Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

1. The authors address an important topic that will be of interest to readers.
2. Although the focus is on Albania, the implications are global.
3. The methodology was clearly described and conducted in an exemplary manner.
4. The findings are consistent with other published studies, but replication in different settings is valuable.
5. The conclusions are appropriately conservative.
6. I'm not familiar with the usual paper length for this journal, but the manuscript seems a bit long to me. If I were reporting this study, I'd probably cut the word count and number of tables by about 30% and move some of the detail into supplemental files.

Author Response

We sincerely thank the reviewer for the positive assessment of our manuscript and for the constructive recommendation to reduce its length by approximately 30%.

We agree that conciseness is important. We have shortened and reorganized the Introduction and Literature Review, reducing their combined length by approximately 18% compared with the previous version. We have also removed selected repetitions and consolidated overlapping explanations.

However, we have not achieved the suggested 30% reduction in the manuscript as a whole. Addressing the Editor’s and Reviewer 2’s comments required additional clarification of the methods, respondent perspectives, analytical procedures, and limitations, together with a more developed discussion of the findings in relation to international evidence. Consequently, the revised manuscript is longer overall.

We have retained these additions because they provide information needed to interpret the findings and assess the study’s methodological transparency. We respectfully ask the reviewer to consider this balance between conciseness and the clarifications requested during revision. We appreciate the reviewer’s encouraging assessment and the opportunity to improve the manuscript.

 

Reviewer 2 Report

Comments and Suggestions for Authors

Thank-you for the opportunity to review this mixed-methods study evaluating wheelchair provision in Albania, and factors associated with independent use. On the whole, the study appears comprehensive and well designed, and the writing and methodology are clear. The statistical analysis appears robust. I have a few questions and comments to improve the reporting.

General notes regarding writing:

Generally, the manuscript would benefit from editing to make it more concise. There is repetition between the introduction and the literature review. It would be better if the justification for the study and research questions came after the literature review, and not before.

There is also unnecessary repetition between methods and results, especially in relation to specific analyses.

Study limitations such as results not implying causal or population-level estimates are also mentioned multiple times, and in several locations – while I appreciate that authors are being cautious and not overstating their results, this repetition could also be reduced.

There are a few terms that should be clarified in order for the study findings to be meaningful to a wider international audience:

Paraplegic and tetraplegic status are mentioned as being legally recognized terms in Albania. The definition needs to be provided – perhaps with examples of relevant diagnoses. In many countries the term paraplegic refers to someone with a spinal cord injury with a lower-level injury, while tetraplegic can mean a thoracic or cervical level spinal cord injury or someone with cerebral palsy affecting all four limbs. How do diagnoses such as stroke, multiple sclerosis, Parkinsons disease, Spina Bifida etc., fit with these definitions?

Adapted home – what exactly does this mean? Widened doorways, accessible bathroom, ground floor access?

Ramp or Elevator – these are methods of external access depending on the type of home. Some houses only require a ramp for access, some require a porch lift for external access to the main floor, some might need an internal elevator to access the bedrooms or bathroom – and apartment buildings typically have elevators. I’m wondering why these were separated in your analysis – as, depending on the home – you might need one or the other, but not necessarily both. I wonder if these should have been combined as adapted external access to the home, or if there is a reason you analyzed separately?

Methods:

The section Study setting and Participants – is providing results, not methods. This section should be about recruitment methods and locations – not numbers of participants and descriptions – please move this information to results

The primary outcome question: Independent versus dependent wheelchair use. You clarify that you did not separately assess transfers, ADL, indoor mobility, community mobility or independent living. How confident are you that participants answering this question were answering that they were independent in all situations? I would suggest adding additional clarification so that the reader understands that participants were not able to answer this question differently for different situations. Many people can be independent in their own home, but not out in the community or may require support only for specific transportation needs.

I also have questions about the different types of transportation. Were those who said they were independent in wheelchair use, able to use all these forms of transportation independently? For example, most wheelchair users travelling by airplane have assistance, because they have to transfer to a different wheeled device in order to get onto the plane – although they may be fully independent in their own wheelchair.

Some participants were family proxy reporters. Can you add information to explain why some individuals were represented by family proxy? Was this due to age, communication difficulties, cognitive limitations, personal choice? Since there is a similar split between dependent and independent wheelchair use in this group, it is more difficult to understand, since it cannot be related to physical abilities.

Why did you not include any family proxy respondents in the focus groups?

Results:

I appreciated the mix of methods used in the analysis, the robust and comprehensive descriptive and statistical analysis, and the integrated joint display or quantitative and qualitative findings. I note that very few participant quotes were included in the text.

I would suggest that you add a table to your supplementary materials illustrating the themes that emerged from the qualitative literature, with sample quotes for each.

Discussion:

Is rather limited, and mainly consists of a summary of results, and some repetition from the introduction and literature review. I would suggest expanding this section to discuss how your findings compare or contrast with reports from other settings – high and low-middle income settings.

Supplementary Materials:

Thank-you for providing all the comparative analyses in Tables S1-S5

The supplementary materials should also include your survey questions and the questions and outline used in the focus groups. The English translations of the direct user questionnaire and the family proxy questionnaire are listed as being part of the supplementary materials, but were not available for this review – and therefore I cannot comment on them. They should be available for future reviews, either as supplementary material or as an appendix.

As suggested above, documentation of your qualitative analysis should also be provided and illustrated with quotes. They can be either supplementary material or an appendix

Author Response

Response to Reviewer 2

Manuscript ID: Disabilities-4495726

 

We thank the reviewer for the positive assessment of the study design, reporting, and statistical analysis, and for the constructive recommendations. The revisions below clarify the measures and respondent sources, reduce repetition, strengthen the interpretation of the findings, and improve the supplementary reporting.

Comment 1 Introduction and Literature Review

Reviewer comment

Generally, the manuscript would benefit from editing to make it more concise. There is repetition between the introduction and the literature review. It would be better if the justification for the study and research questions came after the literature review, and not before.

Response

Thank you for this suggestion. We have revised the Introduction and Literature Review to reduce overlapping explanations while retaining the substantive background and relevant references. The study rationale, aim, and research questions now appear together at the end of the Literature Review. The third research question has also been refined to focus on reported environmental and transport barriers to everyday mobility and participation.

Location of changes: Sections 1 and 2, particularly the final paragraphs of Section 2.

Comment 2 Methods and Results

Reviewer comment

There is also unnecessary repetition between methods and results, especially in relation to specific analyses.

Response

We have revised these sections to distinguish analytical procedures from findings. Methods describes how the composites were constructed and assessed, whereas numerical psychometric findings are reported in Results. We have removed the repeated outcome-valid sample count from Section 3.6.2 and the redundant introductory explanation in Section 4.4. Analysis-specific sample sizes remain reported with the relevant results.

Location of changes: Sections 3.6.1, 3.6.2, 4.2, 4.3, and 4.4.

Comment 3 Repeated statements about limitations

Reviewer comment

Study limitations such as results not implying causal or population-level estimates are also mentioned multiple times, and in several locations – while I appreciate that authors are being cautious and not overstating their results, this repetition could also be reduced.

Response

We agree that these qualifications were repeated unnecessarily. We have consolidated the explanation of the limitations arising from purposive sampling and the cross-sectional design in Section 5.5 and removed redundant general statements from the Discussion and Conclusion. A brief qualification remains in the Abstract, and specific cautions needed to interpret individual findings have been retained.

Location of changes: Abstract; Sections 5 and 5.5; Section 6.

Comment 4 Legal definitions of paraplegic and tetraplegic status

Reviewer comment

Paraplegic and tetraplegic status are mentioned as being legally recognized terms in Albania. The definition needs to be provided – perhaps with examples of relevant diagnoses. In many countries the term paraplegic refers to someone with a spinal cord injury with a lower-level injury, while tetraplegic can mean a thoracic or cervical level spinal cord injury or someone with cerebral palsy affecting all four limbs. How do diagnoses such as stroke, multiple sclerosis, Parkinsons disease, Spina Bifida etc., fit with these definitions?

Response

Thank you for requesting clarification for international readers. We have added the statutory definitions from Article 2 of Albanian Law No. 8626 of 22 June 2000 on paraplegic and tetraplegic status. The law defines paraplegia as paralysis of both lower limbs resulting from spinal cord damage from various causes, and tetraplegia as paralysis of all four limbs resulting from spinal cord damage, with classification by the Medical Commission for Determining Capacity for Work. We have clarified that the study included wheelchair users both with and without this legal status. The questionnaire recorded benefit status rather than establishing clinical diagnoses. We therefore do not infer that the diagnoses listed in the comment automatically fall within this statutory category. The distinction between legal status and clinical diagnosis is also acknowledged as a limitation, and the law has been added to the reference list.

Location of changes: Section 3.2; Section 5.5; reference list.

Comment 5 Definition of an adapted home

Reviewer comment

Adapted home – what exactly does this mean? Widened doorways, accessible bathroom, ground floor access?

Response

We have clarified that an adapted home refers to the respondent’s Yes/No assessment of whether the home was adapted for wheelchair use, with the questionnaire referring to space, doors, and bathroom facilities, including the toilet and shower. This was a broad self-reported indicator rather than a separate assessment of each feature or a technical accessibility audit. Entrance ramps and elevators were recorded separately. The Discussion now explains the limits of this broad measure and distinguishes it from ramp access.

Location of changes: Section 3.4.1; Section 5.3.

Comment 6 Separate measures of ramps and elevators

Reviewer comment

Ramp or Elevator – these are methods of external access depending on the type of home. Some houses only require a ramp for access, some require a porch lift for external access to the main floor, some might need an internal elevator to access the bedrooms or bathroom – and apartment buildings typically have elevators. I’m wondering why these were separated in your analysis – as, depending on the home – you might need one or the other, but not necessarily both. I wonder if these should have been combined as adapted external access to the home, or if there is a reason you analyzed separately?

Response

Thank you for highlighting the importance of the residential context. We agree that the need for a ramp or elevator depends on the dwelling and the route that must be negotiated. The questionnaire recorded these as separate features and did not establish whether each was required, suitable, or sufficient for a particular home. Combining them as adapted external access would therefore imply information that was not collected. We have clarified that both were examined descriptively and in bivariate analyses, while ramp access was included in the primary multivariable model. The revised Discussion explains that availability of either feature does not establish accessibility of the complete route.

Location of changes: Sections 3.4.1 and 3.6.2; Sections 5.3 and 5.4.

Comment 7 Location of the sample description

Reviewer comment

The section Study setting and Participants – is providing results, not methods. This section should be about recruitment methods and locations – not numbers of participants and descriptions – please move this information to results

Response

Thank you for this recommendation. We have clarified the organization of the Methods section by renaming Section 3.2 “Study Setting and Sample Characteristics” and retaining recruitment procedures in Section 3.3. We have retained the overall sample size and participant characteristics in Methods because they describe the study sample and help readers understand the design and respondent sources. This organization is consistent with APA Journal Article Reporting Standards for quantitative research, which place participant characteristics and sample size within Methods. Results reports analysis-specific sample sizes and substantive findings, with duplicate descriptions removed.

Location of changes: Sections 3.2 and 3.3; analysis-specific sample sizes in Section 4.

Comment 8 Meaning of independent wheelchair use

Reviewer comment

The primary outcome question: Independent versus dependent wheelchair use. You clarify that you did not separately assess transfers, ADL, indoor mobility, community mobility or independent living. How confident are you that participants answering this question were answering that they were independent in all situations? I would suggest adding additional clarification so that the reader understands that participants were not able to answer this question differently for different situations. Many people can be independent in their own home, but not out in the community or may require support only for specific transportation needs.

Response

Thank you for this important clarification. We cannot infer independence in all situations from the single binary outcome item. Section 3.4.1 now gives the wording of both questionnaire versions: the direct-user item asks about confidence using the wheelchair alone, whereas the proxy item asks whether the individual uses it alone. Each offered one Yes/No response, without separate answers for different activities or environments. We have clarified that a positive response does not establish independence in transfers, activities of daily living, indoor and community mobility, or travel. The outcome is described as reported independent wheelchair use, and the difference between confidence and reported use is explicitly acknowledged as a measurement limitation.

Location of changes: Abstract; Section 3.4.1; Section 5.5.

Comment 9 Wheelchair use and transport independence

Reviewer comment

I also have questions about the different types of transportation. Were those who said they were independent in wheelchair use, able to use all these forms of transportation independently? For example, most wheelchair users travelling by airplane have assistance, because they have to transfer to a different wheeled device in order to get onto the plane – although they may be fully independent in their own wheelchair.

Response

We agree that independent wheelchair use does not establish independent travel by every transport mode. We have clarified that transport was assessed separately through mode-specific ratings for use without a companion and use with assistance, and that these items did not define the primary outcome. A positive response to the wheelchair-use item was not interpreted as independence across transport modes. The transport ratings did not separately assess boarding, transfers, or other stages of a journey. The Discussion now distinguishes wheelchair operation from accessibility and assistance needs throughout a journey.

Location of changes: Section 3.4.1; Sections 5.3 and 5.5.

Comment 10 Inclusion of family proxy respondents

Reviewer comment

Some participants were family proxy reporters. Can you add information to explain why some individuals were represented by family proxy? Was this due to age, communication difficulties, cognitive limitations, personal choice? Since there is a similar split between dependent and independent wheelchair use in this group, it is more difficult to understand, since it cannot be related to physical abilities.

Response

Thank you for requesting this clarification. We have revised Section 3.3 to explain that family members were intentionally included to capture their perspective on the wheelchair use and support needs of the individual they reported on. Inclusion of family respondents was not determined by whether the individual used their wheelchair independently; therefore, both independent and non-independent wheelchair use could be reported within this group. This study-level rationale does not establish an individual reason, such as age or cognitive or communication difficulties, for every proxy report. Respondent type was recorded and considered in the analyses, including a direct-user-only sensitivity analysis. The limitations of proxy reporting and the differences between the direct-user and proxy outcome questions are acknowledged in Section 5.5.

Location of changes: Section 3.3; Section 5.5; existing respondent-source comparisons and direct-user-only sensitivity analysis.

Comment 11 Participants in the focus groups

Reviewer comment

Why did you not include any family proxy respondents in the focus groups?

Response

Thank you for this comment. We have clarified in Section 3.3 that the focus groups were designed to explore wheelchair users’ first-person experiences and therefore included wheelchair users only. Family members contributed through the family-proxy questionnaire. We acknowledge that this design did not capture family members’ experiences in comparable qualitative depth, and this limitation is now stated in Section 5.5.

Location of changes: Section 3.3; Section 5.5.

Comment 12 Participant quotations in Results

Reviewer comment

I appreciated the mix of methods used in the analysis, the robust and comprehensive descriptive and statistical analysis, and the integrated joint display or quantitative and qualitative findings. I note that very few participant quotes were included in the text.

Response

Thank you for the positive assessment of the analyses and integration of findings. We have added participant quotations to illustrate individualized wheelchair assessment, the interaction between wheelchair functionality and the home environment, and the implications of transport barriers for participation in education. These quotations provide additional context for the quantitative findings. Further illustrative quotations are presented in Supplementary File 3, Table S6.

Location of changes: Sections 4.1, 4.2, 4.3, and 4.5; Supplementary File 3, Table S6.

Comment 13 Supplementary table of qualitative findings

Reviewer comment

I would suggest that you add a table to your supplementary materials illustrating the themes that emerged from the qualitative literature, with sample quotes for each.

Response

Thank you for this suggestion. We have added Table S6 in Supplementary File 3, with illustrative participant quotations organized under six discussion domains: wheelchair provision and individualized assessment; wheelchair suitability and technical components; training and instruction; access to healthcare, rehabilitation, and social services; transport accessibility; and accessibility inside and outside the home and participation. This organization follows the focus group guide and is not presented as evidence that six distinct themes emerged independently from the analysis. A table note explains that the quotations illustrate participants’ accounts and should not be interpreted as estimates of frequency or prevalence.

Location of changes: Sections 3.4.2 and 4.5; Supplementary File 3, Table S6.

Comment 14 Discussion and comparisons with other settings

Reviewer comment

Is rather limited, and mainly consists of a summary of results, and some repetition from the introduction and literature review. I would suggest expanding this section to discuss how your findings compare or contrast with reports from other settings – high and low-middle income settings.

Response

Thank you for this helpful comment. We have substantially revised the Discussion to compare the findings with relevant literature from higher-income and low- and middle-income settings, rather than primarily restating the results. Section 5.1 compares wheelchair provision and accompanying services with the study by Toro et al. in Indonesia. Section 5.2 discusses wheelchair-use training in relation to the systematic review and meta-analysis by Keeler et al. and considers maintenance support alongside the United States trial by Worobey et al. Section 5.3 relates housing accessibility to the international review by Lindsay et al. and transport barriers to the London study by Velho et al. These comparisons identify similarities and differences while acknowledging variation in study design, measures, and service contexts. The revised Discussion also explains the contribution of the Albanian findings and distinguishes reported independent wheelchair use from broader mobility, participation, and independent living.

Location of changes: Revised Section 5, particularly Sections 5.1, 5.2, and 5.3.

Comment 15 Availability of questionnaires and the focus group guide

Reviewer comment

The supplementary materials should also include your survey questions and the questions and outline used in the focus groups. The English translations of the direct user questionnaire and the family proxy questionnaire are listed as being part of the supplementary materials, but were not available for this review – and therefore I cannot comment on them. They should be available for future reviews, either as supplementary material or as an appendix.

Response

Thank you for bringing this to our attention. The English translations of the direct-user and family-proxy questionnaires were included in the original supplementary materials, but we understand that they were not available to you during the review. We have resubmitted both questionnaires as Supplementary Files 1 and 2. We have also added Supplementary File 3, containing the six questions used to guide the focus group discussions and illustrative participant quotations organized by discussion domain in Table S6. The Supplementary Materials statement and the relevant cross-references in the manuscript have been updated accordingly. Tables S1–S5 retain their existing designations.

Location of changes: Sections 3.4.1 and 3.4.2; Supplementary Materials statement; Supplementary Files 1–3.

Comment 16 Documentation and illustration of qualitative analysis

Reviewer comment

As suggested above, documentation of your qualitative analysis should also be provided and illustrated with quotes. They can be either supplementary material or an appendix

Response

Thank you for this recommendation. Supplementary File 3 now brings together the focus group discussion guide and illustrative quotations organized by discussion domain in Table S6. It complements the description of the qualitative analysis in Section 3.6.3 and the integrated reporting in Results. Additional quotations and cross-references have been added to the manuscript. The supplement illustrates the qualitative findings; it is not presented as a full transcript archive or a complete coding audit trail.

Location of changes: Sections 3.4.2 and 3.6.3; Sections 4.1–4.3 and 4.5; Supplementary File 3, Table S6.