Generation and content validation of physical and vocational rehabilitation in paraplegics: An interview guide

Abstract

BACKGROUND:

As the mainstay treatment for paraplegics is rehabilitation, patient satisfaction and experience are important predictors of the care being provided. To understand whether the current arrangements of rehabilitation services are sufficient to help an individual with paraplegia return to a productive life. Patient-centered interview guides to explore their rehabilitation experience are lacking, which calls for a generation of the same.

OBJECTIVE:

To generate and validate an interview guide (PVR-PIG), which aims at understanding and exploring the experience of physical and vocational rehabilitation for individuals with paraplegia.

METHODS:

After an extensive literature search, an initial 27-item interview guide was formulated under three domains: general experience and expectations from rehabilitation care; physical rehabilitation experience, barriers, and facilitators; and vocational rehabilitation. Later, it was sent for content validation to a multidisciplinary expert panel with prior experience in spinal cord injury (SCI) management.

RESULTS:

After suggestions were received from nine experts with an average of 14 years of experience in dealing with SCI, a 15-item interview guide was finalized, with a scale-level and item-level content validity index of 0.897 and 0.78–1, respectively.

CONCLUSION:

The generated interview guide (PVR-PIG) aimed to explore physical and vocational rehabilitation experiences in paraplegics was found to be valid.

Keywords

Experience paraplegia rehabilitation spinal cord injury qualitative

1 Introduction

The prevalence of spinal cord injury (SCI) across the world is 20–50 million per year, whereas in an upper middle income country India, the incidence of SCI accounts for 20 million per year per year’s population, with 20,000 cases added every year (Farmahini, 2021; Srivastava, 2015). The majority of SCI patients are young adults between the ages of 20 and 39, which is the active earning age group of families, posing a serious threat to a country’s productivity, with developing countries such as India having a higher incidence of thoracic and lumbar injuries resulting in paraplegia (Srivastava, 2015; Chiu, 2010).

Although paraplegics have a relatively long life expectancy, they still face some common challenges that significantly reduce their quality of life. Appropriate medical and rehabilitation care can prevent these complications and assist the patient in living a long and productive life (Serpanou, 2019). Individuals with paraplegia often experience physical, emotional, relational, and economic consequences throughout their lives, and their rehabilitation is a lifelong process that may go on for the remaining years of their life. So, an understanding of how people with paraplegia actually make sense of their rehabilitation is necessary for knowing whether the current arrangement of rehabilitation services is sufficient and relevant enough to help an individual with paraplegia return to a productive and happy life (Cieza, 2010).

Currently, the focus of SCI rehabilitation is on quantitative or objective assessment, which answers “what” but fails to answer “why” and “how,” which the individual values (Cieza, 2010). For optimal management of individuals with SCI, an in-depth understanding of their experience of rehabilitation services and their activities of daily living and functionality is needed. These types of studies aim to explore the “patient perspective,” also known as “consumer perspective” studies (Bourke, 2015). These studies use a qualitative research design, which is flexible and gives a first-hand, detailed description of the experience from the patient’s perspective. However, even when qualitative studies offer a thorough grasp of the experience, they are frequently used in rehabilitation research (Kirchberger, 2010), and it is extremely rare that we come across development and validation studies of interview guides (Prescott, 2011). The generation of interview guides often receives less attention in qualitative studies, although it is an integral part of qualitative research (Krauss et al., 2009). It creates a crucial connection between the research problem, research questions, past relevant literature, and sought-after data that can bridge the research gap while keeping the researcher or interviewer on topic (Krauss et al., 2009). The research question is whether the generated interview guide (PVR-PIG) is valid for use in exploring physical and vocational rehabilitation experiences in individuals with paraplegia.

2 Materials and methods

2.1 Preparation of interview guide

The two-step method used by Stein (2007) and Armstrong (2005) for designing the interview guide (PVR-PIG) is shown in Fig. 1. It includes: instrument design and obtaining judgmental evidence from experts. Instrument design was carried out in three steps: A) content and domain specification; B) item generation; and C) instrument building (Zamanzadeh, 2016; Rodrigues, 2017). The second stage involved the content validation of the instrument by means of responses obtained from a panel of experts.

Fig. 1

Flow of generation and validation of interview schedule.

Step 1: Instrument design and construction was done by conducting a thorough literature review from various databases, such as Scopus and PubMed, from 2000 to 2021 to identify the work done on individuals with SCI. The keywords used were: “spinal cord injury” OR “spinal cord lesion” OR “spinal cord diseases” OR “spinal injuries” OR “paraplegia” OR “tetraplegia” for spinal cord injury; for type of study, “qualitative research” OR “focus groups” OR “case study” OR “interview”; and finally, for experience, “life experience” OR “expectations” OR “physical barriers” OR “architectural barriers” Keywords used for search were according to Mesh terminology, and for search from PubMed, a Boolean query was used, i.e., AND, OR, and NOT. Most of the qualitative research was focused on a few open-ended questions for interviews. The preliminary interview guide was inspired by several research studies exploring living experience, barriers, and the role of vocational rehabilitation for both sufferers and practitioners of SCI (Dorjbal et al., 2019; Dorjbal et al., 2020; Kirchberger et al., 2010; Littoonji et al., 2016; Ramakrishnan et al., 2016; Shabany et al., 2019) and followed Miller and Crabtree’s guidelines for interviews (Miller & Crabtree, 1999). After the thorough literature review and multiple drafts prepared by the first author, who has prior working experience with individuals with SCI and is pursuing a doctoral degree in physiotherapy, three major domains were found: general experience and expectations from rehabilitation care; physical rehabilitation experience, barriers, and facilitators; and vocational rehabilitation. Later, after a general consensus between the first author and the other two authors possessing PhDs in physiotherapy, a final draft of 27 items or questions (Table 1) was constructed under the domains mentioned above: general experience and expectations from the rehabilitation care domain had 12 items or questions; physical rehabilitation experience, barriers, and facilitators had 10 items or questions; and vocational rehabilitation had 5 items or questions.

Table 1

Initial Interview guide draft

Domains	Questions
General experience and expectations from rehabilitation care	1. How was your in-patient/intensive care unit experience in hospital? Probes: How was hospital food; how were pain, respiratory care, bowel and bladder managed?
	2. How would you describe your OPD care after a SCI? Probes: Your experience of care, was it good/bad, what would you change?
	3. How are the SCI rehabilitation services at your centre?
	4. Do you know occupational therapy, vocational rehabilitation, psychologists?
	5. Which services are included in your rehabilitation? Probes: E.g. PT, OT, vocational, P&O, etc.
	6. What do you think of the physical rehabilitation services in your centre? Are they different from what you expected? If yes, tell your unmet expectations.
	7. How do these professionals make your exercise protocol? Do they involve you in your rehabilitation protocol formation? Probes: E.g. are your concerns listened to? Give examples.
	8. Are the timings of your rehabilitation protocol comfortable for you? Probes: Do you have any say in timings, therapist choice, etc.?
	9. Have you been provided assistive devices? If yes, is provided information or training sufficient for its usage, is it cost-oriented?
	10. According to you, what is comfortable for you: OPD or IPD for rehabilitation?
	11. Who takes care of you: Attendants, children, family members, spouse, etc.? Have you seen any change in their behavior or taking care of you has changed your relationship with them in a good/bad way?
	12. Do you think taking proper nutrition helps your rehabilitation process in any way?
Physical rehabilitation experience/barriers/ facilitators	13. How has rehabilitation helped in your day-to-day activities or self-care?
	Suggestions: Are you talking about comprehensive rehabilitation?
	14. How has physical or occupational therapy helped in:
	•Transfers
	•Bed-mobility
	•Prevention of complications
	•Mobility
	15. Has physiotherapy helped in your community integration? Probes: Were the exercises done in the centre applicable in real-life too?
	16. Do you think the rehabilitation being provided to you is sufficient enough or is at par to what you have expected?
	17. Are there any architectural barriers in your rehabilitation centre? Probes: Absence of ramps, disabled friendly toilets, etc.
	18. What do you think are the barriers in rehabilitating you or in empowering people with SCI? E.g. Staff issues, improper care, transportation, finances, etc.
	19. What do you think are the facilitators in rehabilitating you or in empowering people with SCI?
	20. What do you think about the government policies, insurance or financial benefits you receive for your rehabilitation? Did these facilities have easy access or are there challenges?
	21. Are you having any menstrual related issues after SCI? If yes, how do you manage it?
	22. Is working with a male therapist uncomfortable for you? Probes: Explain why with examples.
Vocational rehabilitation	23. Are you currently employed?
	24. Have you been enrolled in any program on vocational rehabilitation or given any kind of vocational training?
	25. Are you provided with any kind of financial support? E.g. Pension, unemployment compensation, etc.
	26. In your opinion, what are the obstacles in returning to work?
	27. What are your views on the current rehabilitation scenario in India, do you have any suggestions in improving rehabilitation for individuals with SCI?

Step 2: Content validity. A Delphi survey method was conducted to estimate the content validity of the constructed interview guide by means of communication with a panel of experts (Polit, 2006; Zamanzadeh, 2016). The expert panel consisted of multidisciplinary practitioners (Paredes, 2021), consisting of physiotherapists, occupational therapists, neurologists, and neurosurgeons, all of whom had experience working with individuals with SCI. Ninety-four experts were identified and made into a panel for content validation, followed by filtering of the experts by means of a selection criteria: at least 12 years of experience working with individuals with SCI and one published article on individuals with SCI. Finally, 15 experts were selected and sent the questionnaire through Google Forms (https://forms.gle/Am9EqHW82Gw7QntL9) via Gmail, WhatsApp, and individual messages. The Google form for validation included PVR-PIG and a cover letter explaining the background of the interview guide and clearly stating the need to generate it. The instructions provided in the form were lucid and explained the rating of each item or question in regard to its relevance, clarity, and essentiality.

The critical appraisal of each item for relevancy was done on a 4-point Likert scale, where 1 = not relevant, 2 = somewhat relevant, 3 = quite relevant, and 4 = very relevant to the domain (Polit, 2006; Yusoff, 2019; Zamanzadeh, 2016). For essentiality, a 3-point Likert scale was used, where 1 = not essential, 2 = useful but not essential, and 3 = essential, whereas for clarity, ratings were: 1 = not clear, 2 = item needs some revisions, and 3 = clear. Additionally, suggestions or modifications were also asked after each item or question from experts. According to Lynn, a minimum of six experts were needed to validate a scale or questionnaire. Nine experts with an average experience of 14 years working with individuals with SCI accepted the request and filled out the form with their suggestions; seven were physiotherapists, one was an occupational therapist, and one was a neurosurgeon.

3 Results

Revisions were made in the PVR-PIG according to the responses recorded after their suggestions were collected via the Delphi survey. Some suggestions were made by the experts, such as the conversion of a few questions or items to open-ended form, suggested alternate words for individuals with SCI, removal of a few gender-oriented questions, reduction of the number of questions, and finally switching from an interview questionnaire to an interview guide.

The modifications made were:

1st and 2nd items/questions were clubbed.

Do/Are/Have was changed to open ended adjectives like: Can you tell, what/describe, etc.

4th and 10th items/questions were removed as they had less I-CVI than 0.78.

Items 6, 7 and 8 were clubbed together.

12th item/question was deleted due to irrelevance.

Items 13, 14, 16, 17, 24 and 25 were merged.

Gender-related items/questions 21 and 22 were removed.

One item/question was added: “How has SCI changed your work life?''

Modifications were made accordingly, and a final draft (Table 2) of the interview guide was obtained, which included 15 items or questions under the general experience and expectations from rehabilitation care domain (5 items or questions); under the physical rehabilitation experience, barriers, and facilitators domain (6 items items/questions); and under the vocational rehabilitation domain (4 items or questions).

Table 2
Final Interview guide with Scale-level and Item-level Content Validity Index (CVI)

SR. NO Questions I-CVI

General experience and expectations from rehabilitation care

1. How would you describe your overall time at the:

•Inpatient/ICU unit

Probes: For example, food, hygiene, nutrition, etc. Can you give an example?

•Outpatient care/OPD care unit after SCI

Probes: For example, was it good, bad or both? Why do you think that was? Can you explain it in detail? 0.78

2. What kind of rehabilitation did you receive and how was your experience?

Probes: Which healthcare professionals are on your team? 0.78

3. How do these professionals decide/make your exercise protocol? Can you think of an example when you were involved in decision making of protocol and timings?

Probes: What happened? Who involved you and how did it make you feel? Do you think it worked well in your case? 1

4. Describe your experience with usage of assistive devices.

Probes: Who provided it and was it cost-effective and sufficient enough in everyday life? 0.89

5. Over the years, have you noticed any change in the behavior of your attendants or family members?

Probes: How has the support and social interaction changed? Can you describe any positive or negative changes in your relationship with them? 0.89

Physical rehabilitation experience/barriers/facilitators

6. How has the rehabilitation helped you in: 0.89

a. Your ADL’s or day-to-day activities of self-care

b. Transfers

c. Bed-mobility

d. Prevention of complications

e. Mobility/capacity to move around

7. Describe how physiotherapy/rehabilitation helped in your community integration.

Probes: For example, in moving around, socializing, travelling, etc. Were the exercises realistic or applicable in real life? 1

8. What do you think the barriers are you encounter in your rehabilitation?

Probes: For example, staff issues, improper care, architectural barriers, transportation, finances, etc. 0.89

9. Similarly, what are the facilitators you encounter in your rehabilitation? 0.89

10. Tell about your awareness about the government policies, insurance or financial benefits you receive or can receive for your rehabilitation.

Probes: What about the access to these facilities? Were there any challenges? Please describe them. 0.89

11. Provide us with some feedback regarding your rehabilitation.

Probes: Tell us about your unmet expectations. Can you describe differences in realistic and expected outcomes? 0.89

Vocational rehabilitation

12. How has SCI changed your work life or education life?

Probes: Describe the positive and negative changes. 0.89

13. What kind of support is being provided for future employment?

Probes: Pension, employment compensation, vocational training, etc. 0.89

14. In your opinion, what are the obstacles in returning to work? 0.89

15. What are your views on the current rehabilitation scenario in India? Give suggestions in improving rehabilitation for individuals with SCI. 1

S-CVI(Av)=0.897

SR. NO	Questions	I-CVI
General experience and expectations from rehabilitation care
1.	How would you describe your overall time at the:
	•Inpatient/ICU unit
	Probes: For example, food, hygiene, nutrition, etc. Can you give an example?
	•Outpatient care/OPD care unit after SCI
	Probes: For example, was it good, bad or both? Why do you think that was? Can you explain it in detail?	0.78
2.	What kind of rehabilitation did you receive and how was your experience?
	Probes: Which healthcare professionals are on your team?	0.78
3.	How do these professionals decide/make your exercise protocol? Can you think of an example when you were involved in decision making of protocol and timings?
	Probes: What happened? Who involved you and how did it make you feel? Do you think it worked well in your case?	1
4.	Describe your experience with usage of assistive devices.
	Probes: Who provided it and was it cost-effective and sufficient enough in everyday life?	0.89
5.	Over the years, have you noticed any change in the behavior of your attendants or family members?
	Probes: How has the support and social interaction changed? Can you describe any positive or negative changes in your relationship with them?	0.89
Physical rehabilitation experience/barriers/facilitators
6.	How has the rehabilitation helped you in:	0.89
	a. Your ADL’s or day-to-day activities of self-care
	b. Transfers
	c. Bed-mobility
	d. Prevention of complications
	e. Mobility/capacity to move around
7.	Describe how physiotherapy/rehabilitation helped in your community integration.
	Probes: For example, in moving around, socializing, travelling, etc. Were the exercises realistic or applicable in real life?	1
8.	What do you think the barriers are you encounter in your rehabilitation?
	Probes: For example, staff issues, improper care, architectural barriers, transportation, finances, etc.	0.89
9.	Similarly, what are the facilitators you encounter in your rehabilitation?	0.89
10.	Tell about your awareness about the government policies, insurance or financial benefits you receive or can receive for your rehabilitation.
	Probes: What about the access to these facilities? Were there any challenges? Please describe them.	0.89
11.	Provide us with some feedback regarding your rehabilitation.
	Probes: Tell us about your unmet expectations. Can you describe differences in realistic and expected outcomes?	0.89
Vocational rehabilitation
12.	How has SCI changed your work life or education life?
	Probes: Describe the positive and negative changes.	0.89
13.	What kind of support is being provided for future employment?
	Probes: Pension, employment compensation, vocational training, etc.	0.89
14.	In your opinion, what are the obstacles in returning to work?	0.89
15.	What are your views on the current rehabilitation scenario in India? Give suggestions in improving rehabilitation for individuals with SCI.	1
S-CVI(Av)=0.897

3.1 Content validity

The content validity index was derived at the item and scale levels. The I-CVI (item-level content validity index) was calculated by dividing the total number of experts by the number of experts who gave each item a “quite relevant” or “very relevant” rating. I-CVI scores range from 0 to 1, according to Lynn, and when at least nine experts are there, a value of > 0.78 indicates that the item is relevant (Polit, 2006; Yusoff, 2019). Two items had I-CVI values of 0.78, ten items had I-CVI values of 0.89, and only three items had I-CVI values of 1.0 (Table 2).

The scale-level content validity index (S-CVI) was calculated by the average method. S-CVI/Ave was calculated by dividing the sum of the I-CVI scores of all items by the total number of items. It was found to be 0.897 by the average method, which indicates excellent content validity. The preliminary draft and final interview guide are presented in Table 3.

Table 3
Interview guide with initial and final items

Initial Items Final Items

General experience and expectations from rehabilitation care

1. How was your in-patient/intensive care unit experience in the hospital? Probes: How was hospital food; how were pain, respiratory care, bowel and bladder managed? 1. How would you describe your overall time at the:

•Inpatient/ICU unit Probes: For example, food, hygiene, nutrition, etc. Can you give an example?

•Outpatient care/OPD care unit after SCI Probes: For example, was it good, bad or both? Why do you think that was? Can you explain it in detail?

2. How would you describe your OPD care after a SCI? Probes: Your experience of care, was it good/bad, what would you change?

3. How are the SCI rehabilitation services at your centre? 2. What kind of rehabilitation did you receive and how was your experience with them? Probes: Which healthcare professionals are on your team?

4. Do you know occupational therapy, vocational rehabilitation, psychologists?

5. Which services are included in your rehabilitation? Probes: E.g. PT, OT, vocational, P&O, etc.

6. What do you think of the physical rehabilitation services in your centre? Are they different from what you expected? If yes, tell your unmet expectations. 3. How do these professionals decide/make your exercise protocol? Can you think of an example when you were involved in decision making of protocol and timings? Probes: What happened? Who involved you and how did it make you feel? Do you think it worked well in your case?

7. How do these professionals make your exercise protocol? Do they involve you in your rehabilitation protocol formation?

8. Are the timings of your rehabilitation protocol comfortable with you?

Probes: Do you have any say in timings, therapist choice, etc.?

9. Have you been provided assistive devices? If yes, is provided information or training sufficient for its usage, is it cost-oriented? 4. Describe your experience with usage of assistive devices. Probes: Who provided it and was it cost-effective and sufficient enough in everyday life?

10. According to you which is comfortable: OPD or IPD for rehabilitation?

11. Who takes care of you: attendants, children, family members, spouse, etc.? Have you seen any change in their behavior or taking care of you has changed your relationship with them in a good/bad way? 5. Over the years, have you noticed any change in the behavior of your attendants or family members? Probes: How has the support and social interaction changed? Can you describe any positive or negative changes in your relationship with them?

12. Do you think taking proper nutrition helps your rehabilitation process in any way?

Physical rehabilitation experience/barriers/facilitators

13. How has rehabilitation helped in your day-to-day activities or self-care? 6. How has the rehabilitation helped you in:

a. Your ADL’s or day-to-day activities of self-care

14. How has physical or occupational therapy helped in: b. Transfers

•Transfers c. Bed-mobility

•Bed-mobility d. Prevention of complications

•Prevention of complications e. Mobility/capacity to move around

•Mobility

15. Has physiotherapy helped in your community integration? Probes: Were the exercises done in the centre applicable in real-life too? 7. Describe how physiotherapy/rehabilitation helped in your community integration? Probes: For example, in moving around, socializing, travelling etc. Were the exercises realistic or applicable in real life?

16. Are there any architectural barriers in your rehabilitation centre? Probes: Absence of ramps, disabled friendly toilets, etc. 8. What do you think the barriers are you encounter in your rehabilitation? Probes: For example, staff issues, improper care, architectural barriers, transportation, finances, etc.

17. What do you think are the barriers in rehabilitating you or in empowering people with SCI? E.g. staff issues, improper care, transportation, finances, etc.

18. What do you think are the facilitators in rehabilitating you or in empowering people with SCI? 9. Similarly, what are the facilitators you are encountering in your rehabilitation?

19. What do you think about the government policies, insurance or financial benefits you receive for your rehabilitation? Did these facilities have easy access or are there challenges? 10. Tell about your awareness about the government policies, insurance or financial benefits you receive or can receive for your rehabilitation. Probes: What about the access to these facilities? Were there any challenges? Please describe them.

20. Do you think the rehabilitation being provided to you is sufficient enough or is at par to what you have expected? 11. Provide us some feedback regarding your rehabilitation. Probes: Tell us about your unmet expectations. Can you describe differences in realistic and expected outcomes?

21. Are you having any menstrual related issues after SCI? If yes, how do you manage it?

22. Is working with a male therapist uncomfortable for you? Probes: Explain why with examples. (Only for female patients with SCI.)

Vocational rehabilitation

23. Are you currently employed? 12. How has SCI changed your work life or education life? Probes: Describe the positive and negative changes.

24. Have you been enrolled in any program on vocational rehabilitation or given any kind of vocational training? 13. What kind of support are you being provided for future employment?

25. Are you provided with any kind of financial support? E.g. pension, unemployment compensation, etc. Probes: Pension, employment compensation, vocational training, etc.

26. In your opinion, what are the obstacles in returning to work? 14. In your opinion, what are the obstacles in returning to work?

27. What are your views on the current rehabilitation scenario in India, do you have any suggestions in improving rehabilitation for individuals with SCI? 15. What are your views on the current rehabilitation scenario in India? Give suggestions in improving rehabilitation for individuals with SCI.

Initial Items	Final Items
General experience and expectations from rehabilitation care
1. How was your in-patient/intensive care unit experience in the hospital? Probes: How was hospital food; how were pain, respiratory care, bowel and bladder managed?	1. How would you describe your overall time at the:
	•Inpatient/ICU unit Probes: For example, food, hygiene, nutrition, etc. Can you give an example?
	•Outpatient care/OPD care unit after SCI Probes: For example, was it good, bad or both? Why do you think that was? Can you explain it in detail?
2. How would you describe your OPD care after a SCI? Probes: Your experience of care, was it good/bad, what would you change?
3. How are the SCI rehabilitation services at your centre?	2. What kind of rehabilitation did you receive and how was your experience with them? Probes: Which healthcare professionals are on your team?
4. Do you know occupational therapy, vocational rehabilitation, psychologists?
5. Which services are included in your rehabilitation? Probes: E.g. PT, OT, vocational, P&O, etc.
6. What do you think of the physical rehabilitation services in your centre? Are they different from what you expected? If yes, tell your unmet expectations.	3. How do these professionals decide/make your exercise protocol? Can you think of an example when you were involved in decision making of protocol and timings? Probes: What happened? Who involved you and how did it make you feel? Do you think it worked well in your case?
7. How do these professionals make your exercise protocol? Do they involve you in your rehabilitation protocol formation?
8. Are the timings of your rehabilitation protocol comfortable with you?
Probes: Do you have any say in timings, therapist choice, etc.?
9. Have you been provided assistive devices? If yes, is provided information or training sufficient for its usage, is it cost-oriented?	4. Describe your experience with usage of assistive devices. Probes: Who provided it and was it cost-effective and sufficient enough in everyday life?
10. According to you which is comfortable: OPD or IPD for rehabilitation?
11. Who takes care of you: attendants, children, family members, spouse, etc.? Have you seen any change in their behavior or taking care of you has changed your relationship with them in a good/bad way?	5. Over the years, have you noticed any change in the behavior of your attendants or family members? Probes: How has the support and social interaction changed? Can you describe any positive or negative changes in your relationship with them?
12. Do you think taking proper nutrition helps your rehabilitation process in any way?
Physical rehabilitation experience/barriers/facilitators
13. How has rehabilitation helped in your day-to-day activities or self-care?	6. How has the rehabilitation helped you in:
	a. Your ADL’s or day-to-day activities of self-care
14. How has physical or occupational therapy helped in:	b. Transfers
•Transfers	c. Bed-mobility
•Bed-mobility	d. Prevention of complications
•Prevention of complications	e. Mobility/capacity to move around
•Mobility
15. Has physiotherapy helped in your community integration? Probes: Were the exercises done in the centre applicable in real-life too?	7. Describe how physiotherapy/rehabilitation helped in your community integration? Probes: For example, in moving around, socializing, travelling etc. Were the exercises realistic or applicable in real life?
16. Are there any architectural barriers in your rehabilitation centre? Probes: Absence of ramps, disabled friendly toilets, etc.	8. What do you think the barriers are you encounter in your rehabilitation? Probes: For example, staff issues, improper care, architectural barriers, transportation, finances, etc.
17. What do you think are the barriers in rehabilitating you or in empowering people with SCI? E.g. staff issues, improper care, transportation, finances, etc.
18. What do you think are the facilitators in rehabilitating you or in empowering people with SCI?	9. Similarly, what are the facilitators you are encountering in your rehabilitation?
19. What do you think about the government policies, insurance or financial benefits you receive for your rehabilitation? Did these facilities have easy access or are there challenges?	10. Tell about your awareness about the government policies, insurance or financial benefits you receive or can receive for your rehabilitation. Probes: What about the access to these facilities? Were there any challenges? Please describe them.
20. Do you think the rehabilitation being provided to you is sufficient enough or is at par to what you have expected?	11. Provide us some feedback regarding your rehabilitation. Probes: Tell us about your unmet expectations. Can you describe differences in realistic and expected outcomes?
21. Are you having any menstrual related issues after SCI? If yes, how do you manage it?
22. Is working with a male therapist uncomfortable for you? Probes: Explain why with examples. (Only for female patients with SCI.)
Vocational rehabilitation
23. Are you currently employed?	12. How has SCI changed your work life or education life? Probes: Describe the positive and negative changes.
24. Have you been enrolled in any program on vocational rehabilitation or given any kind of vocational training?	13. What kind of support are you being provided for future employment?
25. Are you provided with any kind of financial support? E.g. pension, unemployment compensation, etc.	Probes: Pension, employment compensation, vocational training, etc.
26. In your opinion, what are the obstacles in returning to work?	14. In your opinion, what are the obstacles in returning to work?
27. What are your views on the current rehabilitation scenario in India, do you have any suggestions in improving rehabilitation for individuals with SCI?	15. What are your views on the current rehabilitation scenario in India? Give suggestions in improving rehabilitation for individuals with SCI.

4 Discussion

This study generated and validated a content-validated interview guide (PVR-PIG) that not only explored individuals with SCI’s experience of physical and vocational rehabilitation but also investigated their perceived facilitators and barriers with their suggestions to improve rehabilitation services in India. This scale was specifically generated for the Indian population but can also be validated for various other developing and developed countries. To the best of the author’s knowledge, this is the first interview guide that has been validated and is exploring the experience of physical and vocational rehabilitation for paraplegics.

Through this interview guide, we anticipate exploring the experience of rehabilitation provided by all three major pillars of rehabilitation, i.e., physiotherapists, occupational therapists, and prosthetics and orthotics (Khanjani, 2017). This generated interview guide can be used to explore the physical and vocational experiences of individuals with paraplegia through a detailed qualitative analysis. Also, it can be used to assess qualitative feedback on rehabilitation from individuals with paraplegia, whether they receive rehabilitation as inpatients, outpatients, or through tele-rehabilitation.

5 Conclusion

The study showed that PVR-PIG is a valid tool that will help in exploring the experience of physical and vocational rehabilitation in individuals with paraplegia.

Footnotes

Acknowledgments

The authors would like to thank the experts who contributed in validating the interview guide.

Conflict of interest

The authors declare that they have no conflict of interest to disclose.

Ethics statement

The study was approved by the Institutional Ethical Committee of Maharishi Markandeshwar Institute of Medical Sciences and Research (MMIMSR) (project number: MMIMSR/IEC/2022-2154) and registered on ClinicalTrials.gov (identifier: NCT05267223).

Funding

The authors report that no funding was received for this study.

Informed consent

Informed consent was obtained from all experts prior to participation.

Author contributions

All authors contributed to the study idea and design, critical revision of the methodology, and development of the manuscript.

References

Armstrong,

T. S.

, Cohen,

M. Z.

, Eriksen,

, & Cleeland,

(2005). Content validity of self-report measurement instruments: an illustration from the development of the brain tumor module of the M.D. Anderson symptom inventory. Oncol Nurs Forum, 32(3), 669–76. https://doi/10.1188/05.ONF.669-676

Bourke,

J. A.

, Jean,

E. C.

, Smith,

, Snell,

D. L.

, & DeJong,

(2015). Attending to biographical disruption: the experience of rehabilitation following tetraplegia due to spinal cord injury. Disability and Rehabilitation, 37(4), 296–303. https://doi/10.3109/09638288.2014.918188

Chiu,

W. T.

, Lin,

H. C.

, Lam,

, Chu,

S. F.

, Chiang,

Y. H.

, & Tsai,

S. H.

(2010). Review Paper: epidemiology of traumatic spinal cord injury: comparisons between developed and developing countries. Asia-Pacific Journal of Public Health, 22(1), 9–18. https://doi/10.1177/1010539509355470

Cieza,

, Kirchberger,

, Sorenson,

F. B.

, Baumberger,

, Charlifue,

, & Posi,

M. W.

(2010). ICF Core Sets for individuals with spinal cord injury in the long-term context. Spinal Cord, 48, 305–12. https://doi/10.1038/sc.2009.183

Dorjbal,

, Zanini,

, Tsegmid,

, Stucki,

, & Rubinelli,

(2019). Towards an optimization of rehabilitation services for persons with spinal cord injury in Mongolia: the perspective of medical doctors. Disability and Rehabilitation, 43(15), 2200–2212. https://doi.org/10.1080/09638288.2019.1696415

Dorjbal,

, Prodinger,

, Zanini,

, Avirmed,

, Stucki,

, & Rubinelli,

(2020). Living with spinal cord injury in Mongolia: A qualitative study on perceived environmental barriers. The Journal of Spinal Cord Medicine, 43(4), 518–531. https://doi.org/10.1080/10790268.2019.1565707

Farmahini,

M. F.

, Khankeh,

, Hosseini,

, Dalvandi,

, & Tabrizi,

K. N.

(2021). Exploring Facilitators of Regaining Autonomy in People with Spinal Cord Injury: A Qualitative Study. Iran J Nurs Midwifery Res, 26, 154–61. https://doi/10.4103/ijnmr.IJNMR_25_20

Khanjani,

M. S.

, Younesi,

S. J.

, Khankeh,

H. R.

, & Azkhosh,

(2017). Exploring Facilitators of Post-traumatic Growth in Patients with Spinal Cord Injury: A Qualitative Study. Electronic Physician, 9(1), 3544–53. https://doi/10.19082/3544

Kirchberger,

, Sinnott,

, Charlifue,

, Kovindha,

, Luthi,

, Campbell,

, Zwecker,

, Scheuringer,

, & Cieza,

(2010). Functioning and disability in spinal cord injury from the consumer perspective: an international qualitative study using focus groups and the ICF. Spinal Cord, 48(8), 603–13. https://doi/10.1038/sc.2009.184

10.

Krauss,

S. E.

, Hamzah,

, Nor,

Z. M.

, Omar,

, Suandi,

, Ismail,

I. A.

, & Zahari,

M. Z.

(2009). Preliminary investigation and interview guide development for studying how Malaysian farmers’ form their mental models of farming. The Qualitative Report, 14(2), 245–260. Retrieved from http://www.nova.edu/ssss/QR/QR14-2/krauss.pdf

11.

Littoonji,

, Leget,

C. J. W.

, Swuste,

J. M. S.

, Doodeman,

, Widdershoven,

G. A. M.

, & Dekker,

(2016). The importance of ‘global meaning’ for people rehabilitating from spinal cord injury. Spinal Cord1047–52. https://doi/10.1038/sc.2016.48

12.

Miller,

W. L.

, & Crabtree,

B. F.

(1999). Depth interviewing. In: Doing qualitative research (2nd ed). SAGE.

13.

Paredes,

C. S-G.

, Ramírez,

E. M. A.

, & Rodríguez-Sabiote,

(2021). Content Validation of a Semi-Structured Interview to Analyze the Management of Suffering. Int J Environ Res Public Health, 18(21), 11393. https://doi/10.3390/ijerph182111393

14.

Polit,

D. F.

, & Beck,

C. T.

(2006). The Content Validity Index: Are You Sure You Know What’s Being Reported? Critique and Recommendations. Research in Nursing and Health, 29, 489–97. https://doi/10.1002/nur.20147

15.

Prescott,

F. J.

(2011). Validating a long qualitative interview schedule. WoPaLP, 5, 16–38.

16.

Ramakrishnan,

, Johnston,

, Garth,

, Murphy,

, Middleton,

, & Cameron,

(2016). Early Access to Vocational Rehabilitation for Inpatients with Spinal Cord Injury: A Qualitative Study of Patients’ Perceptions. Topics in Spinal Cord Injury Rehabilitation, 22(3), 183–191. https://doi.org/10.1310/sci2203-183

17.

Rodrigues,

I. B.

, Adachi,

J. D.

, Beattie,

K. A.

, & MacDermid,

J. C.

(2017). Development and validation of a new tool to measure the facilitators, barriers and preferences to exercise in people with osteoporosis. BMC Musculoskeletal Disorders, 18(1), 540. https://doi.org/10.1186/s12891-017-1914-5

18.

Serpanou,

, Sakellari,

, Psychogiou,

, Zyga,

, & Krepia,

D. S.

(2019). Physical therapists’ perceptions about patients with incomplete post-traumatic paraplegia adherence to recommended home exercises: a qualitative study. Brazilian Journal of Physical Therapy, 23(1), 33–40. https://doi/10.1016/j.bjpt.2018.05.004

19.

Shabany,

, Nasrabadi,

A. N.

, Mohammadi,

, Davatgaran,

, & Yekaninejad,

(2019). Health Professionals’ Experience of Barriers in Empowering People with Spinal Cord Injury: a Qualitative Inquiry. Journal of Caring Sciences, 8(3), 143–8. https://doi/10.15171/jcs.2019.021

20.

Srivastava,

R. N.

, Singh,

, Garg,

R. K.

, Agarwal,

, & Raj,

(2015). Epidemiology of Traumatic Spinal Cord Injury: A SAARC Perspective. International Journal of Molecular Biology and Biochemistry, 3(1), 9–22. http://www.irphouse.com/ijmbb/ijmbbv3n1_02.pdf

21.

Stein,

K. F.

, Sargent,

J. T.

, & Rafaels,

(2007). Intervention research. Establishing Fidelity of the independent variable in nursing clinical trials. Nurs Res, 56(1), 54–62. https://doi/10.1097/00006199-200701000-00007

22.

Yusoff,

M. S. B.

(2019). ABC of Content Validation and Content Validity and Content Validity Index Calculation. Education in Medicine Journal, 11(2), 49–54. https://doi.org/10.21315/eimj2019.11.2.6

23.

Zamanzadeh,

, Ghahramanian,

, Rassouli,

, Abbaszadeh,

, & Alavi,

(2015). Design and implementation content validity Study development of an instrument for measuring patient-centered communication. J Caring Sci, 4(5), 165–78. https://doi/10.15171/jcs.2015.017