Training program and procedures
The One World project included all key elements of the Active Rehabilitation training camps described by Divanoglou et al. (2019). Participants of the training camp had to arrive at the site with their own manual wheelchairs. Individuals with physical disabilities from Morocco were invited to participate in the project if they met the following inclusion criteria: (a) had a physical disability that caused inability to walk; (b) were using a manual wheelchair as their main mode of mobility and were able to push it for a few meters on an even surface; (c) had to be free of severe complications such as pressure sores; (d) were at least 18 years of age; and (e) were residing in Morocco.
Duration period of the Active Rehabilitation camp usually varies from 5 to 10 days depending on available funding and personnel. In Morocco all participants with physical disabilities participated in a 6-day program (September 8-14, 2019) that included 9 training sessions (total for 29 hours). The camp was organized in wheelchair accessible facilities (Kenzi Club Agdal Medina, Marrakech, Morocco).
Activities of daily living and wheelchair skills training were incorporated into the camp schedule, and took place at the natural time and environment. Sports and therapeutic recreation activities such as cardiorespiratory fitness, strengthening and ball sports were part of the training. Education sessions during the camp were intended to help participants acquire or maintain knowledge that would allow them to optimally manage their condition. Topics such as adapted physical activity, fertility, sexuality and relationships were discussed. All the camp activities were delivered by three experienced peer mentors with disabilities who use a wheelchair for daily mobility: two with spinal cord injury, and one with Polio. Setting goals of the camp (improvement of individual wheelchair skills), and both initial and final assessment of these skills were done. The information from initial assessment was used to customize intervention (wheelchair skills training) with regard to the specific needs of participants.
Former participants of the Active Rehabilitation camps can become peer mentors. This transition is completed through participation in a special Train-the-Trainers Camps, as well as by having the ability to deliver practical and/or theoretical sessions. A Train-the-Trainers Camp took place in Marrakesh in the following week (September 16-20, 2019). Non-disabled assistants helped to implement all camp activities.
All participants received oral information about the evaluation procedures. A written informed consent was obtained from each participant. There was no need for an ethical approval for this research, as the wheelchair evaluation study was included in the camp training schedule (good practice program evaluation) as an activity required within the One World project. Each participant took part in the wheelchair evaluation test in the beginning and at the end of training camp using their own wheelchair:
First day of the camp: Evaluation of wheelchair skills and satisfaction with own manual wheelchair, collection of demographic and disability characteristics.
Last day of the camp: Evaluation of wheelchair skills using own manual wheelchair, and assessment of satisfaction with new wheelchairs.
During the training camp all of the participants had a chance to try and use five other type of low-cost wheelchairs which are produced mainly for people with disabilities living in developing countries (https://www.clasphub.org/products). The following wheelchairs were provided by the camp organizers: (1) Whirlwind Roughrider – Folding; four-wheeler with long wheelbase, folding x-brace frame, adjustable back, removable armrests, and adjustable seat depth, (2) INTCO Active – Rigid; four-wheeler with rigid frame, adjustable wheelbase length, backrest height and angle, fold-to-seat back with quick folding mechanism, and removable arm support, (3) INTCO All Terrain – Rigid; four-wheeler with rigid frame, adjustable back height and back recline, arm rests removable and ergonomic, adjustable foot support, and quick release rear axle, (4) Motivation Active – Folding; four-wheeler with folding x-brace frame, adjustable footrests, height backrest, upholstery, and seat depth, rear wheels with slight camber, (5) Motivation Rough Terrain – Rigid; three-wheeler with rigid frame, padded seat and back, adjustable backrest height and angle, removable armrests, and backrest that can be folds down.
To assess differences in wheelchair skills (baseline/completion of the camp) using their own wheelchair, The Queensland Evaluation of Wheelchair Skills (QEWS) was used (14). QEWS was initially designed for use with persons with spinal cord injury in the acute hospital setting, as well as in the community without extensive or specialized testing equipment. The QEWS evaluation is short. It consists of 5 items i.e. negotiating an indoor circuit, ascending and descending a ramp, maintaining balance on back wheels, ascending and descending a gutter, and a six-minute push test (distance in metres covered in six minutes). Each item was evaluated in scores ranging from 0 to 5 depends on level of performance described in the test manual. The total score was calculated by adding all individual scores (range: 0-25). The test is simple (easy to administer), and relevant for the training camp context (can be easily integrated into the schedule of the programme). QEWS is characterized by high reliability and validity, and was used in studies on person with disabilities (14). Divanoglou et al. (2019) reported that QEWS is sufficiently sensitive to detect change over a 10-days period of residential Active Rehabilitation programme.
To assess subjective differences between own and new wheelchairs the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST, Version 2.0) was used (15). The questionnaire consists of 12 satisfaction items. Due to the purpose of this study, this measure was modified in the following way: a) only the first 8 questions related to satisfaction with the device were used (i.e. dimensions, weight, ease in adjusting, safety and security, durability, ease to use, comfort, effectiveness) while omitting 4 questions related to satisfaction with the service (i.e. service delivery, repairs and servicing, professional service–information, follow-up services) as camp participants were not able to answer them with regard to new provided wheelchairs, b) the words assistive device were exchanged with the word wheelchair, as only this assistive device was tested. This questionnaire is a self-administrated tool. It is short and simple. Participants are asked to rate their satisfaction with the device on a 5-point scale that ranges from 1=not satisfied at all to 5=very satisfied. For 8 items related to satisfaction with the device, ratings of the valid responses are added and this sum is divided by the number of valid items in this scale. The participants were also asked to choose the three most important items related to the evaluated assistive device. The previous study suggests that the QUEST is a reliable, representative, and valid instrument to measure the satisfaction of users of assistive technology in persons with disabilities (16,17). Permissions was obtained from the authors to translate QUEST into Arabic using the back translation method. Two professional English-Arabic translators made the translation with final assistance of a bilingual person with a disability who uses a wheelchair and works as wheelchair designer (Arabic person living in the US).
To collect the demographic and disability characteristics, a part of the International Spinal Cord Injury Survey was used. Through this questionnaire we collected information about: gender, present age, marital status, education, type of disability, years since injury or illness, and need for assistance for day to day activities.
Descriptive data was presented as n, Mean and standard deviation (SD). To check the normality of the data, the Shapiro-Wilk test was used. Due to not normal data distribution, the Wilcoxon test was used to check the difference between variables. To describe the magnitude of the difference between different dates of measurement, the effect sizes (d) were calculated as the difference between means, divided by the within standard deviation of the difference. Using Cohen’s criteria, an effect size ≥0.20 and <0.50 was considered small, ≥0.50 and <0.80 medium and ≥0.80 large (18). All statistical analyses were performed with the IBM Statistical Package for Social Sciences software (IBM SPSS Statistics version 21, Chicago, IL, USA). The level of significance was set at p ≤ 0.05.
Nineteen persons (13 male and 6 female) with physical disabilities took part in the project. However, 3 persons were excluded from the analysis due to their late arrival at the training site. The mean age of participants included in the analysis (n=16) was 33 years (SD=9.4) and mean years since injury or illness was 24 years (SD=11.0) for study group. The majority of study participants were single (n=10), 5 were married and 1 was divorced. Seven participants had graduated from at least high school. Others had a lower level of education. With regard to type of disability, 5 persons had Polio, 4 persons had a spinal cord injury, 3 persons had cerebral palsy, and 7 persons had other type of disability. Seven participants did not need assistance with their day to day activities, and 7 persons had assistance from family members. One person had a paid caregiver, and 1 person received assistance from friends.