INTRODUCTION

People with mobility impairments can benefit from assistive devices such as motorized mobility scooters (MMS). In Canada, an estimated 108,000 mobility scooter users have been reported [1]. Various authors have concluded that mobility scooters can potentially facilitate an independent lifestyle for their owners, help them maintain a degree of participation in the community and improve their quality of life [2, 3]. Driving a MMS, however, is not without risk. For example, in an Australian study by Cassel et al [4], 151 people were treated in hospital for injuries sustained following a scooter accident. These injuries included fractured bones (50%) and open wounds (34%). Six deaths involving scooter use were also recorded.

Proper training is likely needed to benefit as much as possible from the use of a MMS, while avoiding accidents and injuries. Some instruments exist to assess driving competencies [5], but the level of evidence in assessing driving skills for MMS users is considered low [3, 6]. There is also a lack of formal training programs for MMS users [2, 3]. Training is nonetheless known to enhance basic skills and driving strategies [7]. ‘Basic driving skills’ refers to the ability to perform simple or complex maneuvers such as acceleration, reversing, right and left turn, U-turn, etc., independent of a specific environmental context [3, 7]. ‘Strategies’ refer to the use of MMS in a specific activity or environment, such as street crossing or shopping. Strategies incorporate basic driving skills, but also a more sophisticated cognitive process. MMS skills training is expected to facilitate the learning of driving strategies.

Considering the current state of evidence regarding new MMS users’ driving skills and strategies, the long-term goal of our research program is to develop and validate a training program which will focus on driving strategies. The first step was to develop a better understanding of the challenges experienced by MMS users in their daily activities. Specifically, our aim was to determine, among three- or a four-wheel MMS users, which activities are difficult for new users who are learning to drive, which contexts may make these activities challenging or unsafe, and which strategies can help users to complete these activities.

METHODS

A qualitative approach was selected to guide this investigative study.

Table 1. Demographics

	MMS users	Clinicians
N	25	25
Age (range)	35 - 85	25 - 65
Gender (F/M)	15/10	21/4
Years of experience	3 months – 25 years	2 – 26 years
Urban/Rural	18/7	17/8

Participants

The demographics data for our participants are presented in Table 1. As we sought to obtain “information-rich participants” [8], we conducted individual semi-structured interviews with 25 MMS users having varying degrees of experience driving three- or four-wheel scooters (from a few months to several years). A heterogeneity in MMS driving experience in our sample was desirable, as expert users may be able to talk about a greater range of experiences than new user; however, new users may better recall their challenges learning to drive. In addition, we interviewed 25 clinicians having expertise working with new MMS users. Inclusion/exclusion criteria for the MMS users were: 1) >18 years old; 2) >3 months MMS experience; 3) absence of language or cognitive impairments preventing participation in the interview. For the clinicians, the inclusion/exclusion criteria were: >25 years old; >2 years of experience related to MMS. MMS users and participants were recruited from two urban centers (Montreal and Vancouver) as well as rural areas in the province of Quebec, Canada.

Data collection

Interviews took place at one of the study sites, at the participant’s home or by phone, as preferred by each participant. All participants provided informed consent, as approved by the institutional review boards of the Interdisciplinary Research Center in Rehabilitation, the G. F. Strong Rehabilitation Center and the University of British Columbia. During a semi-structured interview, MMS users were asked to respond to questions regarding the challenges encountered in basic driving skills and in activities or situations that may be difficult when learning to drive a MMS. Clinicians were asked about their knowledge of the issues and needs of new users driving three- and four-wheel MMS. Interviews lasted approximately 30 minutes. Interviews were audio recorded and transcribed verbatim.

Data analyses

A thematic analysis [9] was performed to identify main themes and salient quotes describing the circumstances of each challenging driving activity. Triangulation and member checking were used as trustworthiness strategies.  [8]. There was triangulation of participants (clinicians and MMS users) and researchers. For example, once the initial themes were created by one of the team members, these were then discussed and refined by the other team members in an iterative manner. The process was repeated until consensus was achieved. In addition, a one-page summary of the results was provided to some of the study participants, who were then asked to review the findings and provide feedback (member checking).

RESULTS

We classified the sub-themes using the categories of the Human Activity Assistive Technology (HAAT) model [10], that is, activity, personal and environmental factors. Within each theme, we noted challenges and strategies identified by participants. Examples of challenges and strategies are also provided in each of the results tables.

In terms of activities (Table 2), participants identified themes related to basic skills, i.e., maneuvers unrelated to a specific context such as adjusting speed and handling slopes. Participants also identified specific complex skills, such as street crossing and road safety, as being particularly important to new MMS users.

Table 2. Sub-themes related to activities

Sub-theme	Example of challenge	Example of strategy or training approach
Adjusting speed	Understanding what is a safe speed depending on activity	Gradually reducing the speed before releasing the control lever (which applies brakes)
Maneuvering in tight spaces	Anticipating the space needed to turn or reposition the MMS in a tight space (e.g., elevator)	Practicing step-by-step at slower speed in a stress-free environment
Slopes	Negotiating lateral and steep slopes	Weight shifting on lateral slopes or going straight if possible
Traffic rules and road safety	Municipalities having different regulations on MMS needing to travel against or with traffic	Calling the municipality to understand the driving regulations for MMS
Street crossing	Knowing when it’s time to cross and when to wait	Learning the environment; how much time does the pedestrian crossing signal stay up?
Avoiding accidents	Accidents due to clothing or straps getting caught on steering handle	Not wearing loose clothing; not hanging purse or bags on handle

Personal factors that can bring additional challenges to new users were mostly identified by clinicians and are described in Table 3. These included behavioral, physical, sensor or cognitive factors that may require additional training, new strategies or adaptations to the MMS so that users adopt safe driving behaviors.

Table 4 describes themes related to the environmental context.  Challenges to MMS driving were associated with specific environmental features, such as automatic doors and adapted transport vehicles, the quality and width of sidewalks, and weather conditions, such as winter and rain.

Table 3. Sub-themes related to personal factors

Sub-theme	Example of challenge	Example of strategy or training approach
Autonomy and independence	Difficulty accepting MMS as mobility aid	Accepting that autonomy and independence may be more important than looks
Anxiety	Experiencing driving in a crowded area for the first time	Talking to the owner/responsible person beforehand
Impulsivity	Reckless or risky behavior	Observing MMS user and telling them to slow down
Physical or sensory impairments	Hearing impairments	Reminding MMS user to put on hearing aids
Cognitive impairments	Difficulty in understanding instructions and identify errors	Performing 2nd evaluation of MMS user’s potential to learn safe driving skills

4. Sub-themes related to the environmental context

Sub-theme	Example of challenge	Example of strategy
Adapted and public transport	Lack of space for larger MMS	Changing means of transportation or use other mobility aid
Automatic doors	Poorly positioned door button	Carrying and using a reaching stick
Indoors accessibility	Shops and offices that are too small or too crowded	Proper planning; choosing less busy moments
Inadequate surfaces	Poor sidewalk condition	Driving carefully in the street
Narrow sidewalks	Sharing space with other users	Driving slower and watching for people exiting shops or cars
Winter	Presence of snow, ice and slush	Learning first to drive in the summer or dry conditions
Rain	Too much rain/water can drown the motor	Protecting console with plastic bag or umbrella
Sand	MMS gets stuck in soft sand	Learning to recognize hard from soft sand and avoid the latter

DISCUSSION

During the interviews, MMS user and clinicians identified challenges experienced by new MMS users. These challenges could be grouped within three major themes, i.e., activity, personal and environmental factors. These challenges represent actual needs that should be addressed through a comprehensive MMS skills training program. Participants also identified strategies they have used or seen, in order to circumvent the identified challenges. For clinicians, these strategies came from their experience in teaching driving skills to MMS users. MMS users identified strategies based on their own experiences.

MMS training interventions described in the literature have mostly focused on the acquisition of basic skills, such as moving forward, turning and braking [6]. Likewise, the wheelchair skills program [11] has been used to train MMS skills and also teaches context-independent skills. It does include some of the more challenging maneuvers identified by participants in our study, such as handling front slopes, cross slopes and different surfaces. The philosophy of these programs is to teach basic skills as a foundation for complex skills that MMS users will acquire through their own practice. However, our data indicates that many challenges are context-dependent. For example, while the wheelchair skills program teaches MMS users how to change speeds, our participants indicated the importance of selecting the appropriate speed depending on the environmental context and of slowing down before applying the brakes to avoid a sudden shock. The importance of learning complex, context-dependent skills is also consistent with results from a survey by Mortenson et al. [12] In the survey, stakeholders identified the need to train complex tasks such as taking an elevator, using public transportation, street crossing and handling accidents, consistent with results from this study. Such context-specific skills should be included in a training program.

Our sample included participants with a variety of backgrounds and experiences (e.g., clinicians versus MMS users, urban versus rural, greater or lesser MMS expertise, Eastern versus Pacific climate). Despite this variety, there were no disagreements between participants in terms of challenges and strategies to MMS driving. On the contrary, data from the various participants are complementary. For example, ‘personal factors’ were mostly identified by healthcare professionals, reflecting the clinical decision-making process when attributing MMS to individuals with various disabilities. Quality of the sidewalks was mostly a concern for urban residents, while rural residents tended to use the roads and had concerns about whether they should be driving with or against traffic. Pacific coast residents were concerned about heavy rains, while East coast residents described the challenges and strategies due to winter conditions. We believe that the variety in our participants’ background helped paint a more complete picture of challenges experienced by MMS drivers.

One limitation from our study is that we did not include comments about the MMS itself. Indeed, the choice of MMS model, proper fitting and adaptations, follow-up services (which may all be guided by the public or private insurance policies) can make driving easier. For example, three-wheel MMS are more maneuverable than four-wheel MMS, although they may be less stable. Participants in the Vancouver area were questioned on assistive technology related factors, and these data will be presented in a future paper. We did not ask, either, how the built environment could be better adapted to MMS users (e.g., wider sidewalks, elevators and doorways, etc.). Another limitation is that while participants did identify strategies they employ to overcome challenges, it is not possible to state whether such strategies constitute the ‘best practice’. An ideal MMS training program would contain a list of skills to be learned, with each skill accompanied by a list of possible errors users can make and how these should be corrected. While our study does provide us with a comprehensive list of MMS-related skills, more research will be needed to develop and validate the actual training guidelines.