Increasing the Winter Community Participation of Older Adult Wheelchair Users
Phase: NA
Conditions: Frail Elderly
Sponsor: University of Manitoba

Increasing the winter community participation of older adult wheelchair users    1 
 
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Increasing the winter community participation of older adult wheelchair users  
NCT02622828 

Increasing the winter community participation of older adult wheelchair users    2 
 
Version date: October 2, 2015           
Increasing the winter community participation of older adult wheelchair users 
Participation has been defined by the World Health Organization as “involvement in a life 
situation” and includes involvement in community, social, and civic realms.1  The concept of 
participation is more complex that simply considering the extent to one does or does not engage in a 
prescribed activity, rather it also has qualitative attributes that relate to the nature and self-perceived 
meaning of participation.2  Research has supported the association between community participation 
among people with disabilities, and outcomes such as higher subjective ratings of quality of life and 
independence, improved sense of belonging, and positive self-perception of health.3-5  
In Canada, 1.2 million people use mobility aids, such as wheelchairs, as a means to participate 
and engage in meaningful occupations within their community.6  Furthermore, the prevalence of 
mobility issues reported increases as people age, with approximately one-quarter of Manitobans age 75 
or over reporting mobility issues.7 However, users of wheeled mobility devices (WMD) face numerous 
environmental barriers to community participation including barriers such as limited access to accessible 
public transportation,8 lack of or poorly maintained ramps,8-11 lack of accessible parking,8  negative 
societal attitudes,8 and lack of enforcement of accessibility regulations.12  
One environmental barrier that WMD users in Manitoba acutely experience is winter weather. In 
a web-based survey of 99 Manitoban WMD users,13 80% of respondents reported needing additional 
help for home maintenance, transportation, and community access in the winter; however 57% reported 
not receiving that needed help. Respondents reported that limited community participation in winter led 
to feelings of loneliness, isolation, fear, and anxiety. Forty-two percent of respondents reported reducing 
their community participation frequency from almost daily in summer, to once or twice a week (or less) 
in winter; this finding was associated with older adult WMD users and those who lack access to 
family/friends for transportation. These results are particularly concerning, given a recent systematic 
review of community-dwelling older adults that provides strong evidence to support the positive impact 
of involvement in social, recreational, spiritual, and physical activity on health and quality of life.14 
Though we are beginning to gain an understanding of participation barriers specific to WMD 
users in the winter, few studies have sought to address these barriers through the development of new 
technology or adapting environmental features.15-17 The five environmental domains identified by 
International Classification of Functioning, Health and Disability (ICF)18 (i.e., technological, natural, 
physical, social/attitudinal, and policy) interact with a person with a health condition to either promote 
or limit activity and participation. Targeted interventions directed toward one or more of those domains 
may be an effective way of addressing reduced winter community participation. The purpose of this 
study is to examine whether intervention strategies targeted at the level of the environment can 
successfully promote the community participation experiences of community-dwelling older adult 
Manitobans who use WMD in the winter. The findings of this pilot study will help determine the 
feasibility of, and guide the development of, a proposal targeted at conducting a larger scale study.  
Method  
Overview   Using a single-subject design, five older adult WMD users will each select three community-
based participation goals to work on throughout the winter months. Each participant will work with an 
occupational therapist to receive individually-focused interventions aimed at increasing community 
participation. A client-centred outcome measure will be used to set initial goals, and to measure change 
in performance and satisfaction with performance.  
Detailed Description   Given the subjective nature of participation the experience of participating, 
community-based interventions should consider the individual nature of participation occupations and 
strive to engage individuals in occupations considered meaningful to them.14 This study will use an 
Interrupted Time Series Design (ITS), a quasi-experimental single-subject design suitable for evaluating 
the effectiveness of individually-designed interventions.19 Using ITS, each participant serves as his/her 

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own control, multiple baseline measurements are taken, and  multiple measures of the targeted outcome 
are collected throughout the study trajectory.20  
Participants 
This application is a pilot study, and thus feasibility of the research approach will be examined by 
recruiting five older adult Manitobans who are wheelchair users. Participants will be recruited through 
collaboration with one or more of the five Winnipeg Regional Health Authority ACCESS Centres and 
other health resource centres for seniors including Active Living Coalition for Older Adults (ALCOA), 
Age and Opportunity, Creative Retirement Manitoba, Healthy Aging Resource Team (HART) and the 
Independent Living Resource Centre (ILRC). Posters will be used to recruit participants. Participants 
will be screened for inclusion by the occupational therapist using the Geriatric Depression Scale-Short 
Form21 (GDS-SF) and the Montreal Cognitive Assessment22 (MOCA). Inclusion criteria include: age 70 
or older, user of a manual or power wheelchair or scooter for outdoor mobility, self-identifies a reduction 
in community participation throughout the winter months, community-dwelling, GDS-SF score of 5 or 
less, MOCA score >26, and lives within the perimeter of Winnipeg. If the score on the GDS-SF is >5 
(indicating mild depression), the individual will not be included in the study and with permission of the 
individual, the occupational therapist will telephone the individual’s physician and suggest further 
assessment.   
Measures  
The Canadian Occupational Performance Measure 23 (COPM) is a client-centered outcome measure 
designed to detect changes in performance and satisfaction in occupations that the individual has self-
identified as being important and difficult to perform. The COPM has well-established psychometric 
properties and will be used as the primary outcome measure and will be used to set treatment goals, 
determine baseline stability, and detect change in performance of, and satisfaction with, the goals.  
The Activity Card Sort 24(ACS) uses a Q-sort methodology where photographs of people performing 
various activities are sorted into categories that the participant indicates interest in performing. The ACS 
will be used to identify valued instrumental, leisure and social activities that the person has performed in 
the past and/or desires to participate in in the future and will guide the formation of goals on the COPM.  
The WHO-DAS 2.0 25 is a generic self-report health status measure, linked to the concepts of health and 
disability outlined in the ICF and intended to identify limitations in six domains, including self-care, and 
community and social functioning experienced over the past 30 days. The WHO-DAS 2.0 is responsive 
to change, has excellent internal consistency, established content validity, and high convergent validity. 
The WHO-DAS 2.0 will be used to identify changes in overall health status that occur through the study.  
Follow-up semi-structured interviews will be conducted at the end of the intervention phase, to gain the 
perspective of each participant of the experience and personal value of working to increase winter 
community participation. Interview questions will address barriers and supports to participating in self-
identified occupations and impact on sense of inclusion and engagement in the community.   
Procedure (repeated for each of 5 participants, entered concurrently into study) 
Recruit/screen for inclusion 
ACS; COPM goal-setting phase 
WHO-DAS 2.0 
Week 0  
Occupational therapist will conduct 
initial assessment to establish goals 
using the ACS and COPM.  
COPM baseline measurements 
(2x/week) 
Weeks 1-4 
Minimum 24 data points required to 
conduct statistical analysis19  
Intervention related to goal 1 (e.g. attend 
weekly spiritual services at local place 
of worship) 
Continue with baseline measurements 
(2x/week) for goals 2 and 3 
Weeks 5-7 
 
A sample intervention for goal 3 
might include working with 
participant to: identify appropriate 
neighborhood grocery store suitable 
for mobility/accessibility needs (e.g. 

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Intervention for goal 2 (e.g. participate 
in wheelchair yoga class 1x/week) 
Continue with baseline measurements 
(2x/week) for goal 3 
Weeks 8-10 
store that has scooter and basket 
available for customer use), 
determine regular transportation 
means and travel route, prepare 
weekly grocery list, learn to use debit 
card to pay for groceries. 
Intervention for goal 3 (e.g. weekly 
grocery shopping at local grocery store) 
Weeks 11-13 
Follow up phase (COPM/WHO-DAS) 
Follow-up interview (week 16 only) 
Weeks 16 
and week 20 
Research assistant conducts follow up 
interviews and administer follow-up 
COPM and WHO-DAS 2.0   
Analysis 
COPM data will be plotted and visually inspected to gain an understanding of the timing and nature of 
any change. Statistical analysis will be conducted using the celeration line and C statistic19, where the 
proportion of data points above and below the line is calculated and compared to a probability table to 
determine statistical significance. Repeated measures ANOVA will be used to identify change on the six 
domains of the WHO-DAS 2.0. Guided by an Interpretive Descriptive approach26, qualitative interviews 
will be transcribed verbatim and directed content analysis27 used to gain a descriptive and interpretive 
understanding of clinically relevant issues and suggestions for future study.   
Importance and Relevance to Aging 
Approximately one-third of Manitobans aged 65 or over reported emotional and social loneliness and 
older adults reported a decline in leisure activity participation with increasing age.7 Older adult WMD 
users in Manitoba bear a disproportionate burden in the winter – when aging, mobility limitations, and 
weather coincide to create conditions not conducive to community participation. A recent systematic 
review identified strong evidence to support the use of occupation and client-centred interventions in 
maintaining instrumental activities of daily living abilities of community-dwelling older adults.28  
However, evidence is required to identify whether, and how, we can use individually-focused 
interventions at the level of the environment to improve or maintain the community participation 
experiences of community-dwelling older adults who use WMD,28 particularly in the winter.  
Qualifications and Strategic New Direction 
My program of research focuses on understanding the intersection between assistive technology users 
and their environments. I primarily use client-centered approaches to inquiry, specifically qualitative 
methods, photovoice, case study, and mixed methods. While aging has not been a particular focus in past 
research, findings from a recent survey that I conducted13  indicated a disproportionate burden placed on 
older adults who are WMD users in terms of limitations in community participation in winter. I view this 
application as an important opportunity to explore innovative ways of addressing those challenges.  
Publications and Future Applications  
One peer-reviewed publication and a minimum of two professional presentations on this research will 
result from this study. While the sample size of five will not provide evidence of a treatment effect, the 
findings can be used to determine sample size required for a larger scale study proposal targeted at the 
Canadian Institutes of Health Research. This study will form a key component of a larger program of 
research focused on improving winter community participation among people with disabilities.  
Timeline 
Hire research assistant and OT; Submit HREB 
July –August 2015 
Recruit/Baseline phase  
November – December 2015 
Intervention (to occur over mid-winter) 
January - March 2016  
Follow up 
Complete by April 2016 

Increasing the winter community participation of older adult wheelchair users    5 
 
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Data analysis  
Complete by July 2016 
Presentations/publications  
May –September 2016 
 
 

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