Let’s Get It Clear: Mobility, and quality of life
How important is mobility to Quality of Life? How can we measure the value of any interventions?
At November 2025’s Oceania Seating Symposium in Rotorua, New Zealand, Dr Nathan Bray, a healthcare economist from Bangor University in Wales presented the outcomes of his study of a new way to define and measure mobility-related quality of life. The resulting new tool, MobQol-7D is described in this article, together with material from Dr Bray’s presentation on his health economist’s perspective on why outcome measures matter in assistive technology provision.
Health Economics, as a discipline, examines the use of resources, their efficiency of use, and their value to healthcare. It uses economic valuation methods to measure cost-effectiveness and value for money.
Most country’s health services have less money available than everyone is wishing for, or is able to spend. However, having larger sums does not necessarily mean better outcomes. Comparing the US with other parts of the world: health expenditure in the US is $12555 per capita as compared with $6372 in Australia or $5493 in the UK.
Despite this, in the UK life expectancy is nevertheless higher at 80.3 years as compared with 76.4 years in the US. Infant mortality is only four per 1000 live births in the UK as compared with 5.4 in the US, and 9.8 maternal deaths per100,000 live births vs 21.1 in the US.
And for a final statistic, avoidable mortality from preventable causes is 97 per 100,000 population in Australia, 151 in the UK, and 238 in the US. These data probably reflect that there is a much greater spectrum of healthcare provision in the US, between those who are well-covered by insurance etc, and those on the poverty line.
The inputs from health economists lead to economic evaluations which provide a framework for identifying the costs and benefits of different options of healthcare. Each evaluation compares the choices between competing alternatives, is concerned with the costs vs benefits, and is used to extract maximum benefits from limited resources. One of the key tools used is to measure the costs against Quality-Adjusted Life Years (QALYs).
QALYs
If health care is effective, it must either increase length of life and/or Improve quality of life. Therefore, successful health care activities (whether curative, preventative or rehabilitative) can be assessed by what are called Quality-Adjusted Life Years (QALYs).
A QALY is a generic measure of disease burden which measures a combination of quantity and quality of life. A value for perfect health, i.e. the best quality of life would have a score of 1. Extended over five years and then death would give a score of 5.
If preventative measures were introduced that extended the person’s life for another two years, but at a 50 per cent quality of life for the extra two, that would add two years at 0.5 to the five healthy years, giving a total of 6. An alternative intervention might offer an additional six years of life but at a 33 per cent quality of life, with the 11 total years of life giving a QALY score of 7.
From a health economics point of view, if the cost were the same it might be considered best to give the intervention with the score of 7 – but for the individual maybe life for 6 years at a 67% impaired quality of life might be a poorer choice than fewer years with a better quality of life.
This is where we enter the philosophical debate as to how much of the decision should rest in the individual’s hands (and then potentially extends into the opposite of extending life, by shortening it by the provision for assisted-dying).
Mobility and quality of life
Dr Bray introduced the background to his study with the data that:
- Almost a quarter of the UK population (>16 million people) report having some form of disability.
- Mobility impairment is the most common cause of disability in the UK, with 48% of disabled people reporting some form of mobility impairment.
- In England alone an estimated £355 million is spent annually by the NHS on wheelchairs and postural seating.
- However, there are limited robust economic/Preference-based Outcome Measure (PROM) data to guide the provision of mobility aids in a cost-effective manner.
PROMs such as the ‘EQ-5D’ and ‘SF-6D’ are the tools commonly used by the likes of NICE to measure QALYs for this purpose. However, due to the generic nature of these specific measures, they often lack sensitivity in specific arenas such as that of disability.
To create a targeted assessment tool to define the concept of mobility-related quality of life, Dr Bray’s carried out research in which participants were asked to discuss how mobility and mobility impairment influenced their quality of life and health status.
Bearing in mind that ‘mobility’ means different things to different people, a questionnaire was created which aimed to cover the range from people who had restrictions in their ability to walk around, to those for whom mobility was about using a wheelchair or other aid.
The aim of the resulting tool was to find how mobility affects the interviewee’s quality of life, no matter how they moved around or whatever mobility aids they used.
MobQol-7D
The research assessed 15 different reduced quality of life aspects that might be attributed to impaired mobility, from which seven areas were brought together to be relevant and significant.
The seven were (each to be scored at one across four levels of degree of severity):
- Accessibility (From ‘I do not find it difficult to get around my home’ to ‘I cannot move around my home’’).
- Contribution – such as contributing at home, work, education, or in the community (From ‘My mobility never makes it difficult to contribute and do things that make me feel valued’ to ‘My mobility always makes it difficult to contribute and do things that make me feel valued’).
- Pain and discomfort (From ‘Moving around in everyday life is not painful or uncomfortable’ to ‘Moving around in everyday life is extremely painful or uncomfortable’).
- Independence (From ‘I am always satisfied with my level of independence’ to ‘I am never satisfied with my level of independence’).
- Self-esteem (including identity, confidence, and self-consciousness) (From ‘I never feel bad about myself because of my mobility’ to ‘I always feel bad about myself because of my mobility’).
- Mood and emotion (From ‘I never feel low, sad, or unhappy because of my mobility’ to ‘I always feel low, sad, or unhappy because of my mobility’).
- Anxiety – such as feelings of worry or stress (From ‘My mobility does not make me feel anxious’ to ‘My mobility makes me feel extremely anxious’).
The result would be a lowest possible score of 7 for someone who had no mobility challenges, to 28 for someone who had the greatest impacts from each aspect from their immobility.
The next stage might be to offer a solution for the challenges experienced by the individual (such as a new piece of equipment, a support person at certain times, counselling, etc), and the individual can then score on a range from 1 to 100 the degree to which that intervention might reduce their total MobQol score.
If budgets are tight, this at least can help to prioritise which intervention(s) to fund in the first place. At a later stage, the questionnaire can be repeated to ascertain whether the selected intervention had reduced the individual’s score.
The ‘medical’ model
Looking at wheelchair provision around the world, the key provision criteria are based on a ‘medical’ model which is based around aspect 1 (Accessibility), probably 3 (Pain and discomfort), and maybe 4 (Independence), but how poorly are the other aspects (which are so important to the individual), considered?
Is it because the other aspects are considered to be the realm of ‘social’ provision, or is it that they are considered to fall under ‘mental health’, and this is beyond the training and remit of mobility equipment prescribers?
Most health services are not set up to include the ‘social’ model. Despite both areas in England being under the one government department, the Department of Health and Social Care (DHSC), the lack of connect falls back on the Treasury’s control where Healthcare is provided as ‘free’ at the point of delivery, and Social Care provision is means tested.
If all of the seven aspects were to be assessed and provided for around the world, the overall health and quality of life for those with mobility impairments would be progressed by leaps and bounds.
The reality of Quality of Life
Returning to the broader perspective of Quality of Life, I’d like to end by sharing a quote from Dr Bary of a young wheelchair user who said:
“I’ve had conversations with friends who are completely able-bodied and they’ve sort of said “Do you wish you could do some of the things I can do?”, but I said “But do you wish you could put a basketball ball in the basket like I can?”. It’s like, everybody’s got things they can do better than other people. It’s like, they can walk better than I can, but I can push a wheelchair better than they can.
A good QoL for me I think is not necessarily being entirely independent, but being in charge of my own doings. So to some extent that means I’m able to move about in my chair, but in other respects where I require assistance, like I have an assistant in college, but I’m still in charge of asking him for help, asking him to get my books out. I am in charge of my own life. I’m not being dictated to by other people or really by my disability.”
Reference
Bray, N et al (2024) Development of a value-based scoring system for the MobQol-7D: a novel tool for measuring quality-adjusted life years in the context of mobility impairment. Disabil Rehabil 46, 5345-5356
Further items can be found at www.beshealthcare.net. If you are interested in receiving further information on the topic, please contact 
barend@beshealthcare.net.
Dr Barend ter Haar has been involved in seating and mobility for over 30 years, including lecturing internationally and developing international seating standards
