ISPO consensus conference on wheelchairs for developing countries: Conclusions and recommendations

The ISPO Consensus Conference on Wheelchairs for Developing Countries was held in collaboration with Leahy War Victims Fund of the United States Agency for International Development (LWVF-USAID) and the World Health Organisation (WHO) at Mobility India, Bengalooru (Bangalore), India from 6^th – 11^thNovember, 2006. The report of the meeting, edited by Sarah Sheldon and Norman A Jacobs, will shortly be published by ISPO. The conclusions and recommendations from the conference follow below. These were the result of extensive discussion in syndicate and plenary sessions. Summaries of these discussions as well as the supporting presentations can be found in the published report.

Wheelchair

Purpose of a wheelchair

The fundamental purpose of a wheelchair is to promote mobility, inclusion and enhanced quality of life of the user.

Definition of a wheelchair

An assistive device which enhances personal mobility and facilitates participation, for a person with walking limitation (WHO definition).

A technical aid intended to provide wheeled mobility and body support for individuals with impaired mobility to walk (ISO 7176 – 26: Wheelchairs – Vocabulary, FDIS 2005).

A device to provide wheeled mobility with a seating support system for a person with a walking limitation (ISO definition modified by the conference).

It is recommended that ISO revise its definition of a wheelchair in order to take account of the currently accepted terminology.

Definition of an appropriate wheelchair

A wheelchair is appropriate when it meets the individual's needs and environmental conditions; provides proper fit and postural support based on sound biomechanical principles; is safe and durable; is available and can be accessed, maintained and sustained in the country at the most economical and affordable price.

User involvement

“It is about the user, not just about the wheelchair”. Wheelchair users should be involved in all aspects of wheelchair provision.

Needs

Needs assessment

According to WHO it is estimated that about 10% of the population are people with disabilities. Studies also show that about 10% of people with a disability require a wheelchair.

There is no accurate figure for the number of people in developing countries that require a wheelchair. It is estimated that about 1% in any given population, i.e. about 65 million people worldwide require a wheelchair.

Anecdotal evidence indicates a very small minority of those in need have access to an appropriate wheelchair.

More accurate data of the needs are required to be collected in order to be able to address them.

It is important to develop and implement standardized tools and methodology for data collection.

The number of people who need wheelchairs is so large that all efforts should contribute towards developing long-term sustainable services.

Outcome measures

Reliable record keeping is essential for all phases of wheelchair provision including assessment, prescription, fitting, delivery and follow-up.

Regular follow-up/evaluation of outcomes of wheelchair provision should be performed.

User satisfaction surveys must be an integral part of outcome assessment.

User satisfaction surveys should be performed and include measures of the impact of wheelchair provision on the quality of life of the user.

Information sharing

There is a lack of shared information about resources, activities and initiatives which may result in a duplication of efforts and gaps in services. The establishment of a website and/or an accessible database would be of benefit to those involved in wheelchair provision.

Services

(Note: in this document Wheelchair Services refers the service delivery of wheelchairs to the individual users. Wheelchair Provision refers to the overall subject including design, manufacture distribution and services)

Wheelchair services are an integral part of wheelchair provision.

User participation is an integral part of wheelchair services.

Wheelchair services should be delivered by trained personnel.

Government has the primary responsibility for sustainable wheelchair service. Wheelchair services should be an integral part of national strategies.

The wheelchair services are encouraged to ensure that people with disabilities from all sectors of society are provided with appropriate wheelchairs including those from marginalised and vulnerable groups such as women and children.

The aim of wheelchair services is to ensure that the person in need of a wheelchair receives it together with the necessary information and support. The wheelchair should meet the individual's needs in terms of mobility, appropriate fit, comfort, safety and ability to carry out activities of daily living and exercise basic human rights.

The following table was agreed as a first draft of specifying the elements and requirements for wheelchair services:

Elements	Requirements
Awareness	• Basic information about needs for and benefits of using wheelchair (e.g. leaflet with information about who needs a wheelchair which is distributed to different organisations based on available services (to avoid expectations that cannot be met))
	• Involvement of CBR/community health/educational personnel
	• Involvement of DPOs
Identification/ screening/ referral/ networking	• Identify and inform people who may need a wheelchair to enhance mobility
	• Simple screening tool to identify those who can benefit from the use of a wheelchair, to identify the complexity, to understand if the needs can be met with available services, and to identify what other needs the person has
	• To identify simple to complicated interventions
	• Identify referral pathways
	• Networking with local government and community development organisations
	• Use existing resources/network (human resources)
	• System for registration (for follow-up) to identify what services need to be developed
Assessment	• Individual assessment (e.g. with an assessment tool which can be adapted or modified depending on situation and context)
	• Assess medical/health/functional condition
	• Individual rehabilitation plan
	• By trained people
	• Involvement of user
	• Establishing a waiting list
Specification of wheelchair/prescription/selection	• Technical and functional description of a suitable wheelchair
	• Information about available wheelchair
	• Need for modifications/adjustments
	• Need for extra equipment
	• Basic guide for self-care
	• List of individual needs
	• Wheelchairs meet an appropriate standard (as yet to be defined)
Procurement	• Choose supplier
	• Funding
	• Minimise the delivery time of the wheelchair
Product preparation	• Assembly, if necessary
	• Cushion
	• Adaptation, modification and/or customisation of the seating system
Fitting	• User trial in local environment
	• Necessary alterations
	• Finalisation of wheelchair
User training	• Basic training should include safety, transfer, basic mobility/handling, basic maintenance, self care/pressure relief, who to contact if something goes wrong, impact/risk of self-modification
	• Final check-out
Repair and maintenance	• Local repair
	• Provision of basic spare parts
Follow-up	• Re-assessment, specially of users with progressing/changing conditions
	• Use of existing networks, e.g. CBR
Accessibility	• Facilitate home modifications/barrier-free environment including lobbying and taking part in the process where possible
General Management	• Coordination of donations/government funding
	• Development of services
	• Sustainability
	• Financing plan (including subsidy)
	• Network of service providers/users
	• Collaboration between different stakeholders in provision of appropriate wheelchair services
	• User involvement/feed-back
	• Evaluation of service provision

Not all elements and requirements are essential, some could be considered as only desirable depending on the context and the socioeconomic conditions that prevail.

Products

As a minimum, developing countries are encouraged to adopt the wheelchair ISO standards as they exist at present, particularly:

ISO 7176-8: Wheelchairs – Requirements and test methods for static, impact and fatigue strengths, 1998

ISO 7176-1: Wheelchairs – Determination of static stability, 1999

ISO 7176-3: Wheelchairs – Determination of the efficiency of brakes, 2003

ISO 7176-5: Wheelchairs – Determination of overall dimensions, mass and turning space, DIS 2005

ISO 7176-15: Wheelchairs – Requirements for information disclosure, documentation and labelling, 1996, and

ISO 7176-16: Wheelchairs – Requirements and test methods for resistance to ignition of upholstered parts, 1997.

These represent the minimum requirements for wheelchairs provided in these countries.

Organisations importing wheelchairs are encouraged to ensure that the wheelchairs meet ISO standards or the wheelchair standards existing in that particular country, whichever is higher.

There is a need to develop more demanding versions of ISO standards to represent the more challenging conditions in developing countries.

It was recommended that ISO be requested to revise the existing standards to take into account the needs in developing countries.

Test methods should be designed to replicate usage in the relevant environments (based on an average life expectancy of 5 years).

It is recommended that a representative sub-committee be identified to propose requirements within each category outlined in the table below:

Static stability	Front, lateral, diagonal and backward tipping for least and most stable axle positions.
Effectiveness of brakes	ISO standard with set angle for tipping of chair and angle at which brakes hold, test for sudden release of the brakes.
Strength durability	Stress testing of front casters, structural integrity, peak force or yield failures and double drum (fatigue) test.
Pressure relief cushion (compulsory)	Ratings for cushions, determine levels. Standard test using indenter, concern about cushion changing centre of gravity, life of cushion, develop test equipment.
Safety	Pinch points and sharp edges, self-locking nuts.
Dynamic stability	Declining ramp with obstruction to cause abrupt stop of wheelchair (testing to assure wheelchair user remains in wheelchair after abrupt stop).
Adjustability	Footrest adjustment range, brake adjustment.
	Information about armrest height, backrest height range, range of seat width/depth and fore/aft rear wheel position.
Postural support	All body contact surfaces supporting adequately (e.g. footrests). Wait for ISO standards on postural support devices. Sub-committee will revisit within 6 months and make recommendations.
Quality of manufacture	Durability testing, sample size and frequency for product testing (quality control), sharp edges and points, corrosion resistance, fit and finish.
Availability of components	Manufacturer to ensure availability or provision of needed parts, reporting of any hard-to-find parts/components.
	Work towards common components/parts across different manufacturers. Consumables separate from replacement parts.
Rolling resistance	Resistance to movement over a range of surfaces such as grass, mud and sand.
Reflectors	All wheelchairs should be fitted with robust reflectors on all sides to increase their visibility within traffic.
Other	Tracking, transportability, include note on handrims and wheel size.

It was further agreed that there would be value in testing current wheelchair designs. Each of the organizations represented at the consensus conference agreed to participate.

Production

Standards and guidelines

All wheelchairs, whether locally produced or imported, and whether made in small, medium or large scale enterprises should meet or exceed ISO standards.

User choice

Stakeholders are encouraged to recognise the right of wheelchair users to choose their wheelchair and to work in collaboration with the user.

Users' needs are best met when there is a variety of wheelchair models from which to choose.

Acquiring wheelchairs

When determining whether to acquire wheelchairs via import or local production, decision makers are advised to balance a variety of factors. These include needs of the local population, quality and variety of wheelchair models, purchase price, cost of repair and replacement, effect on local employment and wheelchair production, and national policies and strategies including long-term sustainability.

Locally repairable

Regardless of scale and location of production, wheelchairs must be locally repairable.

Distribution

There is a vast need for appropriate wheelchairs in developing countries and it is recognised that there are different methods of wheelchair distribution which are not mutually exclusive but can complement each other.

All methods of distribution have a part to play and stakeholders are encouraged to work closely together to ensure that there is no duplication of effort and waste of resources.

It is recommended that, irrespective of method of distribution:

the provider has the capacity to provide the wheelchairs in a reasonable and responsible manner;

the distribution is based on an assessment of the situation in the country or the region of the country and considers the impact on local wheelchair producers and service providers;

procured wheelchairs meet or exceed relevant international standards and be appropriate for the environment of use;

wheelchairs are provided following a provision process that meets or exceeds internationally agreed minimum requirements for service provision, including requirements for assessment, fitting, user training and follow-up;

wheelchairs are repairable in the region of the country where they are provided or expected to be used;

distributors coordinate their distribution with national and local governments as well as producers and providers of wheelchairs in the country; and

distributors of wheelchairs network with each other.

Training and education

It is recognized that training and education are key elements for developing, introducing, maintaining and building sustainable wheelchair services.

All stakeholders need to be trained and/or informed regarding their roles in wheelchair provision.

All individuals involved in wheelchair services should be trained. These may include:

Physiotherapists

Occupational Therapists

Doctors

Nurses

Prosthetists and Orthotists

Engineers/Technologists/Technicians

CBR personnel

DPO/Rights group members.

In particular the user and assistant must be properly informed and trained.

Comprehensive information should be provided to governments, decision makers, donors and other stakeholders.

Training and education for stakeholders can be divided into four types:

Formal training to establish specialists in wheelchair provision where possible.

Special modules for other individuals involved in wheelchair provision.

Comprehensive information for different stakeholders (including government, decision makers and donors).

structured/formalized peer training for users and assistants.

Professional profiles for specialists in wheelchair provision should be developed.

An expert group under the umbrella of an internationally recognized organization should:

develop the professional profiles for the training of people involved in wheelchair service provision.

specify the content of the various training, education and information modules required.

WHO guidelines

The importance of developing the WHO Guidelines on the provision of manual wheelchairs in less resourced settings is recognized.

In order that the guidelines be effective as soon as possible, it is recommended that WHO quickly incorporate the outcomes from this consensus conference into the guidelines and share a draft of the revised guidelines with a larger audience for review.