Introduction

Winter’s accumulations of snow, ice, and cold wind and temperatures can create challenges to community participation for all citizens who face these conditions [1]. For people with mobility-related disabilities and who use mobility devices, accessing community spaces, participating in community-based activities, and engaging in social relationships outside of the home can be greatly curtailed by the challenges that winter conditions create. Mobility devices may not be designed to address winter conditions; spaces that are accessible in non-winter conditions may become inaccessible (e.g. accessible parking spaces that are not cleared of snow); and transportation options may be limited or non-existent, making access to services and activities increasingly difficult [2-4]. Research evidence is accumulating about the winter-specific issues individuals who use mobility devices face, and how those challenges impact on people’s health, well-being and ability to participate in their communities [3-9]. Missing from this literature is a comprehensive overview of what is known about the knowledge, strategies, resources and tools shown to improve winter mobility and community participation for individuals who use mobility devices. Gathering this information in a way that makes it available and accessible to stakeholders (i.e., individuals who use mobility devices; service providers; consumer organizations; researchers) will promote the development of a community of interested parties that can continue to address winter challenges and promote community participation and engagement.

AIM

The purpose of this research is to create a web-based toolkit of evidence-based winter accessibility solutions (i.e., knowledge, products and resources) for people who use mobility devices. The study was conducted in three sequential phases: 1) a scoping review of knowledge, products, and strategies used to address challenging winter conditions for individuals with mobility-related disabilities; 2) online, asynchronous focus groups with individuals across Canada who report winter mobility and accessibility challenges; and 3) development of a prototype web-based toolkit using a rapid prototyping approach.

Methods

Overall toolkit development was guided by a pragmatic stance to mixed methods research, emphasizing constructed knowledge based on problem-solving, action, and context [10].

Phase 1 consisted of a scoping review [11] of the published winter mobility-related interventions in the published and grey literature with the objective of identifying the knowledge, products, and strategies targeted at individuals with mobility-related disabilities used to address challenging winter conditions. Ageline, OVID, Scopus, and CIHAHL were searched for studies that met the inclusion criteria, from inception to April 2018. Grey literature sources included: ProQUEST; government websites; and manufacturer, vendor, and consumer organization websites. Findings were charted using the five environmental domains (i.e., natural, technological, physical, social/attitudinal, and policy) outlined in the International Classification of Functioning, Disability and Health [12].

Phase 2 consisted of asynchronous, online focus groups [13-14] in each of five regions across Canada. Online asynchronous focus groups were selected over in-person focus groups as they provided the opportunity to include geographically dispersed participants; permitted participants to provide reflective responses and respond to the responses of others over the course of the focus group; provided automatic recording of data; and, of utmost importance in this study, provided convenience for participation by people who might experience difficulty attending an in-person focus group [13-14]. Participants were mobility device users, age 19 or older, with Internet and computer access, and who were willing to spend a minimum of 30 minutes per day for 6 out of 7 days (duration of the focus group) responding to facilitator questions and building on the responses of other participants. Over the course of seven consecutive days, participants had access to a discussion board hosted on WordPress.com and were asked to respond to posted daily questions, as well as to respond to and build on the comments of other focus group participants. Questions were organized using the ICF environmental domains [12], and informed by team expertise, other literature on toolkit development [15-16], and the results of the scoping review. An example of a question included is “Can you suggest strategies that help you stay involved in the community in winter months?” Content analysis was used to identify prioritized categories and superordinate themes that were used to guide toolkit development.

Phase 3 of the project was development of a prototype web-based toolkit using a Rapid Prototyping approach. Rapid Prototyping incorporates user-centred design, in a highly iterative process of revision based on multiple stakeholder evaluation and input with a quick turn-around time [17]. A total of four prototyping cycles were identified as necessary to develop and refine the website design. An online survey with directed questions related to the prototype and feedback for further revision was developed. A media expert was contracted to redevelop the prototype at each stage. The development phase initially engaged the interdisciplinary research team in several targeted discussions to evaluate the phase 1 and 2 findings, drawing on their individual content expertise to create core toolkit content.

Three cycles of stakeholder consultation are in progress following development of an initial prototype (Figure 1). These cycles are focused on soliciting input on the usability and practicality of the toolkit content, identifying the relationship between components, and examining acceptability of the delivery platform. Participants from the online focus group will be the first stakeholders to review the prototype, providing structured feedback on content presentation through an online survey and recommendations for the next phase. Following redesign, the prototype will be circulated to 10 health care professionals whose practice incorporates winter mobility-device use, recruited via snowball sampling with recommendations coming from focus group participants and the research team. These experts will evaluate content and delivery of the toolkit and provide recommendations. Finally, after further redesign, representatives from 10 consumer and advocacy organizations from across Canada will review the toolkit and provide further recommendations.

results

Phase 1: Twenty-three published peer-reviewed papers that met the inclusion criteria were located. Study populations were predominantly those who used wheelchairs (mixed wheelchair type 30%; power 17%; manual 9%), canes (13%), specialized winter footwear (9%) and other (22%). The primary focus of these papers was determined to be: tool/device (43%); recommendations (39%); strategy (9%); or resource (9%). Civic policy documents were variable in terms of citizen responsibility for snow clearing. Limited winter-related supports were identified on consumer organization websites.

Phase 2: A total of 24 individuals participated in the online focus groups (n=8 in BC, n=6 in MB, n=5 in ON, n=2 in QC, and n=3 in NS). Analysis of focus group transcripts resulted in 33 codes that were grouped into 14 categories: activity and recreation; added assistance in winter; advocacy and awareness; assistive technology and adaptations; city policy and planning; (impairment specific) community organizations; preplanning; social media; staying activity for mental and physical health; support and peer problem-solving; transportation; winter safety; winter specific strategies; and wishlist (items desired but not available). These topic areas, along with the findings from the scoping review were fed into the first iteration of the prototype toolkit.

Phase 3: The development phase consisted of several teleconferences amongst team members, where feedback on structure was solicited and integrated into a version that was then discussed. Once the team was satisfied that the prototype was ready for study participant distribution, the first cycle was initiated. The first cycle will be complete by the end of February, the second by the end of March, and the third by the end of April. A final prototype and recommendations for coding of the web-based toolkit will be produced by the end of May, 2019.

discussion

While the literature outlines the challenges faced by people using mobility devices in the winter and some winter-specific products exist, very few studies have examined the effectiveness of any of these products. A single compilation of strategies and resources is absent. The online focus groups provided direction for content to incorporate into the prototype website and, importantly, supported the value that people placed on peer-to-peer problem-solving, advice-giving and support when given the opportunity to engage in an online community. The cycles of development in the prototype allow modifications and changes to be addressed in an iterative manner and will result in development of a compendium of information, strategies, and discussions designed to meet the needs and interests of a large and diverse group of stakeholders.

conclusions

After the final phase is complete, a high-fidelity version of the toolkit prototype, established with integration of research evidence, emerging evidence (grey literature), client preferences/values, and clinical expertise, will be ready for submission to a web development firm to develop the online version of the toolkit. The toolkit will serve as a hub of information, inspiration, and innovation important for those interested in improving winter mobility and community participation among individuals using mobility devices.