Introduction
Transport enables people to move around outside their home and to participate in daily activities and in society. The World Health Organization (2021) defines participation as the involvement in a life situation and daily activities as tasks or actions, including shopping, accessing government services, medical appointments, or leisure activities. However, more than one-fifth of the Swiss population faces barriers to performing activities and participating in different areas of life, including moving around using transportation (Federal Statistical Office 2017b). In Switzerland, paratransit services are an important personalised door-to-door transport option for people who cannot use public transport at all or to a limited extent (Egger et al. 2022).
Switzerland implemented the Federal Act on the Elimination of Discrimination against People with Disabilities (DDA) in 2004. The Act aims to mitigate or eradicate barriers encountered by individuals with disabilities. The DDA states that existing buildings, facilities, and public transport vehicles must be adapted by 2024 (The Federal Assembly of the Swiss Confederation 2002). Therefore, Switzerland is making efforts to improve accessibility for persons with disabilities, particularly in the public transport sector. However, after almost 20 years, equal mobility has not been achieved (Schweizerische Bundesbahnen SBB 2023). People with limited or no access to public transport and who rely on paratransit services are marginalised from these efforts to achieve equal mobility. Although paratransit services have many advantages (e.g., door-to-door service, personal accompaniment) and are highly valued, recent research also indicated that there were limitations to their use in Switzerland (Egger et al. 2022). Limiting factors are, for example, the coordination of paratransit services at the regional or cantonal level. Cantons are 26 federated states within Switzerland with their own constitution and substantial self-governing powers. This can make booking paratransit services a challenge because if several services are needed for a journey, each must be booked separately. Other limiting factors are the costs and payment responsibilities. Different cost units (e.g., health insurance, disability insurance, cantonal subsidies) are responsible for the financing under different types of travel purposes, and knowing which payer is responsible for which trip is a challenge for paratransit users. The costs for a journey with paratransit services are usually higher than for public transport. If the subsidies for paratransit services are not sufficient, users must self-fund the costs for a journey. Other factors limiting the use of paratransit services are, for example, if the paratransit services equipment does not meet the user’s needs or if paratransit services are not available (Egger et al. 2022). These limiting factors may reduce use of paratransit services. For those for whom paratransit services are the only option, this can result in reduced overall mobility and transport disadvantage (Egger et al. 2022; Kiss 2022; Naguib, Johner-Kobi, and Gisler 2018; Sitter and Mitchell 2020). Transportation disadvantage occurs when there is a lack of access to transportation (Kiss 2022), resulting in a negative impact on social life (Bascom and Christensen 2017), well-being, and quality of life (Blais and El-Geneidy 2013; Samuel et al. 2013). Transportation disadvantage can lead to negative health issues related to reduced access to health care facilities (Gorman et al. 2019), psychological effects including stress and depression (Delbosc & Currie 2011) and through reduced mobility, physical limitations (Samuel et al. 2013). The relationship between transportation and the performance of activities and participation in society is typically studied in relation to transport accessibility in general, of which paratransit services are only one part. Several studies indicated a positive impact of transportation on activities and participation of older adults with and without disabilities (Latham-Mintus, Manierre and Miller 2021; Levasseur et al. 2020). Further studies identified the positive relationship between access to transportation and social life (Bascom and Christensen 2017). Although qualitative studies by Sitter and Mitchell (2020) and Egger et al. (2022) revealed difficulties in participation through limited usability of paratransit services, quantitative evidence on how specific factors of paratransit services are associated with dissatisfaction with activities and participation remains limited. Dahan-Oliel et al. (2010) stated that older adults using public transport had a higher level of participation compared to older adults who used adapted transport, including paratransit services, suggesting the need for further investigation into how aspects of paratransit services are associated with participation among persons with disabilities.
To improve the provision of paratransit services in Switzerland, providers of transport services and governments need to know if and which aspects of paratransit service use are most associated with dissatisfaction with activities and participation. The researchers hypothesise that factors related to paratransit services are associated with dissatisfaction with activities and participation. The aim of this study is, therefore, to quantify the association of paratransit services with dissatisfaction with activities and participation of persons with disabilities.
Methods
Study design
This is a cross-sectional study using data from a national survey conducted in Switzerland in 2022 (Gantschnig et al. 2023). Besides the primary aim of this study, the survey also served to collect quantitative data on the experiences and needs of persons with disabilities using paratransit services in Switzerland (Gantschnig et al. 2023).
Instrument development
The researchers developed a survey focusing on experienced barriers and facilitators of persons with disabilities when they use paratransit services in Switzerland. The development of the survey included the following steps: 1) The research team (consisting of two occupational therapists, a lawyer, a statistician, and the chief executive of the Foundation for Disabled Transport of one Swiss canton) developed, discussed, and selected the survey items. The items were based on the results (categories and subcategories) of a qualitative study (Egger et al. 2022) with the following research question: ‘What are the experiences and needs of persons with disabilities in using paratransit services’. This qualitative study used five focus group discussions (31 participants) and an extensive literature review. The results not only structured the content of the online survey but also provided a comprehensive overview to ensure that all key aspects of paratransit service use were considered. 2) Experts (researchers, n = 4; paratransit specialist, n = 1; paratransit users with different impairments (visual, cognitive, and motor impairments), n = 8; specialist for simple language, n = 1) tested the online survey three times on a computer and a mobile phone, with one participant employing a think-aloud approach. This process focused on assessing clarity, relevance, and accessibility, thereby contributing to face and content validity of the instrument through qualitative expert review and user-based feedback (Padilla and Leighton 2017). After each pilot test, the questionnaire was adapted (language, number, and wording of questions). An external agency translated the German questionnaire into French and Italian. Two members of the research team verified the accuracy of the translation. 3) The seven survey items with the demographics, health and support, general mobility, use of paratransit services, cost of paratransit services, and mobility satisfaction included a total of 43 questions with different response options (5-point Likert scale, open-ended, multiple choice) and 17 optional follow-up questions. An online version of the survey was implemented using Unipark (Tivian 2021).
Participants and sampling procedures
The participants included self-selected persons, based on the following criteria: 1) 18 years of age or older, 2) users of paratransit services or relatives or caregiver of a person who used paratransit services. The exclusion criteria were people who 1) were under 18 years of age, 2) had never used paratransit services, and 3) did not identify as a person with disabilities.
Sample size procedures and determination
Three months (in March 2022) before the delivery of the questionnaire, the researchers informed stakeholders (paratransit services, organisations for persons with disabilities or older people, politicians, and personal contacts of the project group participants, n = 409) regarding the project and the upcoming survey. In June 2022, the researchers sent a project update along with a pre-written email containing the link to the questionnaire to the same stakeholders, requesting that they forward the questionnaire to paratransit service users. The researchers also shared the link to the questionnaire via their personal social media accounts (Facebook), as well as on the project and stakeholder websites. The researchers sent two reminder emails to the stakeholders four and eight weeks later and closed the survey at the end of August 2022. Respondents were allowed to request assistance in completing the questionnaire. The researchers also offered assistance in completing the questionnaire (e.g., telephone or printed questionnaire).
The number of people using paratransit services is not recorded for the whole of Switzerland. The researchers used available data on paratransit service users in the Swiss canton of Bern (n = 4968) to estimate the sample size and to prove the representativeness of the sample. They referred to this canton because 1) complete data on paratransit service users was available, 2) the canton covers both rural and urban areas, representing the diversity of other Swiss cantons, and 3) the official languages of the canton of Bern are German and French. By applying the proportion of paratransit service users within the population of that canton to the national population, the researchers estimated the number of paratransit service users across Switzerland, which served as the basis for calculating the sample size. To prove the representativeness of the sample, the researchers analysed and compared the data of paratransit service users of this canton with the sample of this study regarding age, gender, typology, and wheelchair users (details in Table 2).
The aim of this study was to show whether there is a statistically significant association between factors of paratransit services and dissatisfaction with activities and participation, with an odds ratio of 2.0, alpha of 0.05, and a power of 0.8, for which a sample size of 347 was required. The researchers hypothesised that factors of paratransit services are associated with dissatisfaction with activities and participation.
Measures
To test the hypothesis, the researchers used nine survey items regarding demographic information, nine items on the use of paratransit services, one item regarding costs of paratransit services, and one item on dissatisfaction with activities and participation.
Dissatisfaction with activities and participation
The World Health Organization defined activities and participation in the International Classification of Functioning and Disability (World Health Organization 2021) as ‘execution of a task or action by an individual’ and ‘involvement in a life situation’. For the purposes of this study, the researchers borrowed this definition but added the subjective perception of activities and participation by asking about dissatisfaction. They assumed that personal perception plays an important role in the evaluation of activities and participation and has an impact on people’s daily lives and health (Hemmingsson and Jonsson 2005). The researchers measured dissatisfaction with activities and participation with the survey question, ‘How satisfied are you with your ability to carry out important activities in everyday life?’ and with the response options (5-point Likert scale), ‘very satisfied’, ‘satisfied’, ‘neither dissatisfied nor satisfied’, ‘dissatisfied’, and ‘very dissatisfied’. They used two dichotomous categories: ‘satisfied’ (‘very satisfied’, ‘satisfied’, ‘neither dissatisfied nor satisfied’) and ‘dissatisfied’ (‘dissatisfied’, ‘very dissatisfied’) for the analysis (see Table 1).
Table 1
Variables, measurement levels, and survey questions.
| VARIABLE | QUESTION IN THE SURVEY | DESCRIPTION |
|---|---|---|
| Dissatisfaction with activities and participation | How satisfied are you with your ability to carry out important activities in everyday life? | Ordinal: satisfied (0), dissatisfied (1) |
| Frequency of paratransit service use | Approximately how often do you ride paratransit? | Ordinal: weekly (1), monthly (2), less than once a month (3), never (4) |
| Using paratransit services outside the canton | How often do you travel by paratransit for extra-cantonal activities or further distances? | Ordinal: weekly (1), monthly (2), less than once a month (3), never (4) |
| Order in advance | How far in advance do you normally order the paratransit service? | Ordinal: spontaneous (less than two hours in advance) (1), same day (more than two hours in advance) (2), more than one day in advance (3) |
| Spontaneous use | How often would you spontaneously be glad to have a paratransit service? | Ordinal: weekly (1), monthly (2), less than once a month (3), never (4) |
| Choice of different paratransit services | Do you have a choice between paratransit service providers? | Nominal: no (1), yes (2), don’t know (3) |
| Availability of paratransit services | Do you always get a paratransit when you order it? | Nominal: yes (1), no (2) |
| Safety of paratransit services | How safe do you feel while traveling with the paratransit service? | Nominal: safe (1), unsafe (2) |
| Costs | How do you estimate the costs for the paratransit service? | Ordinal: (too) cheap (1), just right (2), (too) expensive (3) |
| Pickup location | If you use paratransit services, where does the driver pick you up? | Ordinal: with support to the car (incl. the way) (1), with support in the car (2), without support in the car (3) |
| Accompaniment after the ride | If you use paratransit services, what support/assistance do you receive from the driver at the end of the ride? | Ordinal: from car to destination (the way) with support (1), out of the car with support (2), out of the car without support (3) |
Paratransit service factors
The researchers included ten items on paratransit service use (see Table 1). In preparation for the analysis, they re-categorised seven of the 10 independent variables to reduce the number of levels. See Table 1 for the measurement levels.
Demographics
The researchers asked the participants for the following demographic information: age, gender, housing (living situation), typology of residence, occupation, impairments (cognitive, psychological, walking, sensory, and communication), income, language, and if they use a wheelchair (see Table 2). Questions regarding wheelchair use were included because not all paratransit services are equipped to accommodate wheelchairs, potentially affecting access and usage. Income was assessed as it may influence the ability to afford paratransit services, which could impact overall accessibility, particularly for individuals with lower financial resources.
Table 2
Sociodemographic characteristics of participants at baseline in comparison to users of paratransit services in the canton of Bern.
| BASELINE CHARACTERISTIC | STUDY SAMPLE (N = 536)/CANTON OF BERN (N = 4967) | |||
|---|---|---|---|---|
| n | % | MEAN | SD | |
| Age (years) | 63.6/75.4 | 19.4/18.4 | ||
| Gender | ||||
| Female | 312/3291 | 58.2/66.4 | ||
| Male | 222/1671 | 41.4/33.6 | ||
| Other | 2 | 0.4 | ||
| Language | ||||
| German | 501 | 93.5 | ||
| French | 31 | 5.8 | ||
| Italy | 4 | 0.8 | ||
| Residence | ||||
| Urban | 447/3987 | 83.4/80.3 | ||
| Intermediary | 59/648 | 11.0/13.1 | ||
| Rural | 26/332 | 4.9/6.7 | ||
| Missing | 4 | 0.8 | ||
| Annual household income (CHF) | ||||
| <20,000 | 83 | 18.7 | ||
| 20,000–50,000 | 235 | 53.1 | ||
| 50,001–80,000 | 86 | 19.4 | ||
| >80,000 | 39 | 8.8 | ||
| Missing | 93 | 17.4 | ||
| Housing | ||||
| Alone | 188 | 35.1 | ||
| With others (family, friends) | 171 | 32.0 | ||
| Residential home | 54 | 10.1 | ||
| Retirement home | 75 | 14.0 | ||
| With assistance | 44 | 8.2 | ||
| Missing | 4 | 0.8 | ||
| Impairments | ||||
| Cognitive | 81 | 15.1 | ||
| Mental | 62 | 11.6 | ||
| Walking | 435 | 81.2 | ||
| Sensory | 82 | 15.3 | ||
| Communication | 51 | 9.5 | ||
| Wheelchair user | 185/1853 | 34.5/37.3 | ||
| Occupation | ||||
| Part-time job | 104 | 19.4 | ||
| Full-time job | 31 | 5.8 | ||
| Housework & care | 26 | 4.9 | ||
| Education | 9 | 1.7 | ||
| Unemployed | 11 | 2.1 | ||
| Retired | 155 | 28.9 | ||
| Pension (e.g., disability insurance) | 301 | 56.2 | ||
[i] Note: Multiple choice for the variables: impairments, occupation, and housing. Sample comparison with the canton of Bern to estimate the sample size and to prove the representativeness of the sample. Due to rounding, percentages may not total exactly 100%.
Control variables
The researchers included the control variables: gender, age, impairment (cognitive, psychological, walking, sensory, and communication), income, typology of residence, and living situation. They calculated the net equivalent household income (Eurostat 2021) from the net adjusted disposable household income (69.2% of gross household income) (Federal Statistical Office 2020) using the OECD equivalence scale (OECD 2023).
Statistical methods
The researchers used two statistical methods to examine the data. To present the sociodemographic characteristics, they calculated descriptive statistics (see Table 2). To test the hypothesis, the researchers first checked the data for multicollinearity using the variance inflation factor (VIF). Five of the categories of the variable ‘housing’ indicated a high multicollinearity (VIF > 10), so they decided to exclude four of them (‘living with others’, ‘with assistance’, ‘retirement home’, and ‘residential home’) from the regression analyses. After this step, separate logistic regressions were fitted for each of the ten independent variables (see Table 3; models 1–10) using the dependent variable ‘Dissatisfaction with activities and participation’ and including the control variables age, sex, and five variables concerning impairments (cognition, psychology, walking, sensory, and communication). Finally, the researchers included the statistically significant variables (p ≤ 0.05) of the previous analysis (see Table 3; models 1, 2, 6, 8) in a further logistic regression analysis (model 11) with the dependent variable ‘Dissatisfaction with activities and participation’ and the control variables gender, age, housing, residence, impairments (five variables), and household income. The inclusion of only significant variables aimed to reduce model complexity, exclude irrelevant predictors, and improve interpretability. Missing values for gender (n = 2) and household income (n = 93) were imputed, allowing for more robust and comprehensive analyses. The researchers analysed the data using the statistical programme R (version 4.2.1).
Table 3
Ten separate logistic regression models for dissatisfaction with activities and participation N = 536.
| PREDICTOR | ODDS RATIO | 95% CI. (LL, UL) | HLχ2(df) | HLp-Value |
|---|---|---|---|---|
| 1) Frequency of paratransit service use | 2.81 (8) | .95 | ||
| Weekly | 1.00 | |||
| Monthly | 1.09 | 0.59, 2.09 | ||
| Less than once a month | 2.18* | 1.11, 4.40 | ||
| 2) Costs | 7.00 (8) | .54 | ||
| (Too) cheap | 1.00 | |||
| Just right | 0.95 | 0.54, 1.71 | ||
| (Too) expensive | 1.97* | 1.03, 3.81 | ||
| 3) Using paratransit services outside the canton | 6.60 (8) | .58 | ||
| Weekly | 1.00 | |||
| Monthly | 1.07 | 0.40, 3.40 | ||
| Less than once a month | 1.80 | 0.68, 5.69 | ||
| Never | 2.15 | 0.84, 6.66 | ||
| 4) Ordering in advance | 6.27 (8) | .62 | ||
| Spontaneous (less than two hours in advance) | 1.00 | |||
| Same day (more than two hours in advance) | 0.76 | 0.36, 1.59 | ||
| More than one day in advance | 1.34 | 0.77, 2.42 | ||
| 5) Availability of paratransit services | 16.43 (8) | .04 | ||
| Yes | 1.00 | |||
| No | 1.40 | 0.81, 2.34 | ||
| 6) Safety of paratransit services | 15.09 (8) | .06 | ||
| Safe | 1.00 | |||
| Unsafe | 2.33* | 1.08, 4.86 | ||
| 7) Spontaneous use | 7.36 (8) | .60 | ||
| Weekly | 1.00 | |||
| Monthly | 0.65 | 0.34, 1.26 | ||
| Less than once a month | 0.82 | 0.41, 1.68 | ||
| Never | 0.65 | 0.29, 1.47 | ||
| 8) Choice between different paratransit service providers | 10.43 (8) | .24 | ||
| Yes | 1.00 | |||
| No | 2.38** | 1.40, 4.09 | ||
| Don’t know | 1.80* | 1.03, 3.18 | ||
| 9) Pickup location | 9.87 (8) | .27 | ||
| With support to the car (incl. the way) | 1.00 | |||
| With support in the car | 1.12 | 0.68, 1.85 | ||
| Without support in the car | 1.51 | 0.80, 2.80 | ||
| 10) Accompaniment after the ride | 7.36 (8) | .50 | ||
| From car to destination (the way) with support | 1.00 | |||
| Out of the car with support | 0.97 | 0.59, 1.60 | ||
| Out of the car without support | 1.57 | 0.82, 2.95 |
[i] Note: Control variables: gender, age, and impairment (cognitive, psychological, walking, sensory, and communication). An odds ratio >1 indicates higher odds of being dissatisfied with performance of OR engagement in activities and participation. CI = confidence interval; LL = lower limit; UL = upper limit; HL = Hosmer-Lemeshow. Statistically significant codes: ‘***’ 0.001; ‘**’ 0.01; ‘*’ 0.05; ‘.’ 0.1.
Results
Participants demographics
The researchers included 536 participants (n = 536), 312 (58%) of whom were women. The mean age was 64 years with a standard deviation of 19 years. Most participants spoke German (94%, n = 501), 31 participants (6%) spoke French, and four participants (1%) spoke Italian. A total of 447 participants (83%) lived in an urban area, 59 (11%) lived in an intermediary area, and 26 (5%) lived in a rural area. Data from the Federal Statistical Office (2017a) served as the basis for the classification of these three typologies. A total of 188 (35%) participants lived alone, and 171 (32%) lived with family or friends. Most participants (435, 81%) reported walking impairments, and 185 (35%) used a wheelchair. Further information on the demographics is shown in Table 2. Due to rounding, percentages may not total exactly 100%.
Association between paratransit service factors and dissatisfaction with activities and participation
The 10 logistic regression analyses (models 1–10) revealed statistically significant associations between the frequency of using paratransit services less than once a month (p < .05), the cost (p < .05), the safety of paratransit services (p < .05), not having a choice between different paratransit service providers (p < .01), not knowing whether participants had a choice between different paratransit service providers, and dissatisfaction with activities and participation (p < .05) (see details in Table 3). No statistically significant associations were found between using paratransit services outside of the canton, the ordering of services in advance, the availability of paratransit services, the spontaneous use, the pick-up location, or the accompaniment after the ride and dissatisfaction with activities and participation (see Table 3).
All statistically significant variables from the first analysis (models 1, 2, 6, 8), which were included in the logistic regression analysis (model 11) (see Table 4), revealed significant associations between using paratransit service less than once a month, having no choice between different paratransit service providers, and experiencing dissatisfaction with activities and participation. The (too) expensive costs were statistically significant on the 0.1 level. No statistically significant association was found with respect to the safety of paratransit services and dissatisfaction with activities and participation (see details in Table 4).
Table 4
Logistic regression analysis for dissatisfaction with activities and participation and four independent variables N = 436.
| PREDICTORS | ODDS RATIO | 95% CI. (LL, UL) |
|---|---|---|
| Cost | ||
| (Too) cheap | 1.00 | |
| Just right | 1.14 | 0.59, 2.26 |
| (Too) expensive | 2.12. | 1.00, 4.80 |
| Frequency of paratransit service use | ||
| Weekly | 1.00 | |
| Monthly | 1.91 | 0.87, 4.62 |
| Less than once a month | 2.83* | 1.18, 7.24 |
| Safety of paratransit services | ||
| Safe | 1.00 | |
| Unsafe | 1.45 | 0.59, 3.41 |
| Choice between different paratransit service providers | ||
| Yes | 1.00 | |
| No | 2.22* | 1.21, 4.13 |
| Don’t Know | 1.63 | 0.84, 3.16 |
[i] Note: Control variables: gender, age, impairment (cognitive, psychological, walking, sensory, and communication), income, residence, and housing. An odds ratio >1 indicates higher odds of being dissatisfied with performance of OR engagement in activities and participation. CI = confidence interval; LL = lower limit; UL = upper limit. Statistically significant codes: ‘***’ 0.001; ‘**’ 0.01; ‘*’ 0.05; ‘.’ 0.1. Hosmer–Lemeshow χ2(8) = 4.90, p = .80.
Discussion
This study aimed to identify which aspects of paratransit services are most strongly associated with dissatisfaction with activities and participation. The results show that lower frequency of paratransit service use, higher paratransit service cost, and a lack of choice in paratransit service providers are significantly associated with higher dissatisfaction with activities and participation. In contrast, participants’ perceived safety while using paratransit services was not associated with dissatisfaction with activities and participation. These results align with the qualitative results of Egger et al. (2022) and Sitter and Mitchell (2020), which describe challenges in engaging in activities and participation among paratransit service users. The results of this study specify which aspects of paratransit services are associated with activities and participation, thus providing a more detailed understanding.
However, due to the cross-sectional design of this study, we cannot determine the direction of these associations. It remains unclear whether lower use, higher costs, and limited choice contribute to dissatisfaction, or whether dissatisfaction leads to lower use or negative perceptions of these aspects.
Previous studies have identified high costs as a major barrier to the use of paratransit services and, therefore, to activities and participation (Egger et al. 2022; Sitter and Mitchell 2020). The findings of this study support this by showing a significant association between paratransit services costs and dissatisfaction with activities and participation. However, due to the study’s design, we cannot conclude whether high costs cause dissatisfaction or whether persons with disabilities who are dissatisfied perceive the costs as higher or are less willing to pay.
Including individuals who are unable to use paratransit due to its high cost (rather than only current users) might have led to even stronger results. It is reasonable to assume that this population could have influenced this study’s findings, as previous research by Field et al. (2007) and Awaworyi Churchill and Smyth (2019) has indicated that people with lower financial means experience greater transportation difficulties, which can negatively affect their overall well-being. These findings are further supported by Smith et al. (2005), who demonstrated that the well-being of wealthier people is less affected by the onset of a disability than that of poorer people. However, this difference between wealthier and poorer people diminished over a two-year period. Therefore, further research is needed to determine whether there is a difference between high- and low-income individuals regarding dissatisfaction with activities and participation in using paratransit services.
Another factor that may influence the association between dissatisfaction with activities and participation and paratransit service costs is the availability of alternative transportation options. As described in previous studies, family members and friends of persons with disabilities also provide important transport options (Bascom and Christensen, 2017; Egger et al. 2022; Latham-Mintus et al., 2021). Consequently, high paratransit service costs may lead individuals to rely on alternative transportation options provided by family members and friends, allowing them to maintain participation despite financial barriers. The researchers of this study conclude that while paratransit service costs are associated with dissatisfaction with activities and participation, the severity of this association varies depending on the context.
The findings of this study reveal a significant association, suggesting that individuals who use paratransit services infrequently are less satisfied with their level of activities and participation compared to those who use it more frequently. While previous research has demonstrated that people who rely on paratransit services for transportation have lower participation rates than those who drive themselves, walk, or use public transport (Dahan-Oliel et al. 2010), this study does not provide insights into the underlying factors that explain differences in paratransit service use frequency.
While some studies suggest that the availability of paratransit services affects participation (Adeel, Yeh and Zhang 2016; Bascom and Christensen 2017), this study found that availability did not have a statistically significant association with dissatisfaction with activities and participation. Therefore, it is reasonable to assume that availability may not be a major factor in determining the frequency of use.
As shown in the studies by Samuel et al. (2013) and Olofsson et al. (2020), health status also influences the frequency of transport use and levels of activities and participation outside the home. For example, people with physical disabilities are more likely to use transportation for participation than people with intellectual disabilities or a combination of impairments (Samuel et al. 2013). Furthermore, people with more limitations participate less outside the home (Olofsson et al. 2020). These findings align with the present study, which demonstrates that the frequency of paratransit use is associated with dissatisfaction with activities and participation, which can be linked to health and well-being (Wilcock and Hocking 2015).
These study results show that having more than one paratransit service provider is associated with lower dissatisfaction with activities and participation. Similarly, Latham-Mintus (2021) found that larger paratransit service fleets increase participation rates. Several reasons may explain these results. One possible explanation is that different providers offer greater freedom of choice and spontaneity, which in turn has an impact on dissatisfaction with activities and participation (Björnsdóttir et al. 2016; Egger et al. 2022). For instance, freedom of choice allows users to choose the driver and vehicle they prefer (e.g., an accessible vehicle for a wheelchair, not labelled as a ‘disabled driving service’). Multiple providers also reduce waiting times and enable more spontaneous use or choice between different booking systems. However, the association found in this study between increased availability of paratransit services and lower dissatisfaction with activities and participation cannot be explained by reduced waiting times or the more spontaneous use of paratransit services, as neither variable showed a statistically significant association with dissatisfaction with activities and participation. Therefore, the researchers conclude that more paratransit service providers may lead to more autonomy in participation outside the home. It may be of interest for further research to assess which item (e.g., choice of driver or vehicle, autonomy) is most dominant in the availability of more paratransit service providers and its association with dissatisfaction with activities and participation.
Limitations
Due to the online mode of data collection and the self-selection of participants in this study, limited accessibility of the questionnaire (Goegan, Radil and Daniels 2018; United Nations 2013) and insufficient digital literacy (Julien 2018) may have led to the exclusion of individuals from participating, causing a selection bias. Furthermore, non-users of paratransit services were not included. People living in rural areas were slightly less represented than people living in urban areas, as seen in the comparison group of the canton of Bern. Also of interest here is the influence of hedonic adaptation on people’s dissatisfaction ratings. Hedonic adaptation is when people adapt with changed interests, values, and characterisation of a situation (Lacey et al. 2008) or consciously focus in another direction to avoid negative feelings (Frederick and Loewenstein 1999). Hedonic adaptation could have influenced the dissatisfaction ratings in this study. For instance, individuals might have adjusted to existing circumstances, such as having access to a limited number of subsidised paratransit trips, by adapting their leisure activities (e.g., choosing activities that require less mobility). This adjustment could have impacted this study’s results regarding dissatisfaction with activities and participation.
This study is a contribution to the achievement of equal mobility for persons with disabilities in Switzerland, as called for in the CRPD (United Nations 2021), and it provides a knowledge base for further action. However, the complexity of the various transport factors associated with activities and participation of persons with disabilities in Switzerland is multifaceted. Inherent in the results of this study are other aspects of concern, including local and national policies, other factors influencing the use of paratransit services (e.g., weather conditions), the accessibility of public transport, and personal abilities and preferences (e.g., income, disabilities, needs).
Given that, for some people, public transport cannot be made accessible, paratransit services are an important option. These study findings highlight the need for a frequently available and affordable paratransit service, optimally provided by a variety of providers. All of these factors contribute to dissatisfaction with activities and participation and, therefore, to health and well-being.
Conclusion
Low frequency of use of paratransit services, high cost of paratransit services, and lack of choice among paratransit services are associated with dissatisfaction with activities and participation of paratransit users. These factors should be considered when improving mobility services for persons with disabilities, especially for those who are unable to use public transport.
Data Accessibility Statement
The survey data used to support the findings of this study are available from the corresponding author upon request.
Ethics and Consent
The researchers carried out the study according to different ethical principles. The study did not fall under the scope of the Human Research Act. Therefore, the Ethics Committee of Canton Zurich declared in March 2021 that no ethical approval was required (BASEC-Nr. Req-2021-00257) (Canton Zurich, Ethics Committee 2021). Participants in this study gave informed consent, and the data were anonymised. According to the data management plan, the data collection, transmission, storage, and analysis within this study were subject to the data protection regulations of the Zurich University of Applied Sciences.
Acknowledgements
We thank the project advisory group Damien Mottet, Georg Mattmüller, and Herbert Bichsel, as well as the project evaluation group Milena Berger and Urs Müller. Further, thanks go to Thomas Ballmer and Verena Klamroth-Marganska for their project collaboration and to Allison Scarlotta for the proofread.
Competing Interests
The authors have no competing interests to declare.
Author Contributions
Selina Egger collected, analysed, and interpreted the data. Brigitte Gantschnig and Armin Gemperli were major contributor to the data collection, analysis, and interpretation of the data. All authors read and approved the final manuscript.