Peer Training-Of-Trainers Workshop In Nepal: The Role Of Wheelchair Skills Training

Cher Smith, R. Lee Kirby, Lucy Norris, Patricia Thompson, Abdullah Munish

Dalhousie University, Department of Occupational Therapy, Capital District Health Authority, Halifax, Canada (Smith); Division of Physical Medicine and Rehabilitation Halifax, Canada (Kirby); Motivation UK Bristols, UK (Norris, Thompson); Motivation Africa, Moshi, Tanzania (Munish)


In November of 2013 a 5-day Training of Trainers (ToT) Workshop for peer trainers was held at the Spinal Injury Rehabilitation Centre (SIRC) outside of Kathmandu, Nepal. Eight peer trainers participated in sessions such as spinal cord injury (SCI) theory and management and wheelchair skills training. Master trainers from Tanzania, UK and Canada collaborated to provide the training. The objective of this study was to test the hypothesis that an international collaboration for a ToT workshop would be well received by the participants and would provide a positive learning experience for all involved individuals. Overall the ToT Workshop was a successful collaboration with areas of future development identified such as the burden of written translations and better integration of content of training methods. Some of the experience’s strengths include the training approaches used as well as the workshop content. All members of the training team are looking forward to future collaborations.


For persons with newly acquired spinal cord injuries there are many topic areas for which new learning is required. Many English language sources related to SCI are available for best practice guidelines on numerous topics such as pressure management, bladder function and sexuality (Houghton et al. 2013; Eng et al., 2014; PVA 2008). One essential element for most individuals with SCI is a properly provided wheelchair.

In 2008, the World Health Organization (WHO) published guidelines on the provision of wheelchairs that include an 8-step service-delivery process (WHO, 2008). The guidelines incorporate wheelchair designs from various areas of the world and WHO has now posted these guidelines in 7 languages. The eight steps address the process from referral to follow-up and include the provision of training on the use of the wheelchair. Achieving one’s maximum knowledge and skills of wheelchair use is one key area for people with SCI

In many settings the provision of the required knowledge and skills after SCI is shared by various members of a rehabilitation team. In some settings peer trainers provide much of this information. To ensure the success of peer trainers they must first acquire the knowledge and skills for a broad range of people with SCI. In November 2013 at the SIRC in Sanga, Nepal eight peer trainers participated in a ToT Workshop. The workshop was designed to prepare the participants to facilitate a Peer Group Training session with 12 persons with SCI the following week. To complete the ToT workshop, a collaborative was created between SIRC, 3 members of Motivation and 2 members of the Dalhousie Wheelchair Research Team.

Content for the workshop consisted of a combination of the Motivation ToT workshop resources and the Wheelchair Skills Training Program (WSTP). The WSTP combines motor learning theory and technical skill recommendations (Kirby et al., 2013). There is support of benefits to wheelchair skills training of only 2-6 hours (Best et al., 2005; MacPhee et al., 2004; Routhier et al., 2012). However there were many lessons to be learned in providing this type of training over several days, in a less-resourced setting in a format other than English. The objective of this study was to test the hypothesis that an international collaboration for a ToT workshop would be well received by the participants and would provide a positive learning experience for all involved individuals.



Eight peer trainers with SCI from four Nepalese rehabilitation centres attended the 5-day workshop. Two of the eight participants were female. Six of the participants used 4-wheeled frame wheelchair and the remaining two used 3-wheeled frame wheelchairs.

Workshop Design

The workshop was scheduled to occur Monday to Friday from 8:00am-4:00pm with two days having additional evening sessions. A total of 17 hours of group theory classes were scheduled. Facilitation skills were included within these sessions and as the week progressed participants were provided with opportunities to take on facilitator roles to practice these skills. The session topics included SCI theory, skin care, bladder and bowel management, sexuality and relationships, disability rights as well as stretching, which was taught using self-ranging. Sexuality and relationships was addressed in group-discussion format with separate groups for males and female. These sessions were lead by two of Motivation’s peer master trainers. Note that the term ‘master trainer’ is used to differentiate these individuals from the workshop participant who are learning to become trainers. One of the master trainers used a 3-wheeled frame wheelchair and the other a 4-wheeled frame wheelchair.

Daily sessions of wheelchair skills training were scheduled for a total of 10.5 hours of the workshop. A broad range of wheelchair skills from level propulsion to wheelie skills and fall recovery were taught in progression as per the WSTP. Also as recommended, motor learning principles were used. However, different to when providing training for the sole purpose of skill development, more time was allotted to focus on building trainer skills. Examples of trainer skills included techniques such as the assessment of individual skill performance and appropriate provision of meaningful feedback. These sessions were lead by two of Dalhousie’s able-bodied master trainers who used participants, peer trainers or themselves to demonstrate the skills during teaching.

The wheelchair skills training took place in various areas of the SIRC facility using found obstacles such as pillars, bricks and bamboo trunks. An outdoor mobility area was also on site and was used when the weather and timing were appropriate. This area provided skills such as gaps, high curb and stairs.

The participants used their own judgment as to the need for a spotter and spotter strap with the exception of skills where there is a risk of the wheelchair submarining. For these skills a spotter was strongly encouraged until the participants had demonstrated that they could perform the skills safely.

All written information from Motivation resources and on-site lists and tables were translated into Nepalese. All verbal communication with participants was translated between Nepalese and English.

At the end of the ToT Workshop, the participants completed an evaluation as a group and the translator was used to collect results of an open-ended workshop evaluation survey from all of the participants. 


All eight participants completed the 5-day ToT workshop. Variability with the daily start times had a minimal impact on the schedule and time allotments were generally met. At the time of the workshop, Nepal was preparing for a national election. This resulted in some travel restrictions and isolated violence. This prevented three of the master trainers from attending the evening sessions.

Overall the master trainers reported that the workshop resources were very helpful and well organized but that more photos and illustrations would have been helpful due to multiple languages or dialects within the group.

In regard to the structure of the workshop the master trainers identified the daily checks and reviews of participant knowledge as a strength. This was done in small groups to ensure that the learning format was effective for all participants. The master trainers reported that the participants also seemed to have a good pre-workshop knowledge level. Even with this all participants appeared to increase their frequency and comfort level in interacting with fellow participants and master trainers as the week progressed. During this time, improvements in the participants’ skill performance and their abilities to teach wheelchair skills were observed by all of the workshop master trainers.

The participants’ overall feedback regarding the ToT workshop was positive with all individuals identifying improvements they had made.

When asked to identify the most important learned item of the workshop, two of the six respondents reported “Wheelchair Skills – wheelies and falling skills” and “Training methodology”.

When questioned as to whether the workshop would lead to any change in the participants’ daily lives upon returning home; three areas were identified. The most common response was related to bladder management; specifically identifying that knowledge in this area has been a challenge at all four rehabilitation centres. Secondly, participants reported that the information they gained during the workshop built their level of confidence and it would enable them to participate fully in activities of daily living. Finally, participants reported the importance of role modeling various areas of successful living to fellow peers such as pressure ulcer prevention and being an active member of society.


Providing training in other cultural settings is always a learning experience as much as it is a teaching experience. In this instance, the master trainers came from the UK, Tanzania and Canada to bring together different training programs in an attempt to create a cohesive, positive learning experience for the peer training participants. Knowledge was gained from the team’s various training resources, content, training methods and the participants themselves.

Evaluations from the master trainers and participants suggested that the division of theory and practice as well as the Motivation and WSTP methods used provided an overall positive teaching and learning collaboration.

Some responses spoke to the range of skills of the participants. Although many of the participants began the workshop with an impressively high level of skills and knowledge there was a clear delineation between wheelchair users that were able to perform a wheelie and related wheelie skills. Wheelchair provision and set-up appeared to play a role, as did a lack of previous wheelie training for these few individuals.


Overall the ToT Workshop was a successful collaboration with areas of future development identified. One area is to address the need for translation of extensive written materials given the many languages and dialects and the associated literacy requirements. Other areas include integration of training methods and content between the collaborators to enhance future training and striking a balance between topic importance and time allowances. Some of the experience’s strengths include the training approaches used as well as the workshop content. All members of the training team are looking forward to future collaborations.


Best KL, Kirby RL, Smith C, MacLeod DA. Wheelchair skills training for community-based manual wheelchair users: a randomized controlled trial. Arch Phys Med Rehabil 2005;86:2316-23. 

Eng JJ, et al. Spinal Cord Injury Rehabilitation Evidence (2014). Accessed January 10, 2014.

Houghton PE, Campbell KE and CPG Panel (2013). Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury. A resource handbook for Clinicians. Accessed September 17, 2013.

Kirby RL, Smith C, Parker K, MacLeod DA, McAllister M, Rushton PW, Routhier F. Wheelchair Skills Program. Accessed December 10, 2014.

MacPhee AH, Kirby RL, Coolen AL, Smith C, MacLeod DA, Dupuis DJ. Wheelchair skills training program: a randomized clinical trial on wheelchair users undergoing initial rehabilitation. Arch Phys Med Rehabil 2004;85:41-50.

Paralyzed Veterans of America (PVA). Early Acute Management in Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Providers. J Spinal Cord Med 2008: 31:403-479.

Routhier F, Kirby RL, Demers L, Depa M, Thompson K. Efficacy and retention of the French-Canadian version of the Wheelchair Skills Training Program for manual wheelchair users: a randomized controlled trial. Arch Phys Med Rehabil 2012; 93:940-8.

World Health Organization. Guidelines on the provision of wheelchairs in less resourced settings. 2008. / Accessed October 31, 2013.


We would like to thank Udaya Adhikari and rest of the staff at SIRC for hosting the workshop and Aarjit Adhikary for his seemingly endless translations.

Audio Version PDF Version