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Drivers for Change; Initial Insights from Mapping Half a Century of Inclusive Paediatric Mobility Design



Inclusive Paediatric Mobility (IPM) design is the application of an inclusive design process to create mobility interventions such as wheelchairs, walking aids and exoskeletons, with the fundamental goal of optimising the experience of childhood. The field of IPM has experienced growing attention from a wide range of disciplines and stakeholders, resulting in increased knowledge and the development of new interventions. However, there remains a myriad of issues around the viability, feasibility, and desirability of paediatric mobility products and services, as well as poor documentation of the successes, failures, and approaches used within the field. This paper maps out the history of the field across four categories of contributions i.e. Interventional, Theoretical, Methodological, and Empirical. Key drivers for change identified through the mapping review include Documentation and Representation, Design Approach, Interdisciplinarity, Regionality, and Operational and Market characteristics. These findings offer a starting point for reimagining the future of IPM design.
Drivers for Change: Initial Insights
from Mapping Half a Century of Inclusive
Paediatric Mobility Design
Cara OSullivan
and Farnaz Nickpour
205 Brodie Tower, University of Liverpool, Brownlow Street,
Merseyside L69 3GL, UK
Abstract. Inclusive Paediatric Mobility (IPM) design is the application of an
inclusive design process to create mobility interventions such as wheelchairs,
walking aids and exoskeletons, with the fundamental goal of optimising the
experience of childhood. The eld of IPM has experienced growing attention
from a wide range of disciplines and stakeholders, resulting in increased
knowledge and the development of new interventions. However, there remains a
myriad of issues around the viability, feasibility, and desirability of paediatric
mobility products and services, as well as poor documentation of the successes,
failures, and approaches used within the eld. This paper maps out the history of
the eld across four categories of contributions i.e. Interventional, Theoretical,
Methodological, and Empirical. Key drivers for change identied through the
mapping review include Documentation and Representation, Design Approach,
Interdisciplinarity, Regionality, and Operational and Market characteristics.
These ndings offer a starting point for reimagining the future of IPM design.
Keywords: Inclusive design Childhood Mobility Disability Assistive
technology Mapping review
1 Introduction to Inclusive Paediatric Mobility
Half a century ago, the widely accepted narrative used to address paediatric mobility
disabilities was to normalisechildrens movement, with walking being the ultimate
achievement. This was reected by the stark lack of independence-promoting inclusive
paediatric mobility (IPM) interventions other than walking aids [1]. In the late 1970s,
this mentality, and hence narrative, began to shift towards the goal of motivating
children to use their most efcient mobility approach to participate in meaningful
activities [2]. The eld has since accumulated interest from a range of disciplines and
stakeholders, leading to increased knowledge and understanding of the need for IPM
interventions from an early age [3], as well as the development of new IPM inter-
ventions [4]. Despite this, there remains a multitude of issues and barriers around the
viability, feasibility and desirability of IPM products, as well as poor documentation of
the successes, failures, and design principles and processes used within the eld. The
purpose of conducting this illustrative mapping review is to capture and illustrate the
changing landscape of IPM design and highlight key drivers for change. This in turn,
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could help inform the direction and dimensions of a framework aimed at improving the
design of IPM interventions of the future. Three distinct aims of conducting the
illustrative mapping review are to 1. learn from history; 2. question the present; and 3.
reimagine the future. This paper focuses on the former two aims.
2 Understanding IPM Design; What, Why, Who?
IPM design is the application of an inclusive design approach to create mobility
interventions such as wheelchairs, walking aids and exoskeletons, with the fundamental
goal of optimising the experience of childhood. In the context of commercially
available mobility interventions, young children are the most underserved and excluded
demographic; they are an extremeuser group [5]. There are three predominant
approaches to the application of inclusive design [6] and it is important to consider all
three in order to build a comprehensive, accurate, and insightful picture of the IPM
design landscape. The rst is a user-aware design approach which considers and caters
for extreme user groups in the design of mainstream products, such as supportive
tricycles and go-karts. The second is a customisable/modular design approach which
enables mainstream products to be adapted to cater for the needs of extreme user
groups, such as ride-on toy vehicles. The third is a special-purpose design approach
which caters specically for the needs of an extreme user group without serving a
mainstream market, such as wheelchairs and walking aids.
2.1 Why IPM Design Matters
Signicance. IPM is a global need. Independent mobility facilitates childrens phys-
ical, emotional, psychosocial, perceptual and cognitive development, as well as pro-
viding opportunities to make social interactions and increase condence and
participation with peers in everyday activities [7]. Around 90% of brain development
occurs during the rst ve years of life making early intervention and provision of IPM
an urgent priority to minimise irreversible developmental delays and likelihood of
developing passive, dependent behaviours. IPM interventions are designed to enable
independent mobility and hence help children develop to their full potential.
Issues. There is a myriad of unresolved issues around the design of products currently
available in the market which act as barriers for incorporating IPM into a childs life.
Many IPM interventions exclude children with complex needs and lack up-to-date
integrated and assistive technologies, let alone desirability and childhood appeal which
has long been the norm in other sectors. Issues around IPM designs can be classied
under three meta-levels:
1. Viability i.e. economies of scale, affordability and sustainability [8].
2. Feasibility i.e. usability, technicalities, functionality and features [9].
3. Desirability i.e. acceptability, emotional durability and personal meaning [10].
Drivers for Change: Initial Insights from Mapping Half a Century 823
Opportunities. Emerging initiatives to support the design of inclusive and assistive
technologies [11] provide a timely opportunity to develop a framework to equip and
inform the next generation of IPM designers with foundational knowledge, processes,
and tools; to better steer progress; and accelerate learning in the eld globally.
Advanced manufacturing techniques combined with the advent of open source
movements provides opportunity for full customisation of IPM products and drives
rapid innovation at a global scale. The ability to facilitate inclusive and interdisci-
plinary participation enables: a more holistic perspective on problems and potential
solutions; offers co-creation opportunities; gives choice and agency to end-users; and
results in products which better match the individual needs of users [12]. From the
perspective of health economics, there is also a signicant opportunity to build a case
for state provision of early years IPM interventions [13].
2.2 IPM Design Stakeholders, Expert Fields and Missing Voices
The eld of IPM design resides within the four overarching spheres of Childhood,
Disability, Mobility, and Design. The interpretations, denitions and priorities of IPM
design vary slightly amongst different stakeholder groups: from providing functional,
timely and energy-efcient mobility [2]; to meeting developmental and gross motor
milestones [7]; or from providing a safe means of mobility that can track a childs
progress and enhance their mobility experience [14]; to enable independence and
meaningful participation in life [1]. Each of these priorities reects different disci-
plinary perspectives, i.e. Psychology, Occupational Therapy, Design and Engineering,
and Parents. The importance of taking a multifaceted approach to IPM has been long
established, as has the need for holistic stakeholder input to take into account a range of
views and lived experiences [15]. However, this is not fully reected in the actual
design and development of IPM products and there remains numerous scholarly elds,
disciplines, experts and stakeholder voices from within and between the four overar-
ching spheres, whose currently missing voices could bring signicant value to the IPM
design process.
3 Mapping Methodology and Results
An illustrative mapping review is used to categorise contributions by their key features
and facilitate evidence synthesis. The data is classied under one of the four types of
design contributions outlined in Table 1. Data is presented chronologically to allow for
identication of trends, clusters, and deserts across all types of contribution. Mapped
contributions are then critically analysed to evaluate their quality, signicance, and
relationship to other contributions on the map. This methodology was selected as it allows
various types of design contribution to be plotted at a high level of granularity, using the
same categories. Hence, enabling a holistic visualisation and analysis of the IPM eld,
which is much needed. It should be kept in mind that this is an illustrative mapping review
only, and that methodological limitations will likely skew insights. i.e. conducting the
review in English language only may distort geographic observations (Fig. 1).
824 C. OSullivan and F. Nickpour
The data collection search protocol centred around electronic database searches and
manual searches for grey literature, unpublished eldwork, and artefacts. Inclusion
criteria required contributions to: focus on independent mobility (rather than passive
mobility); be created between 1970 to 2020; provide record of the context of their
creation; relate to at least one child aged 8 years with a mobility disability; be
specically relevant to paediatric mobility; be published in English language. The
authors independently determined if contributions met the inclusion criteria. Findings
were then shared for further review and input, with four paediatric occupational
Table 1. Classication of inclusive paediatric mobility design contributions.
I - Interventional T - Theoretical M - Methodological E - Empirical
New or improved
products, services,
systems or artefacts
I.1 Interventions made it
to market or are
I.2 Interventions
remained at concept or
prototype level
Conceptual models,
policies, principles
or important
variations on those
that already exist
(e.g. disability
Novel or rened
methods, processes,
or techniques with
enough detail to be
replicated by others
Data sets, surveys,
arguments, or
ndings based on
empirical research
which reveal formerly
unknown insight and
analysis of behaviors,
capabilities, or
interactions with
interventions etc.
Fig. 1. Illustrative map of designerly contributions to the eld of IPM between 1970 and 2020,
based on type of contribution and contributors stakeholder group/s.
Drivers for Change: Initial Insights from Mapping Half a Century 825
therapists and four paediatric mobility design engineers. In total, 56 results were
deemed eligible for inclusion from electronic database searches. A further ve con-
tributions provided by IPM therapists and design engineers were included, bringing the
total of contributions eligible for inclusion to 61. Of these, 36 were classied as
interventional, 14 were classied as theoretical, four were classied as methodological,
and seven were classied as empirical. Subsequently, background information was
captured for each contribution. This included year of creation, geographic location,
discipline of contributor, and design approach used. Contributions captured by the
illustrative mapping review were critically analysed by further investigating the con-
tributors experience, motivations, methodologies, narratives, and terminology used.
Analysing the map highlighted insights and drivers for change in the IPM design eld,
which have been summarised and discussed under the following ve themes.
4 Key Findings and Drivers for Change
Documentation and Representation. The review revealed that IPM design efforts
have generally been poorly recorded which may reect knowledge-sharing barriers
[16]oranend-result-orientedmentality. Many of the I.2 interventional contributions
were uncovered via media coverage from receiving aspirational design awards; such
well-presented inspirational prototypes, videos, or illustrations of nal products are
represented as indicators of success whilst design processes, failures, long-term mea-
sures of success, and empirical knowledge are typically kept in-house, if documented at
all. The fact these contributions never made it to being used or commercialised could
reect the complexities and barriers involved with navigating highly regulated
healthcare systems. The overall representation of empirical contributions appears
skewed towards stakeholders with an academic background which could be due to
documentation and dissemination of knowledge being encouraged and allocated more
time in academia in comparison to industry.
Design Approaches and Knowledge. Innovation in the eld appears to have been
incremental, with greater focus given to renement of existing products. Beginner
paediatric power chairs have consistently been the most common type of interventional
contribution. None of the recorded interventional contributions were approached with
the denition of user aware approachwhilst six were approached with a
modular/customisable approach. The remaining 30 employed a special purpose
design approach to create specic assistive technologies which tend to be targeted at
smaller markets, typically resulting in higher costs. The review shows no record of
frameworks, processes, or methods relating to the IPM design process. The limited
number of theoretical and methodological contributions, specic to the IPM eld,
leaves little foundation for new interventional contributions to learn from and build
upon. This also means, there are no rigorous principles to dene, measure, or assess
quality and success in IPM design.
Stakeholder Collaboration and Interdisciplinarity. Recorded interventional con-
tributions have mainly been led by engineers or designers with input from occupational
826 C. OSullivan and F. Nickpour
therapists and parents but there is little evidence of continued involvement from other
disciplines or stakeholders. This could suggest that co-design and multidisciplinary
approaches were not effectively adopted in the majority of cases. This could limit the
diversity of perspectives, mentalities, and insights from the outset of a project, hence
restricting the way narratives and interventions are imagined, and subsequently
designed [12]. When contemplating the future of IPM design, it is important to con-
sider beyond the core eld, to converge current thinking in broader grounding elds
including childhood, disability, mobility, and design. This would require a co-creative,
child-centred, and interdisciplinary approach.
Geographic and Regionality. There is a signicant lack of novel designerly IPM
contributions recorded from developing regions of the world which could be due to
limitations of the search strategy, poor documentation of possible contributions, or
general lack of contributions from these areas. The majority of recorded contributions
come from North America, the United Kingdom, and Scandinavia; this again raises
questions around representation and documentation in the IPM design eld.
Operational and Market Characteristics. A spectrum of operational proles was
identied. On one end of the spectrum, exist projects instigated by those with a vested
personal interest or social responsibility, such as third sector charities, clinicians or
family members. These are typically small-scale organisations, cottage industries, or
startups motivated by the lack of appropriate existing IPM options. These tend to lack
budget or a clearly dened business strategy from the outset. On the other end of the
spectrum are large-scale commercial organisations who already mass manufacture adult
mobility equipment and have well-established routes to market. The former is a more
agile entity with the ability to adapt designs as and when needed, to allow for greater
impact for individuals, but can struggle with economies of scale and nancial sus-
tainability; they tend to involve a social aspect in their business model such as a
subsidised loan scheme. The latter is able to achieve greater impact through reaching
larger markets and hence more end-users. However, they can be slow to introduce new
products unless nancially motivated and generally struggle with affordability issues.
5 Conclusion and Future Research Direction
The illustrative mapping review rendered the eld of IPM design as currently lacking a
holistic and rigorous reference point to dene, measure, assess, and improve the value
and impact of contributions. Thus, distinguishing between change and progress is
difcult, and leaves little scope to help steer and facilitate future contributions.
Designerly contributions to the eld have predominantly been interventional and
adopted the special purposedesign approach. Moreover, there is a clear lack of
content and continuity across Methodological, Empirical, and Theoretical contribu-
tions. The identied key drivers for change include Documentation and Representation;
Design Approach and Knowledge; Collaboration and Interdisciplinarity; Geographic
and Regionality; and Operational and Market Characteristics. These ndings offer a
starting point for reimagining the future of IPM design. They intend to inform future
Drivers for Change: Initial Insights from Mapping Half a Century 827
research around the development of a design framework for inclusive paediatric
mobility to help steer, improve, and facilitate future product and service interventions.
Acknowledgments. This research was supported by the Hugh Greenwood Fund for Childrens
Health Research.
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828 C. OSullivan and F. Nickpour
... Contributions that met the inclusion criteria were categorised, mapped and then further analysed to enable a thorough understanding of the context of their creation and relationship to other contributions on the map. Table 3 translates the objectives of this analysis into high-level questions and serves as the first of two frameworks used to structure this data analysis (O'Sullivan & Nickpour, 2020b). The questions are used to guide further investigation into each contribution and thus facilitate exploration of designerly ways. ...
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... Such review is pivotal in informing the direction and dimensions of an IPM design framework aimed to impact and improve the way IPM interventions of the future are designed. Hence, it is essential that this review comprehensively captures the core elements to be included in such a framework (O'Sullivan and Nickpour, 2020). An examination of the field needs to encompass past and present perspectives, in order to identify failing, successful, missing, or complicated elements within the past and present landscape. ...
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Powered mobility should facilitate independent mobility and improve the individual's ability to engage in meaningful life activities. However, using powered mobility is a complex task. The purpose of this article is to review the many factors influencing use of powered mobility and to summarize the research in the field of powered mobility. The major factors affecting powered mobility include human abilities, technology features, environmental considerations, driving as an activity, and interaction effects. This review illustrates the need for further research. With better research documentation, the provision of powered mobility will continue to be justified. It is important to sustain the momentum achieved so far in technological developments, clinical applications, and funding for powered mobility equipment and service provision.
Traditional design approaches have been accused of failing to engage with users in the design process: compromising commercial opportunity and the interactional experience of users. Alternatively, a participatory design approach was applied to the generation of ideas for new product opportunities in the active wheelchair user market and to the initial stages of a European project aiming to develop an intelligent mobility aid for older people. Users were acutely aware of problems with existing technology or designs, and including them during early discussion and design stages was shown to facilitate new concept generation. This highly transferable approach enhances the user experience and commercial potential of products and services, and will be of interest to product manufacturers, designers, and researchers, alike.
The aim of the study was to support clinicians in recommending and justifying power mobility for children of different ages and abilities, and with different needs. The study comprised three distinct parts: a literature review; a Delphi consensus; and clinical practice considerations. A scoping review of eight electronic databases and manual searches carried out in February 2011 identified 15 themes or transferable messages among 27 articles meeting initial inclusion criteria and these formed the basis of a draft paper. Informal consensus at two international conference presentations refined and modified the paper to include 10 messages supported by 24 articles. The literature review was updated in May 2012 and a modified Delphi process sought to formalize the consensus process with an international panel of 16 expert clinicians and researchers using a priori criteria of 80% agreement. Evidence from studies was classified using the American Academy of Cerebral Palsy and Developmental Medicine guidelines, with evidence from most studies being classified as either level IV or level V, apart from one study each with evidence classified as level II and level III. Expert consensus on the content and wording of nine transferable messages may raise evidence overall to level III. This paper suggests that power mobility may reasonably be considered as an effective and appropriate intervention for children lacking efficient, independent mobility from around 12 months of age including children who may never become competent drivers and children lacking independent mobility only in early childhood.