Exploring Users’ and Clinicians’ Perceptions of an Intelligent Dynamic System for Multi-Component Motorized Wheelchairs

Abstract

Introduction: Motorized components on power wheelchairs (PWC) enable repositioning to pre-programmed positions (e.g., tilt, leg support, verticalization) to prevent prolonged static positions. Smart technologies can track positioning information and give feedback according to clinical recommendations and personal goals. This study aimed to explore users’ and clinicians’ perceptions of an intelligent dynamic seating (IDS) system prototype comprising a PWC with motorized multi-components connected to a web interface. Methods: A purposive sample of six PWC users and eight clinicians were recruited in this exploratory descriptive qualitative study. Semi-structured interviews included viewing a video of the IDS and images of the web interface. Interviews were transcribed, deductively coded, and thematically analyzed using a conceptual model for evaluating eHealth interventions. Results: Clinicians found the IDS system intuitive to use, customizable, relevant in terms of positioning and clinical recommendations, and timesaving. Powered wheelchair users perceived benefits that could motivate behavioural change, autonomy, health, and inclusion. Concerns related to familiarity with complex technology, funding, cognitive requirements, and technical and health risks were raised. Conclusion: The results inform improvements for the integration of the IDS in clinical practice to respond to the positioning needs of PWC users.

1. Introduction

The prevalence of wheelchair (WC) use in Canada is estimated at 0.6% of the population, which is approximately 155,000 Canadians [1]. Among the population aged 15 years and over in Canada, an estimated 42,360 used a powered wheelchair (PWC) due to significant mobility limitations [1]. With severe mobility limitations often comes positioning difficulties, and PWCs may offer greater independent control over postural and positioning capabilities (e.g., verticalization), increasing the accessibility of participation in daily activities (e.g., cooking independently in an upright position, standing beside a friend at an event, traveling long distances) [1,2,3]. Motorized multi-component repositioning technologies (e.g., leg rest elevation, reclining backrests, tilting seats, verticalization) that can be independently activated by the user with little physical effort are commonly integrated within the design of PWCs to better meet the needs of individuals with severe mobility limitations [4].

Facilitating more frequent repositioning, motorized multi-components can improve physical function (bowel and bladder function, blood pressure regulation, and respiratory function) and reduce the risk of health problems associated with prolonged immobilization (pressure injuries, spasms, and osteoporosis) [3,5]. Body repositioning technologies also improve psychosocial wellness (confidence, positive mood) and facilitate better social participation as well as peer interactions [3,5,6]. While these technologies are integral to rehabilitation, some issues can occur (e.g., quick verticalization can lead to orthostatic hypertension), hence the importance of hands-on assistance from clinicians as well as proper training for users [7,8,9].

A PWC virtual coach (i.e., an intelligent system to guide PWC users in body positioning) was developed to assist users in repositioning without the need for clinician intervention, monitor user compliance, and create reminders and alerts to reposition [10]. An array of pressure, tilt, and infrared sensors provides data to the virtual coach, and then tailored clinical recommendations are provided to the PWC user [10]. While the virtual coach was reported by PWC users and clinicians to be acceptable and potentially beneficial for promoting pressure-relief behaviours, the small sample, prototype-based testing, and lack of long-term evaluation limited generalizability and insight into its real-world impact [11]. Moreover, as technological advances continue to introduce new features that may be challenging for PWC users to learn and for clinicians to stay aware of and teach, replicating interventions with updated technology may help guide refinement and support the clinical translation of digital seating health solutions [12,13].

This study explored a novel, recently developed, intelligent dynamic seating system prototype (IDS), similar to the PWC virtual coach [10,11], but which integrated a PWC with motorized multi-components (PMMC) for changing between pre-programmed positions that were connected to a web interface (WI). The WI documents IDS use and issues feedback alerts to the user, and the user can simply effectuate the repositioning recommendations themself or agree that the IDS system may complete the movement. Programming of pre-programmed positions can be customized according to clinical recommendations and users’ needs (e.g., to compensate for hypotonicity, reduce sliding), and the user can also make self-selected seating adjustments without using a pre-programmed position. On a day-to-day basis, one can select the desired position (e.g., sitting at a working desk, standing in the kitchen) by pushing a button on the PWC, and the IDS system can automatically move into the pre-programmed position. The system records real-time usage data for all wheelchair components (e.g., angles, movements, usage time), providing continuous feedback to the user and clinician via the WI (on a phone or computer) to facilitate follow-up. It is also possible for the IDS system to alert users to remind them to do certain movements for health reasons (e.g., tilt to reduce the risk of wounds).

Although electronic health approaches integrating multi-motorized components and clinical recommendations may help reduce clinical burden and help meet users’ positioning needs, there is a lack of evidence-based data on the implementation of long-term, successful electronic interventions and their benefits in health care practice [14]. The aim of the present study was to explore PWC users’ and clinicians’ specific needs and perceptions regarding the use and optimization of the IDS prototype.

2. Materials and Methods

2.1. Research Team

The team members combine clinical and research experience in the domains of rehabilitation and technology. The principal investigator of this study (CA) specializes in the evaluation, design, and development of rehabilitation technologies for self-management. The team also includes a rehabilitation scientist with training in kinesiology and health behaviour change, a rehabilitation scientist specializing in engineering and technology assessment, and a clinical occupational therapist with research involvement regarding social participation and rehabilitation. The interviews were conducted by two students pursuing master’s degrees in occupational therapy, an occupational therapist and a kinesiologist.

2.2. Conceptual Model

Baumel’s conceptual model, developed for evaluating eHealth interventions, describes concepts influencing the quality of web-based interventions and concepts exploring users’ experiences: usability, visual design, content, user engagement, therapeutic persuasiveness, therapeutic alliance, and general subjective evaluation [15,16]. This model was applied in this study to help understand the potential influence of the IDS system [16].

2.3. Design

A qualitative descriptive design, using an interpretivist paradigm, was used to explore the different demands, experiential knowledge, and perceptions of PWC users and clinicians regarding the IDS system. Written informed consent was obtained in compliance with the local research ethics board (CER RDP: CRIR-1090-0715). The Standards for Reporting Qualitative Research (SRQR) were used to enhance the transparency of this qualitative descriptive research [17].

2.4. Participants and Recruitment

A purposive sample of PWC users and clinicians was recruited from two rehabilitation centers, private health facilities, and the community in two large urban centers in Quebec City and Montreal (Canada). Clinicians helped to identify clients on their caseload who may fit the inclusion criteria. Inclusion criteria included clinicians working in rehabilitation who specialized in WC provision and people who had at least one year of experience using a PWC and were able to communicate in French or English. Participants were recruited with or without experience using motorized multi-components and were all 18 years of age or older. Given the exploratory nature of this study, data sufficiency for exploring perceived usability and acceptability was considered when determining the sample size [18].

2.5. Data Collection

Semi-structured interview guides (Supplementary Files S1–S4) were developed by the study team based on Baumel’s conceptual model for evaluating eHealth interventions [15]. Given that the model puts emphasis on the eHealth intervention’s quality and users’ perceptions, questions were added related to clinicians’ perspectives on carrying out the eHealth intervention and helping users attain the desired behavioural change. The Interview Guides were piloted by two students in a Professional Master’s program in occupational therapy to enhance the credibility and dependability of the interview guides.

Each participant completed one 60-to-90 min semi-structured interview in person or by videoconference. At the start of the interviews, a video explaining the study project and IDS was shown to participants to set the context and initiate dialogue. Open-ended questions focused on the participants’ opinion of the IDS in terms of how easy it would be to learn and use, its appearance, perceived relevance, and potential impact on life habits, its WI content, and its compatibility for the target population. An image of a simulated WI was shown to participants (Supplementary File S5), depicting the various data views that WC users and clinicians would receive. More specifically, the WI showed 12 pages, including configuration information (i.e., user and chair details), programmed positions on the PWC, motorized component usage targets, personal and recommended goals, and daily and monthly results of the usage of the various motorized components. This way, participants had a concrete overview of the WI, enabling them to provide feedback and recommendations. Interviews were audio-recorded and transcribed verbatim.

2.6. Data Analysis

Interviews were transcribed verbatim in their original language (French) and reviewed to ensure accuracy. Using NVivo software (Lumivero, 2023 NVivo Version 14; www.lumivero.com, Denver, CO, USA), transcripts were then coded line-by-line based on the seven themes of Baumel et al. [15], and emerging sub-themes were linked to these concepts until a final coding guide was developed. Coding was carried out independently by three team members (AL, CB, AdSL) and discussed during regular meetings of the research team to review the coding and ensure consensus [19] to enhance confirmability. Quotes in this article were translated into English with DeepL translate and verified by bilingual members of the team (AdSL, CA, KLB).

3. Results

The sample included fourteen participants (six PWC users and eight clinicians). PWC users were adults (18 years of age or older), and clinicians were occupational therapists working in public health facilities in Quebec, Canada (i.e., assistive technologies provision programs, long-term care facilities, physical disabilities programs, and local community service centers). Participants’ perceptions of the IDS prototype according to Baumel’s conceptual model is presented below.

3.1. Usability

Usability refers to the ease of learning how to use the eHealth intervention and the ease of utilizing it properly [15]. While learning to use the WI was described as intuitive by most participants, four PWC users and eight clinicians felt it would still be relevant to provide some initial basic training, given varying levels of technological knowledge and clinical experience with this technology. The training could include basic information on how to navigate the WI as well as hands-on experience with various positions of the PWC. PWC users suggested training should consist of short sessions with someone knowledgeable about the technology and PWCs in general, such as an occupational therapist or wheelchair technician. The training methods proposed included face-to-face meetings between the clinical team and the user, short pre-recorded online tutorials compatible with different versions of the tools and customized according to diverse clientele, and a pamphlet. As for clinicians, they suggested training tools that could be consulted at any time (e.g., a user manual with basic functions, a pre-recorded video), considering frequent staff turnover in most healthcare environments. One clinician emphasized the importance of having evidence-based training content that supports the WI’s objectives and the conditions for achieving them: “We need scientific text that tells me that to really increase the capacity of vital organs (…), the frequency and verticalization, it is that much time. I’m sure there’s someone out there who knows that, but I wouldn’t feel comfortable right now. I’d really have to look for evidence of that.” (CL04).

Most participants anticipated several challenges in the IDS’s daily use. For example, two PWC users and six clinicians spoke about the imposing size and weight of the PMMC, which might make it difficult to maneuver when accessing infrastructure, especially in confined spaces, and when using transportation services. One user expressed: “(…) every time you add a motorized system it adds weight to the chair. My wheelchair with the system is about 400 pounds. And if you’re someone like me who goes out a lot, it causes problems for bus lifts (…) and for airplanes. If you have a problem with your wheelchair and it breaks down and you have to put it in manual mode and it’s a very heavy wheelchair, it’s difficult. So, more functions, more weight, more problems.” (US06).

Additionally, two PWC users and two clinicians considered the joystick configuration and accessibility to be an important factor in the ease of use of the chair. They found that some PWCs have very complex controls that make it difficult to change position, as they have to press many buttons in a particular order. One user mentioned: “Simply managing the joystick, knowing (…) how to switch from drive mode to tilt mode, and back again, that’s often complex. There are several buttons to do, especially if the chair has a lot of modes of motorization with the joystick, then you have to move with the joystick to change from one to the other, that’s more difficult.” (US06). To optimize ease of use, the participants suggested selecting a certain position and having two buttons (i.e., one for going into the position and one for returning to its initial position).

Moreover, three PWC users and five clinicians expressed safety concerns due to possible technical issues, incorrectly programmed positions, or architectural barriers. For example, they talked about the risk of sliding when going from tilt to sit without bending the legs, the risk of falling when going from sit to stand if positioning units are set at the wrong height, and the risk of falling if there is a hole in the sidewalk. Some recommended a safety sensor for users if they want to stop the position transfer, for example, one PWC user suggested said “The seat elevator, we’ve already seen that, for example, you’re leaning on your pre-programmed position, but you hadn’t thought that the table is close or that there’s an obstacle nearby. Now you’re lifting the obstacle with your foot. You don’t have full visual contact around you and there are lots of objects. (…) Of course, if you’ve pre-programmed something in a computer that makes a movement in elevation, you’d have to, a bit like a garage door, have a sensor. For example, if I hit something, it stops. (…) So, you know, a safety device that would allow you to stop or downshift, that’s what I’m thinking of. Especially for the sit-to-stand lift.” (CL02).

Participants were unanimous in expressing that the WI would need to be minimalistic, as navigating the interface can be time-consuming and difficult for users, depending on their functional abilities and ease with technology. As opposed to multiple explicative paragraphs and blank spaces to fill in, they preferred having checkboxes to easily personalize, as well as a standard profile option for users who just want the common recommendations. As one clinician stated, “You have to remember that life is really harder for a disabled person in the broadest sense. So everything takes longer. (…) It reduces the amount of time you have to spend on all sorts of things, your hobbies, your meaningful activities and all that. So the client ticks off [checking boxes], I want to work on this, this, this, this, this, this, this; I want to have data on that. (…) You’ve identified yourself what you want to do, here are the objectives.” (CL02). Finally, to enhance accessibility and ease of use, a user questioned the WI’s compatibility with different technological devices, and a clinician mentioned the importance of having several language options for the interface, especially for those who do not necessarily know any French or English.

3.2. Visual Design

Visual design was defined by the look and feel of the eHealth intervention, as well as the visual quality of the interface [15]. Regarding the PMMC, one PWC user and one clinician mentioned that PWCs usually have large head supports, so much so that some users take them off, which prevents them from executing some of the programmed positions. As the clinician says: “We have a lot of clients who, as far as looks go, don’t like to have headrests on their wheelchairs, they think they look big, that they look more disabled, so when they don’t put the headrest on, they don’t use the tilt, or they hardly use it at all and they’re able to hold their neck.” (CL09). However, another clinician highlighted the progress of PMMCs’ aesthetics, with these being smaller and more sophisticated nowadays.

Additionally, four clinicians talked about liking the presence of pictures, the dark and bold colour choices, as well as the illustrations of pre-programmed positions (i.e., arrows indicating movements and colours indicating moving components) on the WI. However, they talked about the quantity of content and how it added to the visual clutter of the web pages: participants suggested sorting out the most important information. As one participant said, “There are too many objectives. It comes back to the same thing: if you want it to speak to the person, it has to be realistic over time. Too many words don’t help you pinpoint what’s important. After that, if there are a lot of recommended objectives, it could be just one sentence, “reduce seat pressure”. The person clicks if they want the information that’s there.” (CL02). The same thing applied to Section 3, as participants observed that too many graphics were distracting them from the essential variables; they suggested larger numbers as well as fewer and more visually intuitive graphics, such as bar and pie charts.

3.3. User Engagement

User engagement referred to the extent to which the eHealth intervention design attracted users to use it [15]. Two PWC users and three clinicians talked about two factors that encourage WI adoption: soft alarms and individualized options. Indeed, two clinicians pointed out that a small vibration instead of a big, audible alarm during programmed position changes, for example, is more pleasant for the user, who is therefore more likely to change positions, especially in a social context. Furthermore, two PWC users and a clinician emphasized the importance of personalizing the WI and the programmed positions’ angles according to users’ unique preferences and wheelchair configurations, for instance, by customizing the PWC pictograms on the interface. As one said, “Here the big wheels are at the back. Some wheelchairs have big wheels at the front. It’s a detail, but we could indicate our model of wheelchair and perhaps the pictograms could follow the model.” (US11).

3.4. Content

This theme explored the content provided or learned while using the eHealth intervention [15]. Participants expressed that the topics on the WI (e.g., positions, objectives, results) were pertinent. However, five clinicians and one user emphasized that it would be clearer and more meaningful for PWC users if the objectives were functional, meaning based on postural and occupational contexts (e.g., work, socialization, leisure). As one person said: “Reducing pressure on the seat: people will talk to us a lot about pain, discomfort and reduced sitting tolerance. So, for example, we’re going to focus more on being comfortable in our wheelchair at the end of the day, because people’s objectives are often very concrete; they want to achieve specific actions. For example, a user isn’t going to tell us, I want to be able to propel my wheelchair 50 m, he’s going to tell us, I want to be able to go to the cafeteria and come back. So, it’s a little more focused on the activity.” (CL07). It was also suggested that the objectives should be presented in the form of a progression, especially for users whose current situation shows a significant gap with the situation described in the objectives, so that attaining these objectives remains a fair challenge for these users.

Additionally, all participants mentioned a lack of clarity in data quantification. Participants found that the use of percentages and angles in the objectives and graphic results was unclear, and they were uncertain about what the numbers referred to or how they were calculated. The participants all preferred content in terms of duration, time of day, number and frequency of programmed positions, and functional objectives, as this would give users a better idea of how to implement the objective daily and allow a clear understanding of the graphics. Adding goal attainment status above the graphics was also proposed by seven participants—four clinicians and three users. As one clinician said: “It is important to have an element of progression because if, let’s say, they look at the graph halfway through the month, they could see where it’s got to in relation to the goal, then maybe give themselves a little extra challenge to try and get closer to the goal.” (CL03).

3.5. Therapeutic Persuasiveness

Therapeutic persuasiveness was the extent to which the eHealth intervention was able to encourage users to make positive behavioural changes or maintain positive behaviours [15]. The most frequently mentioned aspect that would encourage positive behavioural change was the presence of reminders. Four PWC users and five clinicians suggested having optional (depending on users’ needs and level of experience) reminders (e.g., texts, vibration, red light on the joystick) to use a pre-programmed position. These reminders would suggest changing position if they had been in the same position for a long time, and to adopt a recommended position in the wheelchair at prescribed intervals. This would especially benefit those for whom it is harder to remember the recommendations for changing postures: those with a limited intrinsic signal to change posture due to limited sensation or who simply tend to forget. As one clinician mentioned: “Our younger ones, for example, sure they have smartwatches or phones, so you know sometimes little notifications like “have you thought about reclining today?”, things like that, I think it could be interesting. I think it could also be interesting when we deliver the wheelchairs… especially our people who have a bit more cognitive problems, our older people, we always ask that they be accompanied, they’re not always accompanied or you know, sometimes we give so much information and guidelines on delivery day (…), they don’t remember everything when they leave, so if we had a system that could remind them of doing certain positions, remind them of what it’s for, that would be really relevant (…).” (CL09).

The second most mentioned incentive to induce behavioural change was graphic feedback on the WI. Two PWC users and three clinicians indeed noted that visualizing the frequency and duration of use of different positions in a day could help users analyze their behaviour status (e.g., whether certain positions are performed less often than a user thought, whether there is a correlation between certain positions performed or avoided with symptom changes, whether there is an evolution in the achievement of objectives if changes in postures are increased), which would motivate change. As one clinician said, “We’ve got clients too who are pretty autonomous after all. So, I tell them, go check out your website to see if you’re doing it right during the day. (…) A little feedback once a month to check if I’m doing it really right or “ah let’s see, it’s weird in the last few days, I’ve had more spasticity”, then you know maybe links will be made too with the mobilizations recommended (made or not).” (CL09). Not only are these graphs a good benchmark and motivator for PWC users, they also provide clinicians with feedback on what PWC users are doing to try to achieve their objectives. In this was, the information provide from the WI may help to raise awareness and individualize teaching interventions based on the needs of each user.

Finally, a PWC user and two clinicians suggested adding words of encouragement (e.g., by text, on the interface) when achieving a goal so that PWC users feel like they are on the right track. They saw this encouragement as a motivating force and an external reinforcement encouraging users to use the PMMC: “If the system could send encouragements like “bravo you succeeded”. (…) You don’t need a prize afterwards, just a word of encouragement. It’s good because the person looks at the note and says, “Someone’s encouraging me, someone’s looking at me”. Some people need that.” (US10).

3.6. Therapeutic Alliance

This theme was defined by the ability of the eHealth intervention to work with the user to effect beneficial change [15]. All participants emphasized the benefits of clinicians accessing the WI to gain a clear portrayal of the PWC users’ positioning activities. This way, clinicians could provide appropriate responses to individuals’ needs, customize their therapeutic intervention, and promote user satisfaction. From a PWC user’s perspective: “I love the idea of being able to see (the data). I love the idea of being able to have an idea of when I use the chair, what it looks like, how I position myself. I like the fact that the occupational therapist has access to it to come and help someone who needs some guidance or to validate that he’s doing it right. (…) Supervision and support should be very useful, recommendations should be made—to be able to see it, to validate that it’s working, that it’s correct, that you’re doing it well, if it’s presented in a constructive way.” (US12). Two PWC users and one clinician also appreciated the functionality for the user to remove the clinician’s access to their data, as they have a right to their privacy. As one user said: “When I want help, I give it (the information), when I don’t want it, I cut it off. It’s private. It’s my body.” (US10).

3.7. General Subjective Evaluation of Program’s Potential

The theme explored the general potential of the eHealth intervention to generate benefits for its target audience according to raters’ subjective evaluation [15]. In this study, four sub-themes emerged: intention to use (i.e., overall impression of the IDS as an eHealth intervention), target clientele (i.e., population that would best benefit from the IDS), issues (i.e., perceived concerns regarding the IDS), and benefits (i.e., perceived benefits emerging from the IDS).

3.7.1. Intention to Use

Participants had an overall positive impression of the WI, as they perceived it could improve health interventions and benefit users, helping them to achieve functional goals. Having automatic positioning would save time for users in their daily activities, and data tracking in the WI would save time for clinicians in identifying the users’ difficulties and positive habits, reducing unnecessary referrals. As one clinician commented, “I think it could also help us in communicating with the community occupational therapists, because often, clients will be referred to us directly with a problem involving wounds, a chair, or slipping. Clients come back here to the wheelchair clinic, but do they need to come back to the clinic, or can we (community OTs) just say look, if we look at his position changes, then what he does, well, he’s never tilted enough for wheelchair driving. He never tilts, so we work on that first before we see him again. Then, if the problem persists, we’ll see the user again (at the wheelchair clinic).” (CL09).

3.7.2. Target Clientele

All eight clinicians described populations that could best benefit from the IDS, including children, adults, and seniors with long-term needs (e.g., degenerative diseases, spinal cord injuries, losing their autonomy, or becoming susceptible to infections without regular position changes). Indeed, one clinician expressed that the main benefit of WI would be reducing complications “(…) from a pressure ulcer-healing perspective. Some of the clients we see repeatedly don’t manage to heal the wound; they’re bedridden. But with this, it would be great, because there would be a kind of external control. The clinician would be able to see, is the client actually following our recommendation to tilt (…).” (CL04). They also excluded from the target population individuals who are not familiar with the use of technology or with important cognitive challenges, suggesting that using the WI could be difficult and anxiety-provoking. Additionally, costs must be considered, as well as the beneficiary’s good judgment and capacity to use the system correctly. One clinician added, “The first limit, of course, is that patients always arrive wanting the maximum amount of equipment. Well, we must consider their costs. After that, you have to make sure that the person has the cognitive capacity to manage all that. And judgment, I’d say—it’s certain that when you start using this equipment, it’s like starting to jog, you have to train, you can’t create damage. You have to pace yourself.” (CL01).

3.7.3. Issues

Issues were raised concerning the PWC’s multi-motorized components. Indeed, four PWC users and two clinicians discussed the challenges of pre-programming positions and interpreting feedback given certain physical attributes of the person (e.g., kyphosis, obesity, range of motion to reach the WI) and variability in daily pain levels, all of which impact positioning possibilities. As one clinician described: “Everyone has a different morphology. (…) You have to customize, and that’s not necessarily always user-friendly, and it adds delays to the healing process. (…) Suppose, for example, the standing system… people with kyphosis find it difficult to reposition themselves, because we used to have rigid backrests, and then there’s the raising system that comes in, which takes up space, so this limits the positioning we can do to accommodate the curves of the back.” (CL05).

Regarding safety issues, two PWC users and one clinician spoke about the importance of changing position progressively when pushing a button, knowing that some positions, such as verticalization, can cause dizziness and increase the risk of fractures if standing too long: “(the user) has to control the button. He has to manage it at all times, because depending on fatigue, depending on all sorts of factors, I don’t want him to stand up and then have a drop in pressure.” (CL01). Nine participants—three users and six clinicians also recommended that the WI provide position and speed limits in certain contexts (e.g., avoid going very fast in verticalization to prevent falling, avoid verticalization on icy sidewalks in winter). Healthwise, five clinicians recommended setting time limits on certain positions, knowing that some can lead to sliding, which can lead to friction and increase the risk of pressure sores. As one clinician said: “With the reclining backrest, it’s the pressure sore issues that concern me. For people with serious pressure sore problems, friction creates far more wound problems than pressure.” (CL01).

Financially, there were cost concerns expressed by seven clinicians and one PWC user. Most people received their PWC through public insurance programs, while a few purchased it independently. Clinicians expressed the challenge of justifying the needs of their clients to receive public funding and specifically related to justifying a need for a PMMC. Clinicians must clearly articulate the benefits of having MMC versus the risks of not having MMC to justify funding for their clients (e.g., independence versus dependence for accomplishing activities of daily living). As one clinician said: “This is not a service currently allocated by the [public funding agency]. If we could demonstrate a good benefit, perhaps it could be, but these systems are not universally covered at this stage.” (CL01).

On an organizational level, two clinicians and one PWC user reported that healthcare environments have limited follow-up schedules after the allocation of a technical device, and there is frequently no follow-up at all. Limited service can create risks if there are technical issues in programmed positions that are not addressed on time. One clinician suggested yearly follow-ups: “Once the person has their motorized wheelchair, they leave with their device and go about their life. … So it’s clear that in this context, there could perhaps be risks associated with motorization programming if people aren’t seen again after a certain time. (…) I think that annually this (a follow-up) could well be the case.” (CL07).

3.7.4. Benefits

Benefits were also perceived regarding the IDS. Indeed, three clinicians and five PWC users discussed how being in an upright position may enhance opportunities for social participation (e.g., being able to communicate at eye-level with someone who is standing), which can improve self-esteem and morale. As one clinician said, “You know, if there’s one thing that’s recurrent, it’s always the impression that you’re lower than the others when you’re sitting in a wheelchair. (…) I think that having seen a lot of people who end up having depressions, and then moreover, leaving home because it’s finally too difficult. Well, I think (verticalization) makes a big difference about that (…).” (CL02) All fourteen participants also reported better autonomy with verticalization, as it improves quick access to higher objects and better participation in daily activities (e.g., reaching for a high product at the grocery store, pouring a glass of water at a friend’s house). Clinicians highlighted the significant functional impact on users through having rapid position changes at the touch of a button, and easy feedback from the WI. As users can be more independent in position transfers, participants mentioned a reduced need for peer helpers (e.g., the user can pull up his pants after using the toilet by himself). As one said: “We can see that this (pre-programmed positions) could help to improve quality of life, enabling greater autonomy and the maintain people in their homes.” (CL02).

Several health benefits from using PMMC were described by seven clinicians and four PWC users (e.g., better metabolism and elimination control, better skin condition, better circulatory health and bone mass, reduced contractures, better pain management, better body alignment and breathing). As one PWC user said: “You know, if you’ve been sitting on your buttocks for 16 h all day, and 80% or even 70% of your weight has been transferred to the surface you’re sitting on, you can’t get away with it without developing fragility. When standing, there’s almost no pressure on the seat. It sure feels great. It’s known to reduce osteoporosis; it’s better for the joints. For the vestibular system, I think it’s better for the brain too to change position. You know, there are lots and lots of benefits to it.” (CL02). Finally, on an organizational level, one clinician and one user spoke about the impacts of the PMMC and WI on health services, as users would be more functional and independent, decreasing the need for follow-ups, home adaptations, or relocations, which could therefore be a way of justifying the costs. As one user said, “The systems, I don’t know how well they record everything, but apparently if they record a lot of positions, it could help specialists. In my opinion, it could save visits to specialists and justify the cost of the (motorized wheelchair) system. In my opinion, it could save visits, so the person could be independent faster.” (US11).

4. Discussion

The aims of this study were achieved, exploring PWC users and clinicians’ needs and perceptions regarding an IDS system that could respond to user preferences from various sources (sensors and input from a WI) to facilitate body position changes using multiple components of a PWC. We applied Baumel’s conceptual model to explore the perceived quality of the web-based intervention according to the following concepts: usability, content, visual design, user engagement, therapeutic persuasiveness, therapeutic alliance, and general subjective evaluation [15]. Opinions varied due to personal factors, such as the physical characteristics of participants, the cognitive capacity required to use the system, potential users’ comfort with technology, and clinicians’ workplace resources. Overall feedback from participants suggested that the IDS prototype was intuitive, provided pertinent feedback, helped to visualize goal attainment and system use, and generated several benefits for users on the emotional, health, autonomy, and organizational fronts. Similar results have been observed in other studies with comparable digital monitoring tools, highlighting the value of the use of a PMMC and WI [11,16,20,21].

To optimize the WI, participants discussed the need for an even more minimalistic, image-based, and personalized tool. As other studies have shown, the visual aspects of a system influence users’ comprehension and the system’s usability [22,23]. While there were pictures and colour-coded graphics, participants’ general feedback was to add photos that go along with the text, minimize paragraphs, and prioritize bullet points, as well as to choose graphics that better show progression and goal attainment. More specifically, graphics were difficult for participants to understand most of the time due to the choices of variables (e.g., angles). Other variables (e.g., duration of a position) were preferred, as they were more patient-centered: users could better track their progress and whether they had attained their goals (e.g., using the tilt function at a programmed frequency) when tracking time spent sitting and using the tilt throughout the week instead of seeing daily angles. Functional goals also add personalization; for example, wanting more comfort while sitting during leisure activities would be more meaningful to achieve than aiming to change to a given position for a certain amount of time and at a certain frequency. In fact, other authors agree that healthcare practices, including prototypes like this one, need to be patient-centered to be more effective and impact behaviours [24]. Jordan et al. evaluated two mHealth assistive technologies (AW-Shift© and the Sensoria^®), pressure-sensing mats that were designed to support wheelchair users in seating and pressure management. Although both systems were found to be usable and potentially beneficial, the authors reported that user experiences varied based on their individual needs and movement profiles, highlighting the importance of tailoring digital seating health tools to diverse wheelchair user subgroups [25]. Therefore, allowing customization, such as WC symbols matched to the user’s specific WC, or other WI features (e.g., colours, content, sounds, content in multiple languages), would improve the quality of the prototype.

Participants also discussed the ability of the IDS prototype to encourage behavioural change, given that visual feedback about position changes and goal attainment may provide motivation to act on the provided objectives and track progress. It may also help clinicians identify how PWC users use the system and in turn personalize intervention, (e.g., motivating users, raising awareness, validating their achievement of positioning guidelines, delivering constructive feedback, defending the relevance of the technology to attain public funding, or preventing excessive referrals and back-and-forth between services). As reported in previous studies [11,16], PWC users may feel more supported and clinicians more equipped to provide support when they can consolidate information. In this way, PWC users and clinicians may through improved therapeutic persuasion and clinical rapport (i.e., two common outcomes of electronic health intervention programs) [15].

Furthermore, the main benefits of the IDS prototype that participants referred to were its impacts on social interactions and self-esteem, improved metabolism, body posture, and skin management, quicker access to objects in daily activities, more autonomy in transfers, as well as decreased needs for healthcare services. These benefits positively impact social participation, as well as the quality of life of users [3,7,26]. In fact, social engagement amongst people with disabilities is a strong predictor of their life satisfaction, which is a key measure of their quality of life [26]. Both social engagement and autonomy enhance quality of life and reduce levels of depression and other forms of emotional distress [26,27]. Better autonomy also prevents overload and helplessness and, along with better health, reduces the burden of care on families as well as their healthcare expenses (e.g., fewer healthcare follow-ups, fewer institutionalizations) [26,28].

In sum, IDS has the potential to contribute to occupational therapy practice by allowing more effective and individualized follow-up between clinicians and users as needed, by allowing clinicians to identify their clients’ IDS use. Knowing that social engagement and autonomy optimize rehabilitation outcomes and should be key objectives in rehabilitation practices [26], IDS could be key to improving those aspects by letting users target their objectives, be responsible for achieving their goals, and track them, as well as choose preferred positions to better participate in functional activities (e.g., social engagements, work tasks). Further studies should be performed on IDS’s contributions to the rehabilitation field, in general (e.g., physiotherapists, physiotherapy technologists, kinesiologists), and its impacts on healthcare services, to generate evidence-based data

While results suggest a favourable perception from PWC users and clinicians regarding PMMC and the WI, certain issues raised underline the importance of clinical judgement when selecting components and recommending IDS systems. For example, participants mentioned that training on the use of smart technologies would be important for both clinicians and PWC users to deliver optimum benefits and reduce challenges. Indeed, while training generates costs during development and delivery, it remains relevant to understanding the users’ needs, enhancing safety, and preventing under-usage of expensive technologies [29]. Although there is support for the potential benefits of these intelligent systems from our study and others [11], there remains a lack of available guidelines on how to integrate this smart technology into practice. Another main issue concerns the human and financial resources necessary to integrate this new technology. Clinicians, indeed, mentioned having limited time in their work environments for follow-up or regular consultation, resonating with the findings of time constraints being reported as one of the main challenges among healthcare providers [30]. Participants also mentioned difficulties in justifying the coverage for such smart technologies with public funds based on their previous experiences, reinforcing the need for more research to support justifications for this equipment using science. Future studies should consider longitudinal studies and clinical trials that include economic evaluations to determine the cost-effectiveness and cost-utility of IDS and other smart technologies. For instance, the impact of prolonged immobility on health (e.g., demineralization and deformation of bones, fractures, and pressure ulcers) may increase health service utilization and hospitalization [31,32,33]. Economic studies could shed light on technology attribution in line with the associated risk, ranging from lower-cost technologies, such as manual wheelchairs that offer standing [7,34], to higher-cost technologies such as the system presented in this study or exoskeletons [35]. This acceptability study represents an important first step in the research, as end-users must be open to using the new technology. However, clinical trials and economic studies are needed before recommending that this technology be implemented in practice and providing justification for funding.

Strengths and Limitations

The limitations of this research should be considered when interpreting its results. All clinicians recruited were occupational therapists, which excluded other professionals who may also be involved with prescribing or training PMMC users. This reflects the wheelchair prescription process in Quebec, Canada, which largely relies on this profession. The roles of the occupational therapists who participated in the study were also limited to equipment allocation, i.e., they did not deal with post-procurement follow-up other than in problematic situations, thus limiting their experience in user follow-up. Furthermore, at the time of the interviews, the clinicians only had access to a mock-up of the WI; therefore, they were unable to experiment with the WI before giving feedback. Although samples as small as five may be justifiable for usability and acceptability studies such as this one [36], the heterogeneity among PWC users should be considered, and recruitment being limited to one Canadian province reduces the transferability of these findings to larger populations.

To enhance the credibility and dependability of these findings, the methodology was based on a scientifically documented conceptual framework [15]. In addition, the analyses were conducted, reviewed, and discussed among the research team, who have interdisciplinary post-graduate training, thus enhancing the confirmability of the findings. The trustworthiness of these findings could have been further enhanced through member checking. However, this was not performed due to pragmatic reasons, such as limited clinician time. Future studies may also consider reflexive journaling and collecting additional types of data to permit triangulation.

5. Conclusions

The present study aimed to explore PWC users’ and clinicians’ specific needs and perceptions regarding the use of an IDS prototype. To help optimize the prototype and guide further studies, this research provided unique information about users’ and professionals’ understanding of the IDS’s advantages and challenges using a developed evaluation tool for mobile- and web-based health interventions. This study underlines the important potential of IDS to enhance PWC users’ social and occupational participation, while potentially facilitating clinical intervention with reduced burden and strain on the healthcare system. However, remaining societal and individual barriers emphasize the need for continued efforts to improve resources in PMMC and IDS provision and to continue the development of this technology. Future research may propose new prototype development and consider refining the guidelines for digital tool usage in healthcare interventions.