Factors influencing the use and user perception of powered wheelchairs under the long-term care insurance system in Japan: a qualitative study

Abstract

[Purpose] To investigate the users’ perceptions of powered wheelchairs (PWCs) provided by the rental service of equipment for long-term care covered by public aid in Japan and to identify factors influencing the feasibility of their widespread use. [Participants and Methods] This qualitative study was conducted using semistructured interviews with five Japanese individuals who used PWCs rented from the rental service of equipment for long-term care covered by public aid to investigate their usage and perceptions of PWCs. The interview data were organized using the KJ method. [Results] The users chose wheelchairs of their own volition based on their values, developed attachments to their PWCs, and used them as effective tools to lead independent lives. Participants positively evaluated the value of PWCs and accepted their advantages and disadvantages. However, they felt that using PWCs in their daily lives was difficult. [Conclusion] PWCs can be efficiently distributed among wheelchair users who wish to live independently and participate in society. The specific and complex driving maneuvers, safety considerations for operating PWCs in real-life situations, and the low public awareness of PWCs are factors influencing their widespread use.

INTRODUCTION

Wheelchairs are welfare equipment and an indispensable tool for older adults and differently abled individuals with mobility impairments. Wheelchairs are classified into manual wheelchairs and powered wheelchairs (PWCs) based on their power source for propulsion. Manual wheelchairs are propelled by grasping the push rims and rotating the wheels. They can be easily propelled on smooth and flat surfaces because less force is required. However, individuals with reduced physical function often have difficulty propelling their wheelchairs because they lack the force required to move uphill and over rough terrain, and their independence in performing daily activities is limited. Therefore, they require caregivers’ assistance when self-propelling their wheelchairs is difficult. Conversely, PWCs are accelerated by the rotational force of the motor. Therefore, wheelchair users with reduced physical function can independently move PWCs. A previous case study showed that the use of PWCs helped community-dwelling wheelchair users achieve independence in outdoor mobility and social participation¹⁾. A follow-up study showed that the use of PWCs allowed stroke survivors to overcome limitations in activities of daily living and social participation²⁾.

In Japan, PWCs are classified according to specification standards into two types: self-operated wheelchairs and attendant-propelled power wheelchairs³⁾. The publicly funded long-term care equipment rental service provides 13 types of assistive devices, including PWCs that conform to the specifications for self-operated wheelchair subtypes: electrically PWCs with manual direct steering, mobility scooters, and electrically powered wheelchairs with integral seats⁴⁾. The rental service is a publicly subsidized program that allows long-term care-insured individuals to rent PWCs at reduced out-of-pocket costs. However, the number of PWC rentals and users is limited. A previous study examining the allocation of long-term care insurance benefits for assistive device rental services reported that 12,986 individuals used manual wheelchairs, only 2,221 used PWCs⁵⁾. A Canadian survey reported that the number of PWCs prescribed to stroke survivors was lower than that of manual wheelchairs⁶⁾, indicating the existence of factors that hinder the widespread use of PWCs by older adults and differently abled individuals.

PWC users experience difficulties in outdoor mobility, accessing and using public buildings, and performing operations specific to PWCs, such as operating the joystick, getting in and out of cars, and carrying shopping bags⁷⁾. A survey of PWC users, their families, and staff in residential facilities reported that the use of PWCs was associated with improved quality of life by enabling employment, improving self-esteem, and promoting social interaction⁸⁾. However, the use of a PWC entails risks and potential accidents, which are serious concerns⁸⁾. The use of PWCs has been reported to provide significant benefits, such as higher independence and improved quality of life. However, environmental barriers and accidents remain challenges⁹⁾. In addition to the physical functions that enable the actual operation of PWCs, users must have a thorough understanding of how to operate the device and use good judgment to avoid risks and accidents¹⁰⁾. Previous studies have reported the effectiveness of PWC operation practice for people with poststroke syndrome¹¹⁾ and the development of device functions to prevent collisions¹²⁾ and support safe operation¹³⁾. These findings highlight the benefits of using PWCs and the characteristics that should be considered when using PWCs. Additionally, they underscore the need to predict and prevent accidents that may occur after the introduction of PWCs and propose measures to ensure safe use of the device.

The aforementioned factors hindering the adoption of PWCs may be addressed by removing environmental barriers, incorporating accident-prevention features into PWCs, and providing safety training programs for users. Understanding users’ perceptions—particularly how they view the characteristics and intended use of PWCs—is essential for further increasing adoption. Studies involving community-dwelling older adults have shown that individuals who are aware of the availability of assistive devices and who hold positive perceptions of their benefits are more likely to acquire them¹⁴⁾. Although these findings suggest that users’ perceptions significantly influence adoption, few studies have specifically examined users’ perceptions of PWCs. PWC users choose these devices as their preferred means of transportation in their daily lives. Clarifying users’ perceptions of PWCs can provide useful information to support their introduction and continued use and to clarify factors influencing their widespread use under Japan’s long-term care insurance system.

This study aimed to investigate users’ perceptions of PWCs provided through rental services in Japan and to identify factors influencing their widespread use. Qualitative interviews were conducted in accordance with established methodologies for examining perceptions of assistive devices^{14, 15)}.

PARTICIPANTS AND METHODS

A total of 5 wheelchair users (2 women in their 40s and 70s, respectively, and 3 men in their 60s, 70s, and 80s, respectively) who received PWCs on loan from a welfare equipment supplier (hereafter, ‘Company A’) under subsidized rental services were included in this study. Company A is a joint-stock company that provides services, including lending and selling welfare equipment, conducting home renovations, and managing insurance dispensing pharmacies, at 71 business locations nationwide. All PWCs rented by the participants were electrically PWCs with manual direct steering operated via a joystick system. The duration of PWC use varied among participants: one participant had used the device for 2 months, three for 3 months, and one for 6 months. Of the five participants, two used PWCs exclusively at home, whereas the remaining three used them only outdoors.

Semistructured interviews were conducted individually at the participants’ homes using an interview guide from September 26, 2019, to November 22, 2019 (Table 1). The interview guide was developed based on a previous study investigating factors influencing the distribution of power-assisted wheelchairs¹⁶⁾ and through consultations with the author and three welfare equipment consultants (hereafter referred to as the consultants), who had 16, 20, and 28 years of experience in the field, respectively. The interviews were recorded using an IC recorder and verbatim transcribed.

Table 1. Interview guide for powered wheelchair users.

· Please tell us about your current physical and mental functioning and daily life.

· Please tell us how you use your powered wheelchair.

· Please tell us about some problem you encounter when using your powered wheelchair.

· Please tell us what you consider as advantages and disadvantages of powered wheelchairs, as well as your review and impression of them.

The responses were structured using the KJ method, also known as an Affinity Diagram, which is a qualitative research method developed in Japan. In the KJ method, each response is written on a label. Previous studies using this method selected labels for initial grouping as follows^16,17,18): the research theme is written in the center of a large sheet of paper; labels are roughly grouped based on semantic similarity; groups are arranged around the central theme while considering their characteristics and interrelationships; label diversity is assessed before determining the number of labels to be selected; appropriate labels are marked; and the selection process is repeated until the target number of labels is reached. In this study, the author and consultants conducted this process collaboratively. Labels were grouped in both the initial and subsequent stages according to content similarity. The generated groups are assigned a one-sentence label that expresses the core meaning and unique characteristics of the group. Then, they are organized into higher-order groups based on content similarity, and the labeling process is repeated. After completion of group organization, the overall structure of the groups is drawn as a chart on a single sheet of paper and described in a written explanation as a “story”. Formal training using the KJ method was performed by the lead author before this study. The first round of group organization, chart making, and written explanations was conducted by the lead author. Then, the content was reviewed by the three consultants mentioned above. The content was repeatedly revised to ensure reliability.

This study was approved by the Medical Ethics Committee of Tohoku Fukushi University (RS230101). Written informed consent was obtained from all participants.

RESULTS

A total of 130 labels were created for participant responses. The labels were cautiously narrowed down to 50, considering the procedure used in previous studies^16,17,18). Group organization was completed when the four highest-order groups were generated: “Own volition”, “Adoption or rejection”, “Mismatch”, and “Positive emotions and attachment” (Table 2). Figure 1 presents a chart illustrating users’ perceptions of PWCs.

Table 2. Descriptions of the four highest-order groups.

Highest-order group	Description
Own volition	PWC users proactively choose wheelchairs based on their values. They believe that wheelchairs allow them to live independently and freely. Wheelchair users who believe that PWCs are necessary to achieve their wishes choose PWCs. The value of PWCs is determined based on individual values. The specifications of PWCs are not the only criteria that determine their value.
Adoption or rejection	PWC users believe that they are too much for some people to handle and are difficult to approach. Users choose a PWC type that is comfortable for them and skillfully come up with their own ways of using it. Users must adapt to PWCs’ characteristics to ensure their continued use.
Mismatch	PWC users recognize the advantages of PWCs. However, they are sometimes dissatisfied with PWCs because of difficulties in using them. Public awareness of PWCs is low, creating an obstacle to their use or continued use. Users may find a wheelchair difficult to use in their daily lives because of a mismatch between the desired and actual characteristics of it.
Positive emotions and attachment	If PWC users can adapt to PWC’s characteristics, they will develop an attachment to it and evaluate its characteristics positively. Users are satisfied with the excellent performance and quality of PWCs, feel joy and happiness in owning them, and show positive emotions and attachment to them.

PWC: powered wheelchair.

Fig. 1.

Powered wheelchair users’ perceptions of their powered wheelchairs.

PWC: powered wheelchair.

DISCUSSION

In this study, four highest-order categories were generated from participants’ responses regarding their perceptions of PWCs: “Own volition”, “Adoption or rejection”, “Mismatch”, and “Positive emotions and attachment”.

The “Own volition” category suggests that PWC users proactively select wheelchairs based on their personal values. In this study, users chose PWCs of their own volition based on their values and developed attachments to their PWCs once they perceived them as useful tools for living freely and independently. All information, including detailed specifications, was assessed based on wheelchair users’ sense of value, which helped them decide whether to use PWCs.

The “Adoption or rejection” category suggests that some users perceive PWCs as overly complex and difficult for certain individuals to manage. PWCs differ from other commonly used manual wheelchairs in structure, function, and use. PWC users must accept and adapt to the characteristics of their PWCs to continue using them. When operating a wheelchair in real-life situations, users must instantly assess the passageway width in relation to the PWC dimensions to determine whether it can pass. Additionally, users must consider factors such as the difference between the tracks followed by the front and back inner wheels when turning, the behavior of the casters, and bumps and inclination of the road surface¹⁹⁾. In addition to the physical function required to operate a PWC, users must understand how to operate it and have the competency to make judgments to prevent risks and dangers¹⁰⁾. The assessment of a person’s competency in safely using a PWC is an important piece of information that influences the decision to select a PWC. However, no gold standard for this assessment exists⁸⁾. The benefits and risks of introducing PWCs must be carefully considered. Additionally, developing a test to assess user competency and determine eligibility to use PWCs is crucial⁸⁾. The introduction of PWCs requires emphasizing the user’s voluntary choice, assessing values, and appropriately evaluating the user’s performance components when using a PWC. PWC users face many difficulties in their daily lives related to daily tasks and environmental contexts of wheelchair use⁷⁾. In this study, the interviews focused on the specific activities users perform in daily life and the environments in which PWCs are used, which are important for facilitating the introduction of PWCs. The introduction of PWCs has been reported to reduce the burden on caregivers²⁰⁾. However, caregivers may face new burdens that did not exist before the introduction, such as preparing a PWC before use, cleaning it after use, and sometimes assisting with transportation¹⁾.

The “mismatch” category indicates that although PWC users recognize the benefits of PWCs, they sometimes experience dissatisfaction due to difficulties encountered in daily use. Despite their attachment to PWCs, the participants reported difficulties with wheelchair use in their daily lives, such as the low public awareness of PWCs. PWCs promote user independence and social participation. However, specific and complex driving maneuvers and safety considerations are required for continuous use in real-life situations. While PWC users recognize the benefits of these devices and expect them to promote independence, they simultaneously perceive unfriendly social environments and technical performance limitations as significant disadvantages. Consequently, these findings suggest a “mismatch” between the characteristics users expect from PWCs and the attributes they encounter in real-world settings. PWCs have advantages and disadvantages. Therefore, appropriate and continuous support from the community where users live is necessary for continuous use. Welfare equipment consultants and sales representatives of wheelchair providers play a particularly important role in supporting PWC users^{1, 17)}. In addition to providing wheelchairs, they provide PWC users and caregivers with assistance with specific insurance procedures, practice on how to operate PWCs, checking the environmental context before introduction, and performing regular maintenance according to its use¹⁾. Collaboration between PWC users and other professionals to provide medical, technical, and institutional support, thereby ensuring the continuous use of PWCs in real-life situations.

The “Positive emotions and attachment” category indicates that PWC users are satisfied with the performance and quality of their devices and develop attachment to them once they successfully adapt to their characteristics. PWCs bring many conveniences, difficulties, and burdens to users. In this study, participants positively evaluated the value of PWCs with an inclusive acceptance of their advantages and disadvantages, and their responses indicated the degree of attachment that they developed to their PWCs. The attachment to PWCs demonstrated by the participants may have led them to choose and continue to use PWCs.

This study has some limitations. This study was conducted in Japan, where PWCs are available for rent under a publicly subsidized system. A similar study conducted in countries without subsidy programs may provide different findings from those of our study. Furthermore, this study included only five participants from a single welfare equipment supplier, all of whom used a specific type of self-operated standard PWC, thereby limiting the generalizability of the findings. Future studies should include a broader range of PWC users rather than restricting participants to a particular supplier or device type, enabling a more comprehensive examination of the scope and depth of users’ perceptions. In addition, because this study did not involve collaboration with medical institutions, verified clinical data for the participants were not available. Therefore, future research incorporating validated functional and care-related characteristics is warranted.

In conclusion, this study showed that PWC users who obtained PWCs through the rental service of equipment for long-term care covered by public aid chose wheelchairs of their own volition based on their values, became attached to their PWCs, and used them as effective tools to lead independent lives. Participants positively evaluated the value of PWCs and accepted their advantages and disadvantages. However, they reported some challenges in using them in their daily lives. Further studies in other countries that include more diverse models of PWCs and their users are needed to validate the study’s findings.

Conference presentation

A portion of the study results was presented at the 8th Asia Pacific Occupational Therapy Congress (Presentation No.: O2-2-s3-1).

Funding

This study was funded by FRONTIER Co., Ltd.

Conflict of interest

None.

Funding Statement

This study was funded by FRONTIER Co., Ltd.