Mukherjee and Samanta (2005) reported similar mobility restrictions in a group of Indian wheelchair users of basic non-folding wheelchairs. Considering that a wheelchair is primarily a mobility aid, it should not only promote functional activities in sitting, but also promote in- and outdoor mobility.

In contrast with current study findings on satisfaction on wheelchair mobility, Bergstrom and Samuelsson (2006) found that 98% of Swedish users with SCI were satisfied with their indoor mobility and 80% with outdoor mobility. More than 60% of users in a regional study from South Africa agreed that the wheelchair allowed satisfactory indoor and outdoor mobility (Visagie, Duffield & Unger 2015). Environmental barriers were not explored in any one of the studies. The Swedish setting was presumably more urban and accessible and may have enhanced the performance of and satisfaction with the wheelchair and explain the higher satisfaction scores in the Swedish study. In contrast, the South African study had higher satisfaction scores than the current study, despite having a similar setting.

Several features that directly impact on mobility were rated in the QUEST 2.0 and 2.1. Figure 5 shows that, compared to adult users from other studies, users in this study were less satisfied with every wheelchair feature. Although study populations and settings differ, user satisfaction can be compared across these studies, as irrespective of contextual differences, a comprehensive wheelchair service should result in an appropriate wheelchair for each user which meets their functional, posture support, environmental and durability needs.

One explanation for the poor satisfaction with the wheelchair and the challenges with indoor and outdoor mobility found in the current study may be the features of both basic folding and non-folding frame wheelchairs (Figure 1). In these designs the user is positioned relatively high above and in front of the rear wheel axle, compromising efficient propulsion ergonomics, which together with a short wheelbase loads the front castors (Medola et al. 2014). The subsequent increase in rolling resistance requires more energy to propel the wheelchair (Medola et al. 2014; Mukherjee & Samanta 2005). The loaded castors also get stuck easily against obstacles and in holes or ruts and are difficult to lift when trying to clear these obstacles (Medola et al. 2014). Eventually users might lose the ability to push themselves (Ø derud 2014). Wheelchairs with longer wheelbases which reduce the weight on the front castors and ease propulsion on uneven or rough terrain may have increased user satisfaction.

Furthermore, neither wheelchair offers adjustability to optimise propulsion ergonomics. Wheelchairs with adjustable settings, particularly adjustable rear axle positions (Figure 6), contribute to higher levels of satisfaction and function (Bergstrom & Samuelsson 2006; Karmarkar et al. 2009; Medola et al. 2014; Rispin & Wee 2015; Samuelsson & Wressle 2008).

The higher satisfaction levels for outdoor mobility reported by Visagie et al. (2015) might be attributable to the features of the particular wheelchair designs used. In their study 43% of users used adjustable wheelchairs with features designed for outdoor environments (Figure 7). Rispin and Wee (2015) demonstrated the superiority of wheelchairs with a long wheelbase and adjustable rear wheel axle settings (Figure 7) in distance travelled, user satisfaction and physiological cost over basic folding frame wheelchairs when tested on rough, uneven tracks. Both users and service providers in the current study ascribed outdoor mobility challenges to only environmental barriers and seemingly failed to recognise the impact that appropriate wheelchair design and features may have on function and mobility. Similarly, they associated improved durability, safety and function of the local three-wheel wheelchairs with rigidity rather than the features such as a long wheelbase and lessened load on the front castors. These findings highlight the need for training of both groups on wheelchair design and how this relates to environment and user needs.

Comfort is an essential wheelchair feature and was ranked as one of the three key features by adults in the current study and other studies (Bergstrom & Samuelsson 2006; Samuelsson & Wressle 2008). Although comfort achieved the highest satisfaction rate (51.2%) in the current study, the percentage of satisfied users was still at least 10 percentage points below that of other studies (Figure 5) (Bergstrom & Samuelsson 2006; De Groot et al. 2011; Samuelsson & Wressle 2008). Mukherjee and Samanta (2005) found that comfort was ignored in the distribution of donated wheelchairs in India, resulting in higher dissatisfaction and contributed to wheelchairs being abandoned. Only one previous study reported very high levels of satisfaction with comfort (90%) (Samuelsson & Wressle 2008). In their study 80% of users were satisfied with all wheelchair features reflecting the impact of highly adjustable wheelchairs. The high levels of discomfort reported in the current study may be explained by the wheelchair designs that lack adjustability and an inadequate size range (Ø derud 2014), resulting in poor fit and posture support.

Adult users in the current study ranked durability as the most important feature of the wheelchair. Almost 80% of adults (Figure 3) and 70% of children (Figure 4) experienced durability and reliability problems, which may again be attributable to the use of wheelchairs with basic folding frame (Pearlman et al. 2008) and basic non-folding frame designs (Mukherjee & Samanta 2005). This design is not appropriate for active use on uneven terrain such as broken pavement, sand, dirt and mud commonly found in less resourced settings, resulting in undue stress and higher needs for repairs and replacement (Mukherjee & Samanta 2005; Ø derud 2014; Pearlman et al. 2008). Disrepair and safety considerations are common reasons for abandoning wheelchairs (Mukherjee & Samanta 2005; Toro et al. 2012). Durable wheelchairs have been associated with user satisfaction (Bergstrom & Samuelsson 2006; Visagie et al. 2015).

Similar to users in a South African study (Visagie et al. 2015), users in the current study were mainly dependent on minibus taxis for transport and experienced challenges related to attitudes, embarking and disembarking, as well as space. Taxi operators often either do not stop for wheelchair users or charge them extra (Cawood 2012; Chakwiriza et al. 2010), emphasising the need to consider specific wheelchair features for transport, together with an intersectoral approach to finding solutions for transport challenges.

The poor satisfaction rates and user comments on service delivery may reflect inadequate training of service providers. Both the UN Convention (UN 2006) and the WHO wheelchair guidelines (WHO 2008) promote comprehensive service delivery by trained service providers. Wheelchair services delivered by well-trained providers have been associated with increased satisfaction amongst wheelchair users (Bergstrom & Samuelsson 2006; Glumac et al. 2009; Routhier et al. 2003; Samuelsson & Wressle 2008). Users in the current study expressed more dissatisfaction with services compared to other studies (Figure 8). Varying and sometimes conflicting user needs (Bergstrom & Samuelsson 2006; Visagie et al. 2015) contribute to the complexity of wheelchair assessment, prescription, fitting and training; thus service personnel require adequate knowledge on wheelchair design, as well as the physical, environmental and psychological needs of the user (Bergstrom & Samuelsson 2006; Glumac et al. 2009; Routhier et al. 2003; Samuelsson & Wressle 2008; UN 2006; WHO 2008). Although occupational and/or physiotherapists commonly provide wheelchair services in resourced settings (Greer, Brasure & Wilt 2012; Samuelsson & Wressle 2008), rehabilitation technicians were the primary service providers in this study. The WHO wheelchair guidelines (WHO 2008) emphasise suitable training of wheelchair service providers rather than occupation and promote training of other categories of service providers such as community health care workers, community based rehabilitation workers, prosthetists, technicians and craftsmen.

Users were not consulted on their needs, received limited training, and little information. Inadequate service provision in this study negatively impacted on assessment, fit, user training, function and user rights. Visagie et al. (2013) demonstrated the negative impact that fragmented services may have on user outcomes. Similarly, Mukherjee and Samanta (2005) and Ø derud (2014) describes how in the absence of comprehensive service delivery, little if any user assessment is done and wheelchairs are provided without consideration of fit, posture support, functional and environmental needs. The subsequent poor match between the wheelchair features and user needs contribute to discomfort, poor mobility, loss of function and stability, poor durability, as well as safety challenges found in the current study and by Mukherjee and Samanta (2005) and Toro et al (2012). Adult users in this study ranked safety as one of the top three priorities for their wheelchair. Poor fit and posture support may compromise health needs and can cause secondary complications such as pelvic and trunk deformities and pressure ulcers, a common cause of mortality amongst wheelchair users (Ø derud 2014; Toro et al. 2012).

The high mechanical wheelchair failure reported (see durability and reliability items in Figures 3 and 4) necessitates adequate repair services, yet satisfaction with repair services was considerably lower compared to resourced settings (Bergstrom & Samuelsson 2006; De Groot et al. 2011; Samuelsson & Wressle 2008) (Figure 8). This may be due to a lack of technical knowledge and spare parts, which are common in less resourced settings (Mukherjee & Samanta 2005; Ø derud 2014; Toro et al. 2012). Most accidents in wheelchairs are due to technical malfunction and can be prevented by regular maintenance (Hansen, Tresse & Gunnarsson 2004).

Follow-up services were limited in this study. The 33% satisfaction with follow-up services is again much lower than the rates reported by De Groot et al. (2011), Samuelsson and Wressle (2008) and Bergstrom and Samuelsson (2006). Changing user needs, growth or changes in the health conditions make follow-up essential to ensure that problems with fit, posture support, function, durability and safety are identified and addressed (Hansen et al. 2004; Samuelsson & Wressle 2008; Toro et al. 2012; WHO 2008).

Findings of this study illustrate that donated wheelchairs provided without the necessary comprehensive support services can lead to poor user outcomes. Whilst outside the scope of this study, it is also important to mention that donations provided through a charity model can disempower users rather than promote their rights. Considering the cost of and the need for wheelchairs, many low-resourced settings like Zimbabwe will require donor assistance in its wheelchair service delivery. Donated wheelchairs, if appropriately managed by trained staff and through comprehensive services, can result in satisfactory user outcomes (Glumac et al. 2009).

In light of the challenges identified in Zimbabwe and the discussed positive impact of comprehensive services, trained staff and appropriate wheelchairs on user function and satisfaction, it is recommended that policy and minimum service standards based on evidence and good practice are developed to guide training of wheelchair service providers, wheelchair provision and wheelchair service delivery in Zimbabwe. Wheelchair services in Zimbabwe are heavily dependent on donations. To optimise the outcomes of the impact of these donations it is recommended that these guidelines include management strategies to source and distribute appropriate wheelchair donations through existing service networks. Monitoring and evaluation should form an integral part of the service standards and programme management at service, provincial and national level. The findings also showed a need for access to a wider range of wheelchair design options in order to meet different user functional, posture support and environmental needs. Further studies on the impact of the WHO guidelines (WHO 2008) on wheelchair service delivery, user satisfaction and function are recommended, as is studies on the impact on environmental factors on access to wheelchair services in less resourced settings. A systematic review of studies reporting adult satisfaction with wheelchairs using the QUEST 2.0 is also recommended.

The study contributes to the body of knowledge on wheelchair user satisfaction and function in less resourced settings. Compared to users from resourced countries, Zimbabwean users were on the whole much less satisfied with their wheelchairs and in particular with their overall mobility, wheelchair durability and comfort as well as wheelchair services. Users were excluded as active participants in the process and, subsequently, were not adequately informed and empowered about wheelchairs and their rights. The study found that, despite high levels of dissatisfaction, inappropriate wheelchairs contributed to some autonomy, freedom and independence in everyday tasks, but simultaneously emphasised the extent to which users` mobility impairment was perpetuated, particularly by failing to meet their environmental, mobility and durability needs. These factors will ultimately limit the users’ inclusion, participation, freedom and independence, whilst simultaneously increasing the risk for injury due to mechanical malfunction. Faced with something versus nothing, or an inappropriate rather than an appropriate wheelchair, users will always be grudgingly grateful: ‘You cannot expect much from a donation, but for you to be thankful’ (Man, 41, User).

But from a rights-based and mobility perspective, wheelchairs, wheelchair services and wheelchair donations should meet the objectives of Article 20 on personal mobility (UN 2006), and place the same value on wheelchairs that users do: ‘The value you put on your legs I place on my wheelchair’ (Woman, 26, user).