The challenges of wheelchair provision and use in less resourced settings are the focus of global efforts to enhance wheelchair service delivery. The shortage of professional wheelchair service providers in these settings necessitates the collaboration of multiple stakeholders, including community-based rehabilitation (CBR) workers, whose role needs to be further understood.
The aim of this study was to determine what CBR workers in three areas of Uganda perceived as (1) the challenges with wheelchair provision and use, (2) the factors contributing to these challenges, (3) the role they themselves can potentially play and (4) what facilitators they need to achieve this.
This qualitative study in the transformative paradigm comprised focus group discussions to gather perceptions from 21 CBR workers in three areas of Uganda, each with an operational wheelchair service, participant observations and field notes. Thematic analysis of data was implemented.
Community-based rehabilitation workers’ perceptions of challenges were similar while perceived
Community-based rehabilitation workers can contribute in various ways to wheelchair service delivery and inclusion of wheelchair users; however, their capabilities are not consistently applied. Considering the diversity of contextual challenges, CBR workers’ range of responsive approaches, knowledge of networks and ability to work in the community make their input valuable. However, to optimise their contribution, specific planning for their training and financial needs and effective engagement in the wheelchair services delivery system are essential.
wheelchairs; less resourced settings; community-based rehabilitation; wheelchair service provision; service steps; Uganda; empowerment; inclusion; assistive device.
The right to personal mobility is mandated by the United Nations Convention on the Rights of Persons with Disability (UNCRPD) (UN
Wheelchair service delivery includes eight sequential service steps described in
Service delivery steps.
No. | Step | Description |
---|---|---|
1 | Referral and appointment | Identifying, referring and making appointments for persons with disabilities to ensure equitable access to the wheelchair service. |
2 | Assessment | Individual assessment to determine needs related to lifestyle, vocation, home environment and physical condition. |
3 | Prescription | Process to identify wheelchair type and training needs. |
4 | Funding and ordering | Identifying funding source and ordering the wheelchair. |
5 | Product preparation | Trained personnel prepare the wheelchair for initial fitting. |
6 | Fitting | The user tries the wheelchair and final adjustments are carried out to ensure the wheelchair is correctly assembled and set up for the user. |
7 | User training | Instructions on how to safely and effectively use and maintain the wheelchair. |
8 | Follow-up, repair and maintenance | Opportunities to check the fit, comfort and stability of the user, ensure the wheelchair is in good working condition and maximise functioning. |
The World Disability Report estimates that, in low- and middle-income countries, only 5% – 15% of those needing a wheelchair have what they need (WHO
Consequently, services are commonly centralised and limited to cities and large towns, impeding access for people from remote and rural communities (WHO
Community-based rehabilitation has been recommended as a strategy to address some of these challenges: stakeholders at the 2006 international consensus conference on wheelchairs pointed out that ‘unless CBR is involved in wheelchair provision, we will not reach very far’ (ISPO
While provision of assistive devices is included under the health domain of the CBR matrix, access to and use of an appropriate device impacts every domain (Heinicke-Motshe
The practice of CBR varies greatly because of its inherent focus on individual needs, the varied organisations initiating CBR programmes and variants of training for CBR workers in different organisations and communities (Chappell & Johannsmeier
An overview of key events in the history of wheelchair provision in Uganda is presented in
Overview of key events in the wheelchair provision in Uganda.
Year | Historical development | References |
---|---|---|
1967 | The start of the wheelchair sector in Uganda. | Øderud, Brodtkorb & Hotchkiss |
1992 | CBR adopted by Uganda Ministry of Gender, Labour and Social development (MGLSD). | Abimanyi-Ochom & Mannan |
2004 | Establishment of The National Wheelchair Coordinating Committee (NWCC). Research in 2005 recommended that a wider range of community organisations pay attention to wheelchair provision. | Mukisa & UNAPD 2005 |
2006 | Launch of Uganda’s National Policy on Disability, inclusive of provision of assistive devices. Highlights the role of civil society organisations and DPOs. | MGLSD |
2008 | Uganda ratified the UNCRPD. | Abimanyi-Ochom & Mannan |
2011 | Launch of the ‘Code of practice for design, production, supply and distribution of wheelchairs and tricycles’ drawing on principles of the WHO Wheelchair Guidelines. | UNBS 2015 |
2013 | UNCRPD report by the National Union of Disabled Persons Uganda (NUDIPU) estimated that 80% of PWD are in rural areas. |
Abimanyi-Ochom & Mannan |
2015 | Updated ‘Code of practice for design, production, supply and provision of wheelchairs and tricycles’. | UNBS 2015 |
UNBS, Uganda National Bureau of Standard; DPO, Disable People’s Organisation; PWD, persons with disabilities; UNCRPD, United Nations Convention on the Rights of Persons with Disability.
Since 1967 when local production of wheelchairs was initiated in Uganda, challenges in the wheelchair sector have included a lack of awareness, insufficient skills and absence of clear roles and responsibilities of stakeholders (Øderud et al.
Uganda has adopted a CBR approach and the WHO Wheelchair Guidelines (UNBS
It is crucial to understand the community perspective and include the voice of CBR workers in creating solutions to the complexities and ensuring long-term change (Owusu-Ansah & Mji
What do CBR workers in three areas of Uganda, each with a wheelchair service, perceive as the challenges with wheelchair provision and use in their communities? How do they think they can assist to overcome these and what facilitators are needed to achieve this?
Objectives were to determine what CBR workers perceive as:
the challenges with wheelchair provision and use
the factors contributing to these challenges
the role they can play
the facilitators needed to achieve this.
A descriptive, qualitative design was applied, with participative aspects as recommended when carrying out research including CBR workers (Deepak et al.
The three areas of Uganda (
Kisubi, an area both rural and urban, in Wakiso district, 40 km north of the capital, Kampala.
Kasese, a rural and remote mountainous area in the west.
Gulu, a predominantly rural area in the north.
The three areas in Uganda from which participants were recruited: Kisubi in the Central region (bottom right), Kasese in the Eastern region (left) and Gulu in the Northern region (top).
The situation in the three areas differed making this a diverse sample. Wheelchair services, all active less than 18 months, were delivered by a non-government hospital, mission hospital and a government district hospital. Personnel from the occupational therapy, physiotherapy and/or orthopaedic technology departments had been trained and were providing the service alongside other professional functions.
The CBR programmes identified per area were operated by three different types of organisations including a department in the same hospital as the wheelchair service, a non-governmental organisation (NGO) working with parents of children with disabilities and disabled people’s organisation.
Summarised overview of geography, wheelchair services and community-based rehabilitation programmes per study setting.
Variable | 1. Central region – Kisubi | 2. Western region – Kasese | 3. Northern region – Gulu |
---|---|---|---|
Description of area | Mix of urban and rural living | Rural, remote & mountainous | Predominantly rural |
Wheelchair service delivery by: | NGO rehabilitation hospital and rehabilitation centre | Local mission hospital | District Hospital – Ministry of Health |
Description of wheelchair service at time of the study | Active for 1 year 11 months. |
Active for 1 year 3 months. |
Active for 1 year 6 months |
CBR programme delivery by: | Department at the same NGO hospital as the wheelchair service | NGO: Association of parents with children with disabilities | NGO: Disabled Peoples Organisation |
Description of activities | CBR programme with workers based at the hospital and network of volunteers in the community | CBR activities with volunteers supporting children and families | Community workers supporting PWD in their homes |
CBR, community-based rehabilitation; NGO, non-government organisation; PWD, persons with disabilities.
Purposive sampling was used to identify three community-based organisations (CBOs) who were known by the researcher to be working with the wheelchair services, and then CBR workers working for, or in collaboration with, these CBOs. The inclusion criteria required participants to have a role supporting wheelchair users, to have at least 6 months’ experience working in the particular geographical area and to have worked with a minimum of 10 beneficiaries of the new wheelchair service. Job titles varied, and for the purposes of this article, ‘CBR workers’ was used. To avoid influence of power that researcher or CBO manager bias could have caused, each CBO manager appointed a focal person who, with written information on the purpose of the study, inclusion criteria and ethical considerations, assisted with initial selection and recruitment (Mertens
The final participant group (
Summary of participant profiles.
Variable | Central region – Kisubi | Western region – Kasese | Northern region – Gulu |
---|---|---|---|
Total numbers | Total: 7 |
Total: 8 |
Total: 6 |
Participants’ disability status and/or relationship to a wheelchair user | 3 PWD (1 wheelchair user) | 2 PWD (1 wheelchair user) |
4 PWD |
CBR organisation | 4 CBR workers based at CBO; 3 volunteers in community (local councillors) | 3 CBR workers directly connected with CBO; 4 with other CBOs; 1 based at mission hospital | 4 directly connected with CBO; 2 with other CBOs |
Professional qualifications; CBR training and experience (in years) | 1 occupational therapist; 1 physiotherapist; 1 social worker with additional CBR training. |
5 people had attended the CBR training course delivered through COMBRA |
1 social worker, |
Details of past wheelchair training | 4 attended 3-day training facilitated by the wheelchair service in 2015. One other had 1 day in 2013 | 4 had training ranging from 2 h to 2 days in 2014 delivered by the wheelchair service | One person received an orientation |
COMBRA, Community-Based Rehabilitation Alliance; CBR, community-based rehabilitation; CBO, community-based organisation; PWD, persons with disabilities.
In each of the three research sites (in the central area, in the west and finally in the north), data collection was done in two steps in March 2015. Thus, all participants first completed a structured self-administered demographic and general information questionnaire in English or in their local language (compiled in
What are the challenges for people who need or use wheelchairs in your community?
What are the reasons for these challenges?
What can you do about it?
What do you need?
Such an approach is often used in community development (Chambers
Field notes and the researcher’s reflective journal entries captured observations and thoughts before, during and after each FGD and were also included in analysis, as also described by Birks, Chapman and Francis (
Data sets from each source, named Area 1 (Central), Area 2 (West) and Area 3 (North), included questionnaire responses translated as needed and transferred to a password protected Excel sheet, FGDs recorded verbatim and the English contributions transcribed, flip charts, field notes and reflective journal entries.
Six phases of thematic analysis as described by Braun and Clarke (
Once themes and subthemes were identified, the transcriptions were confirmed against the electronically captured flip chart notes and combined with the researcher’s field notes and journal observations into one comprehensive document for each focus group. Finally, a consolidated table was prepared to capture the themes and subthemes from the three data sources (areas 1, 2 and 3) to expose similarities and differences through data triangulation from the three data sources (Carter et al.
Qualitative research is by nature idiographic but gathers rich detail of valuable experiences and can enhance learning of complex environments (Carter, Lubinsky & Domholdt
The South African Medical Research Council (MRC) guidelines (MRC 2004) were applied and permissions were obtained from the Stellenbosch University Health Research Ethics Committee (S14/10/210) and the Uganda National Council for Science and Technology. All participants provided written informed consent, either in English or in the applicable regional language or dialect. The researcher was mindful of possible interventionist-researcher bias (O’Leary
The findings and the discussion are integrated here to reduce duplication. A tabulated overview of the relationship between the study objectives, the guiding questions, the resultant themes and subthemes, as well as the frameworks used to interpret them is presented in
Tabulated overview of the link between the objectives, the guiding questions, frameworks applied (for analysis), themes and subthemes.
Objectives To determine what CBR workers perceive as: | Questions for focus group discussions | Applied frameworks | Themes and subthemes |
---|---|---|---|
The challenges with wheelchair provision and use. | ‘What are the challenges?’ | ICF: Activity limitation and participation restrictions | Theme 1: Challenges identified Mobility limitations Participation restrictions Unavailable and/or unskilled support system Difficulty maintaining health. |
The factors contributing to these challenges. | ‘What are the reasons for these challenges?’ | ICF: Contextual factors: that is, Environmental factors including wheelchairs and 8 wheelchair service steps; personal factors | Theme 2: Contributing factors Inadequate supply of appropriate wheelchairs Inadequate services, systems and policy Attitudes and cultural barriers Inaccessible physical environments Lack of peer role models Poverty. |
The role they can play. | ‘What can you do about these challenges?’ | 8 Wheelchair service steps |
Theme 3: Potential role of CBR workers Facilitate access to services Assist with user training, follow-up, maintenance and repairs Facilitate empowerment and inclusion Gather statistics. |
The prerequisite facilitators to achieve this. | ‘What do you need in order to do this?’ | Training for transformation (Hope & Timmel |
Theme 4: Facilitators needed to achieve this Training related to wheelchairs Communication with wheelchair services Financial resources More CBR workers Recognition of CBR workers in communities and hospitals Opportunities for peer support. |
ICF, International Classification of Functioning, Disability and Health; CBR, community-based rehabilitation.
In response to objectives 1 and 2, the International Classification of Functioning, Disability and Health (ICF) (WHO
The CBR workers across the three groups indicated that the number of people needing wheelchairs was high. In the west and north, both areas with large rural communities, the need was estimated to be far greater than officially known.
West: ‘Those people who don’t reach into the community think there’s not many disabled persons. Most of these parents hide their children. We as CBR workers know about these people because we’ve been deep in the village.’
Additional reasons for people lacking the necessary mobility device included lack of awareness of the service and policy literacy regarding their rights, low service capacity, lack of appropriate products and attitudinal barriers.
CBR workers from the central and northern areas explained the negative experiences of approaches to providing wheelchairs by some local producers,
Central: ‘Some organisations say I’ve got 50 wheelchairs. Then the issue of not being measured and assessed also comes in, because it’s a gift. Have that one! If it fits you – good! If it doesn’t fit you, you still have it.’
Conversely, for those who did access the new wheelchair services, feedback from the CBR workers highlighted benefits to users, similar to recent findings in Kenya and the Philippines (Williams et al.
North: ‘There is assessment [ ] they take measurements, [
Despite the availability and benefit of the new wheelchair services, the CBR workers identified challenges with access and utilisation. In the north and central areas, apparent gaps between policies and their implementation resulted in confusion for PWD as well as the CBR workers and further reduced use of the available services.
Central: ‘Uganda are supposed to produce wheelchairs, but you are finding because the government doesn’t have a goodwill, there’s no proper funding. The guidelines are also weak and personnel are very few. [ ] That’s why production wheelchairs is very low.’
North: ‘In Uganda the law says the government should assess PWD and provide them with movement facilities. So I think maybe PWD [ ] know their rights, and that’s why they won’t pay.’
North: ‘Our situation is not that we have very few wheelchairs – the wheelchairs are there. Or that the need for the wheelchair is not there – it is there. But they are not given out as fast as possible because people think that it has to go for free.’
Attitudinal barriers were cited as a further reason why people lacked mobility. The groups from the north and west explained that many people were too afraid to access the health facilities in which the new wheelchair services were located fearing negative attitudes and behaviours directed towards them. Persons with disabilities from the north pressured the CBO to continue to provide them with wheelchairs rather than refer them to the hospitals.
North: ‘If one is afraid [
This echoes findings in southern Africa where historical and a prevailing medical model approach to disability resulted in fears of PWD regarding discrimination from health providers leading to their avoidance of health institutions (Grut et al.
According to CBR workers from the north, some people also resisted referrals to the wheelchair service because of past disappointments, which included products promised and not received; services only provided to select groups; or once acquired, the wheelchair not being suitable. Such disappointments result in lack of trust to accept new opportunities (Grut et al.
Central: ‘I stood on my feet and said no, my child won’t get a wheelchair. That would mean they would never walk again.’
Despite the positive experience of the new service approach, the length of the process and the resulting low output of the services were experienced negatively. Reasons given for the delays and low output in the north included limited service personnel; wheelchair service delivery restricted to 1 day a week; and, as previously highlighted by Bray et al. (
West: ‘Transporting those wheelchairs, [ ] and two technicians from [
North: ‘You may need to travel to the hospital, maybe twice or even three times to access the chair, and most of the parents give up.’
Earlier findings elsewhere indicate that insufficient maintenance led to premature wear and tear and avoidable break down (Bazant et al.
North: ‘General negligence around maintenance… a simple problem on a wheelchair that could be fixed is usually not done till the problem gets worse.’
West: ‘This repair has to be done in the (service). This parent has no money and the distance is too long.’
Concurring with findings by Toro et al. (
Central: ‘Sometimes we give wheelchairs to these people, but then it doesn’t change a lot in their quality of life. For example, if a child is school-going, and you give them a wheelchair, but still they stay at home?’
Using a wheelchair in these low income and often rural areas with multiple environmental and attitudinal barriers was reported to result in undue fatigue of the user and family and negatively influence agency. Interestingly, Grut et al. (
North: ‘We don’t use the road, we use the path and the path is very narrow. At times we have to cross the river, and there is no bridge, so you have to carry the wheelchair on your back or on a bicycle.’
Central: ‘She stopped over six taxis, but they were all leaving her because she had a wheelchair.’
Central: ‘It’s very expensive for someone who is very poor [ ]. These wheelchairs are bulky. [ ] If you use a Boda (motorbike taxi), then that means you have to get three, one for you, one for the wheelchair and one for your guide.’
West: ‘… their parents regard it as a tiresome exercise – they say they have a lot in terms of looking for survival, and now … getting time to spend on this child…?’
Central: ‘It’s the parents to decide which is more beneficial, him staying with the wheelchair at home, or the wheelchair being kept at school; it can’t be in two places [ ] it means he won’t move [ ], engage in play or interact with peers.’
There was also a lack of wheelchair users as positive role models:
North: ‘Most disabled children that have had limited exposure and mentorship from adult disabled person look at themselves as valueless in the community.’
Lang et al. (
Challenges including those discussed above contributed to high levels of dependence of wheelchair users. Reported caregiver support was however limited by their competing priorities, such as the need to earn an income or care for other children.
Central: ‘If this child has to be wheeled to school, [and] the mother has so many other commitments, he won’t attend school; because she’s the only person to wheel the boy.’
Extended family and community members were in some instances willing to assist, but lack of knowledge and skills impacted on safety and waning interest often reduced reliability.
Central: ‘At first some teachers were willing to do so, but then their attitude changed. I think because he was new [ ] but after he had stayed for a year, it feels like it’s a lot of work for them. Now no-one feels interested to do so.’
However, fears of vulnerability of women and girls also led to rejection of offers of support.
North: ‘Because of such support many especially the females have been objects of sexual abuse. Many because of this will want support from their parents or close relative. Most parents are very protective of the girl child.’
Thus, not participating in activities was at times preferable to requesting support and inconveniencing others.
In many instances, wheelchair users and assistants were reportedly not using the wheelchair correctly or optimally and not taking good care of it. This is similar to findings in other low-resourced settings (Bazant et al.
West: ‘…parents are trained but on a small scale because of limited time and few service providers and they don’t remember everything.’
Furthermore, the person receiving the initial training from the service was not always the main, only or permanent assistant but rather someone who was available at the time (e.g. the grandmother). Newly learnt skills were often not transferred to others in the family and local community thus further affecting how the wheelchair was used and maintained.
North: ‘The toolbox might be there but there is only a grandmother – don’t even know a spanner – you need someone who has a skill.’
North: ‘Sometimes even the family members are not aware of how to maintain the wheelchair and how to take care for that person. That’s why we find that the wheelchairs get destroyed.’
Wheelchair users struggled to maintain their health because of inappropriate wheelchair designs, misuse of wheelchairs and poorly fitting wheelchairs, factors previously also documented by Scovil et al. (
Similar to the findings in Zambia (Banda-Chalwe et al.
Central: ‘Kids who are using wheelchairs [ ] have to transfer from a wheelchair and then use their hands and enter in a latrine which is already very dirty. They end up getting secondary infections.’
Furthermore, lack of understanding and insight in the community presented risks to health management (e.g. when school children in the north were disciplined for transferring out of their wheelchairs when they wanted to change positions to relieve pressure). Health is further impacted when health needs are not recognised and medical input is not received timeously.
Central: ‘Because the mum is sick, and the child is not able to wheel herself, she finds herself not going to the hospital, even when she was supposed to get medication.’
In response to Objective 3, the WHO Wheelchair Service Delivery Steps as well as the WHO (
The participants here made a range of suggestions for their role. Including typical functions of CBR workers, such as referral, support and empowerment, they also highlighted their potential role in supporting wheelchair service delivery. They illustrated the contextual sensitivity required because of the wide range of challenges. Suggestions showed how their ability to move to the location of the PWD, to the wheelchair service and to other stakeholders and to spend the time needed provided them the opportunity to identify and address some of the diverse challenges. Their experience of working with PWD and understanding of local networks and contextual challenges contributed to various suggestions and further reinforced, as observed by Chappell and Johannsmeier (
The CBR workers who had observed wheelchair service delivery from assessment to fitting and user training commented on the efforts of the service personnel and the positive outcome and suggested that they could assist in the referral process by transferring information and encouraging people to accept referrals.
North: ‘You say that you pay some small amount of money, but the real cost of the wheelchair is almost a million [Uganda Kwacha/USD280]. [ ] If they have understood, then people will start paying that money.’
Other suggestions included arranging for PWD to reach the service by helping to raise funds, source transport and gather groups of PWD together along with facilitating the service providers to plan and prepare for outreach visits. Some of their stories highlighted determination and skills in communication and negotiation as useful traits to be effective – along with resources, such as telephones, airtime or money, to reach people.
West: ‘We talk to [
In some instances, accompanying the PWD to the service was perceived as useful to help them locate the service and overcome fears of unfamiliar situations. The impact for the service provider in accurate assessment is inferred in this statement.
West: ‘The CBR worker is known to the parent, [ ] then the parent will [
One participant suggested assisting with product preparation and/or user training during the service to increase service efficiency.
Following up the wheelchair user at home was advocated as a continuum of service for the CBR worked to reinforce, refresh or transfer skills and knowledge regarding use and maintenance of the wheelchair and to assist in overcoming environmental barriers in the home.
North: ‘Those mothers can have enough time with you to ask what they don’t know, and you also have enough time to explain to them and demonstrate.’
West: ‘Caretakers [ ] get tired. So, when they get tired, CBR workers make some follow-ups. You can train another one to carry on with the activity.’
Some participants suggested they could help with maintenance and basic wheelchair repairs during visits and others spoke of the importance of these visits to alert wheelchair services to critical issues needing their input. These follow-up visits would benefit durability and safety of the wheelchair (Chen et al.
Added benefits of home visits by CBR workers include awareness of and response to a range of common daily difficulties in communities where few people understand wheelchairs (Fefoame, Walugembe & Mpofu
Resilience, determination and resourcefulness along with utilising community networks were shown to impact inclusion elsewhere (Geiser & Boersma
North: ‘The community will act as vigilantes to see that assets, wheelchairs for people with disabilities, are protected. If the community is aware they will severely punish whoever causes problems.’
Participants perceived their potential role in identifying and strengthening peer role models and linking wheelchair users to one another for support (Chappell & Johannsmeier
North: ‘If we empower a wheelchair user they will be able to explain their own experience and they [
Some of the CBR workers in the north and central areas demonstrated that their exposure to the range of wheelchairs and provision approaches in their area could benefit wheelchair services, thus confirming earlier evidence (Fefoame et al.
When the CBR workers were asked what they required to fulfil what they had suggested, all groups identified training, financial resources and collaboration with health services, confirming earlier findings (Booyens et al.
North: ‘What I know is there is a need for capacity building [ ]. We may be doing different things.’
Only 10 of the 21 participants had received training on wheelchairs, and this ranged from 2 h to 3 days. Some recommended that the trainings should be attended by all CBR workers, while another mentioned that parts of the training received were not useful for his role.
Groups suggested similar items for training content including wheelchair types and features; mechanisms to access the service and a better understanding of why a new approach to wheelchair provision is needed. Furthermore, skills in using and maintaining the wheelchair and environmental accessibility and adaptations were also commonly identified as important skills (Heinicke-Motshe
Central: ‘It got me thinking this is not really something easy, I really got in their shoes, I must confess it was really hard.’
Close collaboration with the wheelchair services was advocated. For those CBR workers not based at the same location as the wheelchair service, receiving updated information and planning logistics typically depended on the efforts and resources of an individual CBR worker. As suggested by Geiser & Boersma (
Financial resources to make home and service visits possible were mostly lacking with some workers telling how they used their own resources, when available. Resources are thus required, also for empowerment activities such as introducing wheelchair users to peer role models. Some of the workers particularly in the west suggested tools to assist with basic repairs.
Many group contributions displayed passion, commitment and determination similar to that found by Booyens et al. (
One CBR worker showed interest in increasing skills to take measurements during follow-up to identify problems and alert the service. As recommended in the Accelovate study (Bazant et al.
Owing to the limited time frame, human and financial resources in this small scale study for degree purposes, only one FGD was possible per group. Data would have been richer with two or with other data collection methods aiding triangulation (Mack et al.
The findings indicate that stakeholders interested in developing or improving wheelchair service provision in low income contexts would benefit from engaging with local CBR workers to anticipate the challenges and factors which may affect access to wheelchair services and prevent PWDs from benefitting from an appropriate wheelchair. The potential role of CBR workers and facilitators for this role should be jointly identified with a plan to equip them and ensure effective collaboration. A standardised but flexible training package drawing on the WHO Wheelchair Service Training Packages developed by the international wheelchair or CBR community would simultaneously facilitate consistency and support trainers to adapt it and apply it to their context.
Further engagement with key stakeholders in Uganda could include the findings of the report and explore perspectives of other stakeholders on whether and how to further develop the role of CBR workers in wheelchair service provision. Further research is recommended in areas where CBR workers have been well equipped and purposively engaged to evaluate the impact, broaden the understanding on their role and implement the necessary steps to achieve this.
The CBR workers in this study identified and described many ongoing challenges for wheelchair users in the areas with wheelchair services, most notably the PWDs’ continued lack of mobility either from not accessing the wheelchair service or because of their wheelchair being damaged or worn out and from limited or inconsistent levels of participation. Perceived reasons were diverse and demonstrated the interaction between contextual barriers prevalent in low income settings with an undeveloped wheelchair service provision system.
With regard to the WHO comprehensive wheelchair service steps, the CBR workers expressed their role in identifying, referring and facilitating access to the service; reinforcing and transferring skills and knowledge in wheelchair use; carrying out home and community visits to follow-up; and contributing to maintain the wheelchair. Further, they can implement strategies for empowering wheelchair users and overcoming environmental barriers to participation. Their inputs on the CBR workers’ potential role indicated their insight to the diverse, observed challenges and highlighted how the attributes of CBR workers could benefit the system. Being at grassroots level, being known to the community and being familiar with the culture and networks equip them to identify issues and navigate solutions. Their commitment to PWD was evident in the wide range of suggestions on how they, with the needed support, could assist.
Determining and formalising the role of the CBR workers in collaboration with the wheelchair service could achieve a degree of consistency in their role, enable comparability and ensure that the wheelchair service can benefit from their grassroots experience. Suggestions to achieve and maintain this included provision of training and financial resources and establishing effective communications between the CBR workers and the wheelchair service providers.
The authors gratefully acknowledge the support of Motivation Charitable Trust during this study for financial, human resources and logistical support. The authors would also like to acknowledge the valuable and constructive inputs of the late Dr Paul Chappell and Mrs Gakeemah Inglis-Jassiem during the examination stage of this study for degree purposes and those of the anonymous peer reviewers. All three authors were affiliated to Stellenbosch University, Centre for Rehabilitation Studies at the time of completing and writing up this study.
The authors declare that they have no competing interests with regard to the writing of this article.
N.S. carried out the research and wrote up the study as part of a structured master’s degree under the guidance of M.G. as main supervisor and E.S. as co-supervisor.
This research was partly funded by the Motivation Charitable Trust and the Harry Crossley Foundation (2015).