Self-regulation when using a mobility scooter: The experiences of older adults with visual impairments

Research design

An interpretive description approach was used because of the intention to ensure clinical application of the results (Thorne et al., 1997). The interpretive description methodology provides health professionals with a non-categorical, generic methodology that allows integration of clinical context and practitioner knowledge rather than a sole focus on creating theory from the data set (Thorne et al., 1997).

Data collection included a combination of ‘go-along’ participant observation, interviews and optometry reports.

The study was granted ethical approval and all participants provided written informed consent. Participants chose or were given pseudonyms to preserve anonymity. Participant information and informed consent documents were provided in large text, and an audio file of these documents was available.

Participants

The study was undertaken at several sites in NZ, deliberately including a variety of terrains and town sizes. Purposive sampling was used to recruit participants through advertisements, word of mouth and by asking key contacts to pass on information about the study. In this way, contact was made with scooter retailers, a low vision rehabilitation clinic and retirement villages. Respondents contacted the researchers if they were interested in volunteering for the study.

The inclusion criteria were that all participants had to have a diagnosed uncorrectable visual impairment, be aged over 60 years and use a scooter regularly. In total, 15 participants were recruited and agreed to take part (Table 1). Eight of the participants came from retirement villages and all the participants identified as pākehā (European/New Zealand European). Due to a variety of comorbidities, all of the participants reported they were unable to walk the distance of the journeys that they undertook on their scooter. One participant was unable to walk unaided, whereas other participants could walk some distance but could not, for example, carry groceries.

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Table 1.

Participant descriptions.

Name (& support person)	Age range	Sex	Eye condition	Vision Report
Arthur (& Anna)	90–99	M	ARMD	R) 6/60L) 6/? ‘Poor central vision’
Chiconne	80–89	F	R) Retinal tear	R) 6/9–1L) 6/15 + 2
Clint (& Evelyn)	80–89	M	Bilateral cataract, Bilateral ARMDL retinal pigmentary epithelial detachment	R) 6/60L) 4/60, pinholing to 6/60
Flo	90–99	F	Open-angle glaucoma	–
Francis	80–89	F	ARMD, hemianopia (congenital) Stereopsis	R) VA: 6/24. VFI: 75 degreesL) VA: 6/60. VFI: 5 degrees approximately
Leonard	90–99	M	ARMD, cataract L)	–
Matilda	90–99	F	R) Wet ARMDL) Dry ARMD	R) 6/15L) 6/12
Maurice (& Maeve)	80–89	M	Glaucoma	R) 6/12, N10. Some temporal field remains useful. VFI: 46%L) 6/9 + 2, N10, VFI: 35%
May	70–79	F	ARMD	R) 6/12L) 6/12
Mouse	80–89	M	Open-angle glaucoma, diplopia	Bilateral VA: 6/12.
Poppy	60–69	M	Dry ARMD, diplopia, L) corneal scarring	R) VA: 6/10L) VA: 6/11
Susan	60–69	F	Diabetic retinopathy	–
Thomas	90–99	M	Dry ARMDL) ocular surface disturbance	R) 6/30–2L) count fingers only
Una	90–99	F	ARMD	R) hand movements onlyL) 6/30–2,
William (& Rose)	80–89	M	ARMD	R) unavailableL) VA 6/24- pigment epithelial detachment, intraretinal oedema at macula

ARMD: age-related macular degeneration; F: female; M: male; L): left eye; R): right eye; VA: visual acuity; VFI: visual field index.

Procedures

Data collection

The lead researcher carried out the data collection during 2017, meeting participants on one occasion in their own homes. Each interview took between 40 and 90 minutes.

Data analysis

Data analysis followed the Qualitative Analysis Guide of Leuven (QUAGOL) and was coded using the Quirkos software (Dierckx de Casterle et al., 2012). The go-along and sit-down interviews were transcribed verbatim, with observation notes embedded into the text. The transcriptions were then summarised into a report giving a narrative of each interview. These interview reports were analysed by both authors for preliminary codes before testing codes against the original transcript and then against other interviews. A list of concepts related to the preliminary codes was applied to the transcripts, exploring the definition of these concepts in order to determine an essential structure across the data set and come to the final themes. This process of data analysis was non-linear and iterative, with regular meetings between the two authors to arrive at the final findings.

Trustworthiness

Participants were provided with a verbatim transcript of the interview and a narrative interview report to view the information that would be included in the study and make any amendments or additional comments for member-checking (Shenton, 2004). Peer-reflexivity was enhanced through presentations to and discussion with occupational therapists and other stakeholders (Shenton, 2004). Both this study and the previous study (McMullan and Butler, 2018) were introduced in online presentations, at visual impairment consumer group meetings and at conferences, welcoming scrutiny from peers including practising NZ occupational therapists and others interested in visual impairment, accessibility and disability rights. The use of participant observation (the go-along) and interview provided a form of triangulation with all but the three participants who declined the go-along (Shenton, 2004).

Reasons for getting a scooter

Participants’ self-regulation began with the decision to acquire a scooter, with participants detailing their individual reasons for getting a scooter.

Alternative transport was generally limited to lifts from family members. Five participants could use a bus, and most would use a taxi. However, buses or taxis were often non-existent, irrelevant, unaffordable and/or inaccessible. Three participants lacked any alternative modes of transport, as May explained: ‘What else would I do apart from scooter? I can’t walk, I can’t hop, I can’t skip. It’s a really strange question… I grow wings and fly? So you suggest another way I can get from A to B’.

Scooter use also served to maintain connections with the neighbourhood or to enhance their overall wellbeing. Una stated, ‘that’s the big thing about scooters, you’re out in the fresh air, you’re not inside. You don’t get bedsores and things like that’. Scooter use also supported emotional self-regulation, as Mouse explained: ‘[when I get upset] it makes me feel like I want to get on the [scooter] and go for a ride’.

Poppy and Clint both used their scooter to access safe spaces for walking. For example, they went to large stores because these offered warmth, adequate clear, flat space and good lighting. The scooter appeals to individual values of independent travel, allowing expressions of freedom, autonomous community engagement and doing so with privacy. May particularly used her scooter to support her social needs: ‘[my grandson] came down and did the rail trail with me last year, he was only nine’. Scooters could also contribute to the feelings of adventure and freedom:

I love it. I need it. It just gives me independence. My daughter and my family would do my grocery shopping for me, but I don’t want to lose that. I want to still be able to choose what I want. (Chiconne)

Social supports also played a role in the decision to get a scooter. Some participants felt supported in their decisions, while others felt discouraged but still went ahead: ‘I know that the Blind Foundation are not happy with having people with low vision on them… my GP was just a little bit concerned’ (Arthur).

May had a choice between a wheelchair and a scooter, and felt that the scooter was less stigmatising: ‘you’re a lot more patronised in the wheelchair, and they usually talk to the person pushing. But when you’re on a scooter, they must think that you can do something’.

Risks and barriers associated with using a scooter

Self-regulation is only necessary in response to risk of harm, so before discussing self-regulation techniques, the risk of harm and barriers to participation need to be introduced. Participants described many physical features, personal limitations and social environmental factors that posed as risks and barriers to effective scooter use. These risks and barriers are compiled in Table 3 to allow a quick reference to the variety of issues that participants reported. Across the sample, the degree of concern about each item varied according to the individual’s personal circumstances, discussed further in ‘Strategies used by scooter users’.

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Table 3.

Risks and barriers associated with using a scooter.

bad weather busy times/crowds change in terrain without contrast warning collision with pedestrians collision with vehicles at a driveway or a road crossing damaging the scooter in rough terrain or poor weather experiencing aggression/intimidation from pedestrians orvehicle drivers footpath clutter such as vegetation and rubbish bins inaccessible or unsafe streets inside buildings lack of designated kerb ramps lack of interesting spaces not seeing terrain change objects that compromised the line of sight on the road beside cars poor footpath condition poor footpath design road crossings at intersection corners with 3 or 4directions of traffic roadworks tipping the scooter travelling too fast unfamiliarity

Strategies used by scooter users

Consequently, the third theme and its subthemes present specific details of self-regulation tactics used in response to the described risks and barriers.

The participants indicated that the presenting risks and barriers described above could be managed through maximising available safety features either with the scooter itself or environmental features. These features are presented in Table 4.

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Table 4.

Features for promoting effective scooter use.

Scooter features	increasing visibility through flags that sit on the back of the scooter, providing height and ‘high-viz’ colour on the seat of the scooter preference for a four-wheeled scooter using mirrors to increase visual fields and compensating for restricted body movement using the speed dial on the control panel to manage speed, rather than using only the throttle
Environmental features	designated crossings: traffic lights, zebra crossings or pedestrian islands (areas designated for pedestrians to stop halfway through a road crossing) flat terrain and gentle slopes kerbs with manageable ramps for street access parking space for a scooter pleasant areas shared pathways with minimal road crossings underpasses for busy roads

In addition, participants described planning their routes and preparing for anticipated disruptions by carrying a mobile phone, wet weather gear and walking aides.

Key results

Insights provided by the participants reveal how self-regulation allows effective mobility and key areas for further investigation and action.

The self-regulation practices described in this study fit with Donorfio et al.’s (2008) and Laliberte Rudman et al.’s (2006) theories of driving self-regulation. This involves ongoing decision-making process accounting for risks, barriers and needs, while adjusting behaviour to suit the particular situation.

When looking at the need for self-regulation by IVI who use scooters, many of the barriers are similar to those experienced by IVI as pedestrians. These barriers include poorly maintained footpath infrastructure, difficult road crossings and the threat of embarrassment (Blaylock et al., 2015; Brouwer et al., 2008; Gallagher et al., 2011; Laliberte Rudman et al., 2016; McGrath et al., 2017; Montarzino et al., 2007). The need to improve community mobility conditions seems obvious, and is also supported by a range of other studies into the experiences of pedestrians with visual impairment, powered mobility device users and older pedestrians (Blaylock et al., 2015; Brouwer et al., 2008; Fomiatti et al., 2014; Gallagher et al., 2011; Laliberte Rudman et al., 2016; McGrath et al., 2017; May et al., 2010; Montarzino et al., 2007; Mortenson et al., 2015; Wilton and Davey, 2007).

At a personal level, IVI can be affected by decreased motivation, and a loss of confidence and resilience (Laliberte Rudman et al., 2016). In addition, overall mobility for IVI can be affected by perceived risk and the need to ask for assistance (Brouwer et al., 2008; Laliberte Rudman and Durdle, 2008; McGrath et al., 2017). Participants in this study responded to all these issues in ways that demonstrated initiative and resilience.

A common experience for the participants was difficulty with the urban physical environment. The environmental production of disability is a key area for occupational therapy intervention through advocating for physical and social changes at a societal level, not focusing solely on individual remedial approaches to intervention (McGrath et al., 2016). For example, footpath maintenance and design improvements can mitigate the physical access issues listed in Table 3 and, when employed with universal design principles, improve access for a wide range of people, not just IVI who use scooters.

In this study, identified barriers in the environment included both social and physical elements. The social environmental barriers include attitudes, poor consideration of other footpath users and institutional systems that do not consider diverse mobility needs (Hamraie, 2013). Scooter users can feel judged when they have invisible mobility impairments and onlookers may not understand the use of a scooter for energy conservation, pain or the inability to walk independently (Fomiatti et al., 2014). Ripat et al. (2018) found that wheelchair users experience negative social attitudes and any campaign to label the scooter as a disability tool carries the risk of similar stereotyping. As Stowe and Mulley (2010) suggested, media can play a role in improving attitudes toward scooters users by reporting the positive elements of scooter use, and occupational therapists can provide such positive stories.

Cordes et al. (2018) indicate there are many factors that need to be considered when determining competent scooter use. The participants in this study represented a wide range of functioning, both visual and in terms of other disabilities such as hearing and overall capacity. A key finding is that personal awareness of the impact of the visual impairment allows for better self-regulation. For example, two participants with low depth perception had very different management strategies. Poppy took the impairment into account and travelled defensively, whereas Chiconne learned gradually through making mistakes.

An important contribution made by this study is the documentation of specific self-regulation strategies of scooter users. Tables 3 and 4 describe both risks and features for promoting effective scooter use, along with detailed strategies, and these can be used to influence infrastructural design and encourage public campaigns. They could also be incorporated into scooter training programmes and support evidence-based practice for any clinician who works with an IVI who uses a scooter, empowering the client with self-awareness and practical approaches to managing hazards.

Limitations and further research

The sample for this study consists of participants from geographically similar locations, which affects the study’s generalisability to other locations and a larger population. However, many of the findings describe ubiquitous risks and barriers, and practical strategies that could be trialled in many locations or with many scooter users, meaning that application of the findings is at the reader’s discretion. As with an interpretivist viewpoint, the findings are presented as details but with an understanding of multiple realities. Therefore, the findings are not presented as definitive; rather, they encourage an ongoing conversation and suggest further research into effective scooter use by IVI.

One limitation of the study was the lack of measurement of whether self-management strategies used by these participants actually improved overall safety. However, such an evaluation is a challenge that other studies detailing driving self-regulation strategies also struggle to measure (Molnar et al., 2015). Until such a study is undertaken, it must be assumed that scooter users (along with other road users) have enough insight to know how and whether self-regulation strategies improve their safety.

Further research evaluating the risks associated with scooter use are needed. Currently, scooter injury statistics are inconsistently recorded and so there is a lack of baseline measures such as how many scooter users/journeys there are in NZ (Lieswyn et al., 2017). A comprehensive risk evaluation would also compare the risk of scooter-related injury to risk of social isolation, poverty or other harmful states for which the scooter can compensate. Such an evaluation can support further research that assesses whether self-regulation is satisfactory or at what point formal interventions are warranted for promoting safer environments.

Implications for practice

This study provides a small, but significant, addition to the growing literature from occupational therapists involved in scooter research.

Occupational therapists have a role in promoting community mobility by advocating at institutional levels, such as central and local government, for the built environment to be accessible (di Stefano et al., 2012). This study provides valuable descriptions of footpath infrastructure that promotes or reduces accessibility for IVI who use scooters.

Current scooter training is often ad-hoc and community initiated. Occupational therapists can have a role advocating for and/or advising community-led scooter training and scooter clubs. The occupational therapy perspective of the interaction between the person’s capability, the occupation’s features and the environmental demands is valuable for community groups wanting to promote effective community mobility training. This study specifically highlights barriers and risks of scooter use by IVI and the self-management strategies to be incorporated into scooter education.

While scooter assessment and provision are yet to be established as a common scope of practice for occupational therapists, any research detailing scooter use supports the emerging practice. This study’s insights can support an occupational therapist working in any capacity with a client who has a visual impairment and uses a scooter. As Deverell (2011) found, some professionals working with IVI actively deter clients from using a scooter. This study provides a more positive approach, with evidence of proficient scooter use by IVI and self-regulation practice. Risk-averse perspectives are clearly apparent in research on visual impairment, and this study presents a pragmatic view of how to manage risk without unnecessarily limiting an individual’s agency. Such evidence is needed for practitioners to promote an activity that is perceived as risky (Laliberte Rudman et al., 2016).

Occupational therapists can empower their clients by ensuring they are aware of the influence of their visual impairment on general function. They can also facilitate appropriate scooter use by highlighting both the value and the known risks. It is important to provide education about management strategies in order to support and foster the client’s own capacity for self-regulation. In any adult learning situation, it is important to start where the person is. In the case of scooter users, there is obviously a huge variety of starting places.