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Development of a new self-report questionniare[sic] : the Ambulatory Self-Confidence Questionnaire (ASCQ) Asano, Miho 2005

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DEVELOPMENT OF A NEW SELF-REPORT QUESTIONNAIRE: THE AMBULATORY SELF-CONFIDENCE QUESTIONNAIRE (ASCQ) by M I H O A S A N O B . S c , Clinical Exercise Physiology, Concordia University, 2003 A THESIS S U B M I T T E D IN P A R T I A L F U L L F I L M E N T OF T H E R E Q U I R E M E N T S F O R T H E D E G R E E O F M A S T E R OF S C I E N C E in F A C U L T Y O F G R A D U A T E S T U D I E S (Rehabilitation Sciences) T H E U N I V E R S I T Y OF B R I T I S H C O L U M B I A October 2005 © Miho Asano, 2005 Abstract Ambulation is one of the most important aspects of mobility as a whole. Difficulty with ambulation is a common problem among older adults in North America. Accordingly, maintaining or regaining their ambulation, at home and in the community, is a major goal and a great concern for older adults in rehabilitation programs. For researchers and clinicians in rehabilitation sciences, major goals and challenges include developing and using sufficient and effective measurement tools. Measurement tools that assess ambulation are an essential form of clinical and research information. While tests of walking speed and endurance are considered the gold standard for assessing ambulation, self-report approaches have recently become more accepted because they offer information not obtainable from the performance walk test. For instance determining individuals' confidence can be critical as studies have shown that confidence in performing a skil l can be predictive of successful performance. Therefore, we created the Ambulatory Self-Confidence Questionnaire ( A S C Q ) because there was no existing measurement tool that captured this information. The A S C Q contains 22 items using item is scored from 0 (not at all confident) to 10 (extremely confident). The test-takers are asked to report how confident they are in their ability to walk in different situations. The objectives of this study included assessment of: 1) content validity of the A S C Q by a panel of experts; and 2) reliability and construct validity of the A S C Q among older adults. The results of the study suggest that: 1) the A S C Q evolved based on the experts' responses and was successfully created with valuable feedbacks; 2) the A S C Q demonstrated excellent internal-consistency and test-retest reliability; and 3) the support for construct validity was evident for a sample of older adults. i i Table of Contents Abstract • • 1 1 Table of Contents iii List of Tables • vi List of Figures v n Acknowledgements . viii Chapter 1 - Introduction and Purpose 1.1 Overview of the Thesis 1 1.2 Purpose 1 1.3 Introduction and Rationale 1 1.4 Theory and Concept behind the Proposed Study 4 1.5 Study Objectives and Hypotheses 13 1.6 Significance of the Proposed Study 13 1.7 References 15 Chapter 2 - Content Validity of the Ambulatory Self Confidence Questionnaire (ASCQ) 2.1 Introduction • 24 2.2 Purpose 25 2.3 Methods 26 2.3.1 Design 26 2.3.2 Participants 26 2.3.3 Protocol 27 2.3.4 Measures 27 2.3.5 Data Analysis 28 iii 2.4 Results • 2 8 2.5 Discussion 30 2.6 Conclusion and Future Research 35 2.7 Acknowledgements 35 2.8 References • 3 6 Chapter 3 - Reliability and Validity of the Ambulatory Self Confidence Questionnaire (ASCQ) 3.1 Introduction 54 3.2 Purpose 5 6 3.3 Methods 5 6 3.3.1 Design 5 6 3.3.2 Participants • 5 7 3.3.3 Protocol • 58 3.3.4 Measures 59 3.3.5 Data Analysis 6 2 3.4 Results 6 3 3.5 Discussion 66 3.6 Conclusion and Future Research 71 3.7 Acknowledgements 71 3.8 References •• 73 Chapter 4 - Findings and Conclusion 4.1 Overview 85 4.2 General Findings • 85 4.3 Limitations 87 iv 4.4 Study Implications 89 4.5 Final Thoughts 90 4.6 References 91 Appendix I: The Ambulatory Self-Confidence Questionnaire - Version 1 93 Appendix II: The Ambulatory Self-Confidence Questionnaire — Version 2 94 Appendix III: The Ambulatory Self-Confidence Questionnaire - Version 3 95 Appendix IV: Sample Size Calculation 96 Appendix V : The Six Minute Walk Test 97 Appendix V I : The Timed "Up & G o " Test 99 Appendix VII : The Activi ty specific Balance Confidence Scale. 100 Appendix VIII: The Instrumental Activi ty of Daily L iv ing Scale 101 Appendix IX: The Folstein's M i n i Mental State Exam 102 Appendix X : Socio-demographics and measurement outcomes categorized by the type of recruitment location 105 Appendix X I : Socio-demographics and measurement outcomes categorized by the non-fallers and fallers 106 Appendix XII : Principal Component Analysis 107 Appendix XIII: A Sample Study Advertisement 108 Appendix X I V : A Sample Survey - 1 109 Appendix X V : A Sample Survey - II 110 Appendix X V I : A Sample Fol low-Up Questionnaire I l l Appendix X V I I : A Sample Information and Consent Form 112 v List of Tables Table 1: Characteristics of Selected Measures of Walking 20 Table 2.1: Demographic of A l l Participants 39 Table 2.2: Occupational and Educational Background of A l l Clinicians, Academics, and Students 40 Table 2.3: The Results of Survey I: Item Clarity and Appropriateness. 41 Table 2.4: The Results of Survey I: the A S C Q "Yes or N o " Questions 44 Table 2.5: The Results of Survey I: the A S C Q Response Format Preference 45 Table 2.6: The Results of Survey II: Item Clarity, Importance, and Disacrimination 46 Table 2.7: The Results of Survey II: the A S C Q "Yes or N o " Questions 50 Table 2.8: A Br ief Summary of the primary changes in the A S C Q 51 Table 3.1: Sociodemographics of A l l Participants 77 Table 3.2: Results of the Self-Report Questionnaires and Performance-Based Tests 79 Table 3.3: Internal Consistency and Test Retest Reliability of A S C Q 80 Table 3.4 - Correlation of the A S C Q with Other Study Measures 82 v i List of Figures Figure 1.1: Theoretical Model for the Proposed Study 22 Figure 1.2: ICF Model & Definition 23 Figure 2: Protocol 53 Figure 3.1: Protocol 83 Figure 3.2: Scatter Plots of the Relationships between the A S C Q and Other Measures... .84 vn Acknowledgements Great appreciations to my thesis committee, Dr. B i l l Mi l le r , Dr. Catherine Backman, Dr. Janice Eng, and Dr. Roger Wong for their support and invaluable input. A special thank you to my graduate supervisor, Dr. B i l l Mi l le r , for his patience and for providing me with an amazing opportunity to learn about science and research as well as for his fantastic guidance without which I could not complete my master's education and projects at U B C . I would also like to state my appreciation to the participants, doctors, therapists, nurses, and centre coordinators who made this research possible as well as the graduate students and people at the school of rehabilitation sciences at U B C and the G F S research lab. Lastly, I would like to thank my friends and family for sharing their knowledge and experience with me and providing me with such great support. v i i i Chapter 1: Introduction 1.1 Overview of the Thesis This thesis is comprised of four chapters: 1) an introduction, rationale, and purpose of the proposed study; 2) a manuscript examining the content validity of a new measure of ambulation confidence; 3) a manuscript examining the reliability and construct validity of a new measurement of ambulation confidence; and 4) overall conclusions and future implications of the study. 1.2. Purpose The overall aims of this study were to develop a new self-report questionnaire that assesses an individual's ambulatory self-confidence in various living environments, to: assess the content validity of the new questionnaire using a panel of experts (academics, clinicians, and professional or graduate level students, and older adults) and to assess the reliability and construct validity of the new questionnaire among community- dwelling older adults. 1.3 Introduction and Rationale For older adults, the ability to walk safely and independently is a basic yet important part of daily living (Shumway-Cook et al., 2002) and a key determinant of their quality of life (Spector et al., 1987; O'Boyle , 1997). In older adults, mobility can become impaired as a result of age-related changes including a reduction in muscle mass, strength, and prolonged reaction time (Bennett, 2000; Nair, 1999; R i k l i & Jones, 1997). In addition, common medical illnesses or health conditions among older adults, such as 1 neurological and heart diseases, or orthopedic problems, can further increase difficulty with balance and mobility (Schmid, 1991; Browne et al., 1994). Difficulty with mobility is common amongst older adults. In 1984, the "Supplement on Ag ing" reported that as many as 19% of the 26,4 mil l ion "non-institutionalized adults", older than 65 living in the United Sates had difficulty with walking (Havilk et al., 1987). More recently, in 2001, Human Resources Development Canada ( H R D C ) reported that 39.5% of Canadian adults between 75 and 84 years of age, and 57.7% of adults 85 years and over, had mobility-related disabilities ( H R D C , 2003). Furthermore, the ambulation problem is expected to grow in line with the increase in longevity number of older adults in North America (Guccione, 1993; Moore et al., 1997; R i k l i & Jones, 1997). Therefore, maintaining control of one's own body, maintaining or regaining independent mobility at home and in the community, are often major goals for older adults in rehabilitation programs, as well as after hospitalization (Guccione, 1993; Katz et a l , 1983; Lerner-Frankiel et al.,1986; Fries et al., 1980; Richardson et al., 2000). To confront this problem, researchers and clinicians face the challenge of determining and classifying patients' health conditions to provide the best available treatment (Wagstaff, 1989; Guccione, 1991; Rudberg et al., 1996). The importance and necessity of having a tool to assess patients' conditions and prescribe appropriate rehabilitation programs, best suited for use in everyday practice of rehabilitation sciences, has been stressed for some time (Ware et al. 1981; Jette, 1989). Consequently, remarkable amounts of research designed to quantify an individual's ability to function have been reported (Applegate et al. 1990). A number of valid and reliable measurement tools have been developed to evaluate an individual's handicap, impairment, or diability 2 and to assess change over time (Sherman et al., 1998). Even though it is widely agreed that this kind of screening of an elderly individual's functional status (such as physical and psychological impairment and disability) is important, the preferred standardized method is still unknown (Sherman et al.,1998). Measurement and Mobility Measurement tools are an essential source of information for researchers and clinicians, because they have been shown to be predictive of the ability to perform activities of daily living ( A D L ) (Harada et al., 1999; Suzuki et al., 2003). Performance-based measurements, such as timed walk tests or distance walk tests, are commonly used and often considered as the gold standard of ambulation measurements since there is currently no better approach to assess ambulation than to measure it directly (Guralnik et al.1995; Guccione, 2000). Some commonly used performance-based walk tests include the Timed "Up & G o " test (TUG) , and the 6-Minute Walk Test (6MWT) . The T U G is an assessment of many of the components of basic mobility (Podsiadlo & Richardson, 1991; Steffen et al., 2002). It is reported to be a reliable and simple test for older adults to complete. In addition, the T U G was reported to be able to identify older adults who have experienced falls or have balance problems (Shumway-Cook et al., 2000). The 6 M W T is a measurement of the distance that an individual is able to walk at his or her "normal" speed in a given amount of time (American Thoracic Society, 2002). The 6 M W T measures the global responses of the systems that are required to perform the activity (such as physiological or cardiovascular function). Moreover, the self-spaced 6 M W T is reported to measure the sub maximal level of functional ability (Steel, 1997). Timed walk 3 tests, especially the 6 M W T are accepted as simple, practical, and reliable performance-based walk tests that are a better indication of an individual's daily activity level (Enright et a l , 2003). However, these performance-based walk tests are sometimes considered to be exhausting, and other times they are considered to be too easy for the patients, not to mention time-consuming for the clinicians (Guccione, 2000). Additionally, some researchers have questioned how accurately these performance-based test results reflect an individual's actual performance in their real l iving environment (Lerner-Frankiel et al., 1987). That is, does capability in a testing situation truly reflect how an individual performs on a daily basis? The unrealistically safe and simple environment may lack validity. A n individual performs these tests on a flat and straight floor, without any obstructions or problems with roads, vehicles, traffic lights, or other obstacles such as curbs and stairs. In everyday life, at the hospital, at home, or in the community, this controlled environment is unlikely to exist. This means that these well-accepted and established performance-based tests may fail to capture an individual's ambulatory skil l after they return to home or community from their hospitalization. Furthermore, these tests measure what can be done, and not an individual's self assessment of their ability. Perception has been found to be particularly important for predicting performance, more so than an individual's skil l or ability (Bandura, 1997; Pajanes, 2002). 1.4 Theory and Concept behind the Proposed Study 4 In 1977, Bandura introduced self-efficacy theory and social cognitive theory to the world of psychology (Bandura, 1977). Since then, these theories have been used to support many investigations in psychology and health sciences (Gage et al., 1994; Lorig et al., 1996; Tiger et al., 1998). "Self-efficacy is the belief in one's capability to organize and execute the sources of action required to manage perceptive situation" (Bandura, 1977& 1986; Bandura & Adams, 1977). In other words, self-efficacy addresses the question of "Can I. . .?" This theory purports the notion that an individual's perception or cognitive appraisal influences his or her decision to engage in a particular activity, and also how well they can perform that particular activity under given conditions (Bandura, 1977 & 1982; Bandura & Adams, 1977). Self-efficacy affects the choice of activities and environmental settings regardless of whether the individual's assessment is accurate or not (Bandura, 1982). More precisely, individuals avoid activities that they believe exceed their ability or capacity; but they accept and perform confidently those they judge themselves capable of (Bandura, 1977). The dynamic interaction of personal, behavioural, and environmental factors can be seen in the model (Figure 1.1). Bandura stated that self-efficacy can influence the choice and effort that an individual makes, the duration an individual persists in performing a particular activity, and an individual's feelings (Bandura, 1992). A s such, self-efficacy is considered to be an important factor in determining actual performance. According to Bandura (1986), there are four fundamental sources of information that influence an individual's self-efficacy: 1) performance attainment, 2) vicarious experience, 3) verbal and social persuasion, and 4) physiological state. 5 Performance attainment, such as experience of learning skills, is believed to be the most powerful source of self-efficacy. Bandura stated that success enhances self-efficacy and failure reduces it. Performance attainment experience or an individual's effort to do something can encourage healthy perceptions of the process. With or without difficulties and obstacles, performance attainment experience can ultimately help individuals master the necessary skills. Vicarious experiences are the second principal source of self-efficacy. Individuals can also gain knowledge and experience by observing others, especially others with similar mobility issues, performing comparable activities. Baudura also stated (1977 & 1997) that vicarious experience is not a strong source of self-efficacy; however, it can create significant effects on an individual's performance, as well as self-efficacy. Verbal and social persuasion is the third essential source of self-efficacy. Within realistic limits, support from others or from society is also an important source for self-efficacy. Positive verbal and social persuasion can motivate individuals to achieve their goals or master and perform required skills (Bandura, 1977 &1997). Physiological state is the fourth fundamental source of self-efficacy. Individuals depend partially on information from their body (physiological state) in deciding their performance ability. For instance, in activities concerning strength or endurance, individuals examine their fatigue and body discomfort as indicators of physical inefficacy. Programs or treatments that address these four tenets can reduce emotional frustration, fear, or threats, and can enhance individuals' self-efficacy, resulting in performance improvement. 6 The aforementioned four sources of self-efficacy are crucial factors to be considered and implicated in the field of rehabilitation sciences. If the theory is applied correctly in the field, we can assess individuals' ambulation skills using a self-report scale of ambulation confidence that is more cost, space, and time effective, as well as less of a burden for patients in carrying out the performance-based tests during their hospitalization. A successful self-report scale may provide researchers and clinicians with extra information that cannot be assessed by performance-based tests. Our new self-report questionnaire, which assesses individuals' ambulation confidence, can be such a tool. For example, patients admitted to hospitals or clinics who are deemed less confident in performing some ambulation activities can benefit from this type of assessment followed by necessary consultations and therapy with their doctors and therapists. Patients can also learn to control and overcome the fears and concerns that influence their physiological state; at the same time they may gain vicarious experience by observing other patients with similar conditions during their rehabilitation process. Therefore, assessing and enhancing patients' ambulatory self-confidence may help them safely return and reintegrate into in their community. Self-efficacy theory has been widely used to improve the understanding and prediction of actual performance or achievement levels (Gage et al., 1994; Bandura, 1997). For instance, one of the commonly-used scales in the rehabilitation sciences, the Activity-Specific Balance Confidence ( A B C ) Scale, was developed to include the concept of self-efficacy (Powell & Myers, 1995). The A B C measures perceived-balance ability while an individual is performing a series of specific activities. The A B C has revealed the degree to which an individual believes they are capable of participating in 7 particular activities without falling. The studies using the A B C scale have demonstrated that an individual's perception (balance confidence) is a good reflection of their actual performance (Hatch et al., 2003). The International Classification of Functioning, Disability and Health (ICF) model of Functioning and Disability The International Classification of Functioning, Disability and Health (ICF) model was created by the World Health Organization (WHO) to assist health professionals define and classify elements of health, acknowledge the interactions between its components (Health Condition, Body Functions and Structures, Activities, Participation, Environmental Factors, and Personal Factors), subject to change, and effects factors both intrinsic and extrinsic to the individual, such as physical and social features within an environment ( W H O , 2001). Figure 1.2 presents ICF model and defines the primary components. For our study, we focused on two important factors that may influence an individual's level of activity (such personal factors and environmental factors). Among older adults, the inability to cope with the demands on mobility, and/or personal factors, such as their perceptions towards and experiences about a particular activity, can affect their engagement in activity, ambulation in this case, in their l iving situation. The A S C Q is, designed to assess an individual's self confidence in their ambulation. We believe that it reflects a measure of the individual and personal resources, which might be influenced by Environmental Factors and Activi ty (ambulation). We recognize the importance of personal and environmental factors and 8 health conditions as predictors or determinants of activity performance. This is why we have proposed this study to develop the new self-report questionnaire, to measure an individual's confidence (self-efficacy) of ambulatory in various l iving settings. The A S C Q reflects level of confidence (personal factor) and it takes into context of environment and should be an indicator of activity exertion, ambulation. B y developing a reliable self-report questionnaire based on self-efficacy theory, we hope to measure an individual's actual ambulatory performance skil l . The Influence of the Environment on Activity Performance More recently, in addition to the W H O ' s notion of Environmental Factors, some researchers and clinicians also began to recognize that the environment plays an important role in an individual's activity performance and participation (Fougeyrollas et al., 1999 & 2002; Shmuway-Cook et al., 2002; W H O , 2001). The importance of understanding the association between the environment and an individual's ambulatory (mobility) skil l has been emphasized for both prevention and rehabilitation of ambulation disability i n various populations, especially amongst the elderly (Cohen et al.,1987; Gray & Hendershot, 2000; Fougeyrollas et al., 1999 & 2002; Gage, 1994; Lerner-Frankiel et al., 1986; Noreau et al., 2002; Robinette et al., 1988; Shmuway-Cook et al., 2002; W H O , 2001). Several studies were conducted to assess an individual's physical requirements related to the community ambulation. One study reported that the requirements included the ability to walk 332m continuously, negotiate a 17.8cm to 20.3cm curb, climb 3 steps and a ramp without a handrail, and walk 70m/min to cross a street in the time provided by 9 an average traffic light (Lerner-Frankiel et al., 1986). Moreover, the authors suggest that subjects required community-walking distances ranging up to 600m. Another study reported individuals needed the ability to walk 73m/min as physical requirements for the community ambulation (Cohen et al. 1987). Researchers also suggest that the distance required for ambulation in an individual's community was far greater than the one used commonly by the physical therapists to indicate ambulatory independence (Lerner-Frankiel et al., 1986). These values differ depending on the individual's living environment (distances and city block designs). Creating individualized assessment tests or training tools that simulate one's environment would be expensive, considering the number of people who are admitted to hospitals or rehabilitation centers, not to mention the limited medical care funding and resources. This is one reason why it is essential to find an effective method to evaluate an individual's ambulatory skil l in his or her own living environment. A s briefly mentioned earlier, self-report approaches have become well accepted in research and have been increasingly incorporated into clinical practice. Self-reports are considered the most feasible and cost-effective method of collecting standardized functional status information from an individual (McDowel l & Newel l , 1996). In some instances, self-reported functional status measures are preferred to performance-based methods (Myers et al., 1993; Tager et al., 1998). Self-report assessment can also be the best method to capture what people think and how they are feeling. With a self-report questionnaire, the test takers can answer questions while reflecting on their own individual and unique living situation. For example, a question like "how confident are you walking from one room to another in your home?". Even though each individual has 10 different l iving arrangements, this type of question allows everyone to apply it to their own living situation. Selected Self-Report Measures of Walking Used in an Older Adult Population Literature search was performed using three electronic databases (2001-2005): M E D L I N E , E M B A S E , and C I N A H L . We used several combinations of selected key words including: older adult, aged, senior, walk, ambulation, gait, locomotion, mobility, questionnaire, survey, scale, or self-report in order to find articles that introduced or used self-report questionnaires for the assessment of older adults' ambulation. In addition, a manual search of reference lists of those articles identified by the electronic database search was also conducted. We introduce few existing questionnaires used in an older adult population in this chapter. These questionnaires include the Environmental Analysis of Mobi l i ty Questionnaire ( E A M Q ) that assesses the frequency of encounter and avoidance of 24 items (physical obstacles) in eight dimensions (such as attention dimension, physical load dimension, and distance dimension) using a five-point ordinal scale (Shmuway-Cook et al., 2003). This questionnaire was examined in an older adult population inhabiting a community dwelling and was reported to have high reliability (ICC = 0.81 - 1.00) and positive correlation to observed mobility (Shmuway-Cook et al., 2005). Alexander et al. (2000) used three of the Rosow-Breslau scale items (Rosow & Breslau, 1966) to assess the walking ability of older adults in their study. The results suggested that the three-item scale demonstrated a strong correlation with the result of a brief walk test (10-feet). The Rosow-Breslau's three items are basic ambulation questions (such as an individual's ability to walk a couple of meters) using a 'yes or no' answering 11 system; thus, they may not encompass all the necessary elements of home and community ambulation. The items of the Walking Abi l i ty Questionnaire ( W A Q ) , originally created for and used with the stroke population, also have similar items to our new questionnaire (Perry et al., 1995). The questionnaire contains 19 home and community ambulatory activity items and assesses the patient's social limitations (such as visiting friends or families or participating in activities) due to his or her walking disabilities using a five categories response format ("independent", "supervised", "assisted", "wheelchair", and "unable"). Unfortunately, there were no psychometric properties of the W A Q reported in the study. Table 1 presents an additional summary of self-report walk or mobility questionnaires. None of the aforementioned questionnaires address the assessment of an individual's confidence with ambulation taking into context the environment (Alexander et al., 2000; Rosow & Breslau, 1966; Collinsa et al., 2004; Deathe & Mil le r , 2005; Leyden et al., 2003; Mi l le r et al., 2001; Shumway-Cook et al., 2003; Viosca et al., 2005; Vorrips et al., 1991). Bandura's self-efficacy theory suggests that a person's level of confidence is a reliable predictor of their performance (Bandura, 1977, 1992, & 1997; Panjanes, 2002). Therefore, we speculated that successful assessment of an individual's confidence (self-efficacy) in environmental ambulation may provide clinicians and researchers in this field with important information regarding environmental ambulation performance. For that reason, we developed a new instrument designed to specifically focus on this area. The A S C Q may identify potential ambulatory problems specific to the patient's environment, and therefore guide rehabilitation treatment plans aimed at helping patients to acquire the necessary ambulatory skills to return to active l iving in their homes 12 and communities safely and independently. Table 1 presents a summary of the self-report waling scales. A t present there is no self-report questionnaire that focuses on the assessment of confidence in ambulation in an individual's real living situation. In order to address this shortcoming the primary purpose of this study was to develop a self-report questionnaire of ambulation confidence. 1.5 Study Objectives and Hypotheses The objectives of this study are to: 1) develop a questionnaire that records information about an individual's perception of confidence while walking in different environments; 2) assess the content validity of the questionnaire using a panel of experts; and 3) assess the reliability and the construct validity of the questionnaire. We hypothesized that the Ambulatory Self Confidence Questionnaire ( A S C Q ) w i l l have: 1) acceptable content validity (more than 50% agreement in the A S C Q content among our participants); 2) high internal consistency (Cronbach's alpha > 0.90) and two-week test-retest reliability (Cronbach's alpha > 0.90); and 3) moderate to high correlation (Spearman's rho > 0.60) with the questionnaires and performance-based tests, based on the standard outlined by Portney and Watkins (2000). 1.6 Significance of the Proposed Study North America's aging population is a major social phenomenon that is currently growing and w i l l continue to grow in the future ( H R D C , 2003). Wi th age, many 13 individuals have ambulatory-related disabilities, and this can lead to an increasing likelihood of the hospitalization of older adults for medical and functional issues. Requirements for the independent ambulation in a real l iving situation can differ depending on an individual. A s the concept of environmental ambulatory skil l is difficult to define or measure, there are no questionnaires or preferred performance-based measures to directly assess an individual's ambulatory skil l in his or her real l iving situation. A s has been rioted previously, a self-report questionnaire would be easier and less time, energy, and space consuming compared to performance-based measures. Thus, i f this new self-report questionnaire demonstrates strong reliability and validity as a measure of an individual's perceived ambulatory skil l in his or her living situation, the use of the questionnaire may assist researchers and clinicians in their efforts to measure ambulatory function. More importantly, the A S C Q may help clinicians target individuals/patients who need additional treatment to improve their confidence ultimately their participation in daily activities. 14 1.7 References Alexander, N . B . , Guire, K . E . , Thelen, D . G . , Ashton-Miller, J .A. , Schults, A . 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International Classification of Functioning, Disability and Health. Geneva: World Health Organization. 19 Table 1. Characteristics of Selected Measures of Walking Instrument Item # Conceptual Focus Scale Format Population Purpose E A M Q Shumway-Cook et al., 2003 24 items Likert scale Walking Capacity Older adults Assesses the frequency of encounter and avoidance of physical obstacle in eight dimensions (density, attention, terrain, postural transition, physical load, ambient, template, and distance dimention) F A C H S Viosca et al., 2005. 6-level Lower-extremity Classification performance observation Older adults Assesses the performance by lower Stroke extremity j oint movements Neighbourhood Walkability scale 10 items Walking Capacity General Assesses the capability to walk in a Leyden et al., 2003. Likert scale neighbourhood H P A Q Vorrips et al., 1991. 22 items (total) 3 items (walking) Metric system Physical activity & walking performance Older adults Assesses walking frequency, distance, and duration Rosow-Breslau scale Alexander et al., 2000. 3 items Walking Capacity Older adults 'yes/no' questions Assesses basic walking ability P E Q - M S Legroet al., 1998. 13 items Perceived Likert scale Capability Prosthetic Assesses the perceived mobility mobility (amputation) capability P P A - L C I Gauthier-Gagnon et al., 1998. W A Q Perry et a l , 1995. WIQ Collins et al., 2004. 11 items Likert scale 19 items Category response 14 items Likert scale Transfer & ambulation Capacity Prosthetic Assess the ability to perform selected (amputation) loco-motor activities such as transferring, or climbing stairs Walking Capability Older adults Assesses an individual's social limitations due to his or her walking disabilities Walking Capacity Young adult Assesses an individual's degree of (55< age) difficulty to walk by distance, speed, stair climbs, and more. E A M Q - Environmental Analysis of Mobi l i ty Questionnaire F A C H S - Functional Ambulation Classification of Hospital at Sagunto H P A Q - Habitual Physical Activi ty Questionnaire P E Q - M S -Prosthetic Evaluation Questionnaire Mobil i ty Subscale P P A - L C I - the Prosthetic Profile of the Amputee Locomotor Capabilities Index W A Q - Walking Abi l i ty Questionnaire WIQ - Walking Impairment Questionnaire Behaviour Personal Factors Environmental Factors (Cognitive, affective, and biological) Figure 1 .1- Theoretical Model for the Proposed Study 22 Health Condition Body Functions and Structures Activities Participations Environmental Factors 1 Personal Factors Body Functions - the physiological and psychological functions of body system Body Structures - anatomical parts of the body Activities - the execution of a task by a person Participation - an individual's involvement in a life situation Environmental Factors - factors that structure an individual's physical, social and attitudinal environment Personal Factors - an individual's life and personal background Figure 1.2 - ICF Model & Definition 23 Chapter 2: Content Validity of the Ambulatory Self-Confidence Questionnaire 2.1 Introduction Older Adults & Ambulation Problems Aging is often associated with many physical, psychological, and sociological changes that lead to health and medical conditions (Bennett, 2000; Guccione, 2000; Nair, 1999). For older adults, ambulation is recognized as one of the most important skills to maintain quality of life (Shumway-Cook et al., 2002; Lawton, 1999; Spector et al., 1987). Moreover, difficulty with ambulation is one of the most common problems seen in older adults l iving in North America (Havilk et al., 1987; H R D C , 2003). Approximately 70% to 80% of Canadian adults aged 65 years or older reported having ambulation problems related to disability (Statistics Canada, 2001). In the field of rehabilitation sciences, maintaining or regaining independent mobility, at home and in the community, is often identified as one of the primary goals for patients post-hospitalization or for older adults in rehabilitation programs (Fries et al., 1980; Katz et al., 1983; Lerner-Frankiel et al.,1986; Richardson et al., 2000). In order to meet the aforementioned goals in the rehabilitation process of older adults, it is crucial to have reliable and valid assessment tools such that clinicians and researchers can assess a patient's needs and prescribe effective and efficient treatments. The Self-Report Questionnaire Approach & Bandura's Self-Efficacy Theory The self-report questionnaire approach is often used by rehabilitation scientists to assess patients' ambulation status and is believed to be the most reasonable and cost-effective method available (McDowel l & Newell , 1996). A recent review of the literature 24 revealed that there is no self-report questionnaire that exclusively focuses on the assessment of confidence in ambulation such as the A S C Q . Developing a New Scale & Content Validity Creating a new test involves both science and art. A test developer must choose strategies and materials and make day-to-day research decisions that w i l l positively influence the quality of the promising instrument (Gregory, 1996). Assessing content validity is considered to be one of the most important steps in instrument development, because it addresses the degree to which prospective items in an instrument adequately represent the area intended to be measured. If an instrument lacks content validity, there is no point in confirming its reliability (Beck & Gable, 2001; Gable, 1986; Gregory, 1996). Researchers stress that since content validity is a prerequisite for construct and criterion-related validity, it should be given the highest priority during instrument development (Beck & Gable, 2001; Gable, 1986; Gregory, 1996). Assessing content validity helps to identify which items should be eliminated, revised, or added to the instrument before it is finalized (Beck & Gable, 2001). 2.2 Purpose The purpose of this study was to assess the content validity of a new self-report questionnaire, the Ambulatory Self-Confidence Questionnaire ( A S C Q ) , with experts including academics and clinicians; students in the field of rehabilitation science and medicine; and community-dwelling older adults. 25 2.3 Methods 2.3.1 Design Two mail surveys were sent between July and September 2004 to collect data regarding the participants' opinions about how well the A S C Q represented the construct of ambulation confidence. In addition, participants were asked about the clarity of the questions and which response format they preferred. 2.3.2 Participants The participants included academics and clinicians in the field of rehabilitation sciences and medicine, and professional or graduate-level students who: 1) were familiar with the assessment of ambulation or walking skills; and/or 2) had knowledge or personal experience about ambulation or walking skill-related measurement tools. Participants were excluded i f they were unable to comprehend English. A sample of older adult judges included individuals who: 1) were > 65 years of age; 2) could comprehend English; and 3) were capable of walking with or without a walking aid. A variety of recruitment strategies were used including postings on University bulletin boards and local community centers, and invitations to individuals who were recommended based on their expertise in the area of ambulation and mobility and who were identified from the G.F. Strong Rehabilitation Centre Research Lab Database as potential older adult participants who regularly use walking aid. A total of 51 potential participants were informed about the study by e-mail or mail. 26 2.3.3 Protocol After initial contact and agreement to participate, a survey package, which included an introductory letter, consent form, version 1 of the A S C Q (Appendix I), and a survey questionnaire about the A S C Q was mailed to the participants, along with a self-addressed stamped envelope. Demographic information, such as age, sex, profession, years of experience and specialty was collected from the practitioner/researcher participants. Age, sex, use and type of walking aid information was collected from the older adult participants. If no response was received within 10 days of the initial mailing, participants were sent the first reminder at two weeks and a second reminder (if necessary) at four weeks from the initial mailing. Approximately one month later, a revised version of the A S C Q (version 2) and a second survey were mailed to participants for final feedback. The study protocol was reviewed and approved by the University of British Columbia's Behavioral Ethic Review Board. Figure 2 presents the protocol in detail. 2.3.4 Measures The survey that accompanied version 1 of the A S C Q asked i f the item was: 1) clearly worded; 2) appropriate as a factor of ambulation confidence; 3) important to the ambulation confidence measure; and 4) able to discriminate between individuals who have ambulation disabilities and those who do not have ambulation disabilities evaluated using a 4-point Likert scale, where l=strongly disagree, 2=disagree, 3=agree, and 4=fully agree. The purpose of the A S C Q was explained to the participants, so they had the basic information upon which to make decisions about individual item appropriateness. In 27 addition, several 'yes/no' questions were included to determine whether items should be added, deleted, or modified. If participants reported that they would like to add, delete, or modify any of the A S C Q items, they were asked to identify the item and briefly comment on why they chose their answer or how they would like to modify or change the items. The original A S C Q template was created by Dr. Janice Eng and Dr. B i l l Mi l l e r at the University of British Columbia. A copy of the A S C Q version 1, version 2, and version 3 (final version) are presented in Appendix I, and Appendix II is in Appendix III, respectively. 2.3.5 Data Analysis Data analysis was performed using descriptive statistics using SPSS Windows 11.5. The number of participants responding were reported for each question. Agreement on suitability of an A S C Q item was inferred i f >50% of participants agreed or strongly agreed. 2.4 Results O f the 31 participants who were recruited for the study, all completed the first survey and 27 completed the second. The group of academic, clinician, and student, participant (8 females and 10 males) had an average of 11.3 ± 10.4 years experience in their field of specialty. The group of the community-dwelling older adults (7 females and 6 males) had an average age of 75.6 ± 7.4 years. Approximately 46 % of older adults reported to be a regular walking aid user. Tables 2.1 and 2.2 present a summary of the participant characteristics. 28 The first survey The results of the first survey questions are shown in Table 2.3. Results are grouped by question (i.e. clarity and appropriateness of the A S C Q items). For the clarity, appropriateness, and importance section, the experts commonly agreed (> 50% of experts) that the questions were clearly worded, and that they were appropriate and important to the A S C Q . Additionally, in their opinion, they believed that the A S C Q items would discriminate between individuals with/without am ambulatory problem. For the 'yes or no' item addition, deletion, and modification and selecting the best-suited response format questions, 52% of the experts agreed that there was no need to add further items to the questionnaire; 71% agreed that there was no need to delete any items from the questionnaire; and 61% agreed that there was need to modify some items in the questionnaire (Table 2.4). In addition, 90% of participants stated that the A S C Q instruction was appropriate and easy to understand. The most favored response format selected by our participants was '1-10' scale (52%) followed by '0-10' scale (26%), and '0-100%' scale (22%) (Table 2.5). Examples of the modified or replaced items include getting in and out of a car or bus; sitting down and up from your car or bus seat; and riding an escalator. Several experts suggested that getting in and out of transportation and sitting down and up from a seat should be classified as a balance and strength skill rather than as an ambulation skil l . Accordingly these questions were removed from the original version of the A S C Q . A s for riding an escalator-type items, the infrequency of the use of the escalator or the option of using a different method such using an elevator were suggested by several experts; thus, 29 this type of item was removed from the original version of the A S C Q . The revised version of the A S C Q (version 2) also included 22 items. The second survey In the second A S C Q survey, the experts were asked a set of questions similar to the first A S C Q survey, regarding the modified A S C Q items. The experts generally agreed that the 22 items (including the five additional modified items) were clear and important for the A S C Q ; in addition, the 22 items were thought to distinguish between individuals with or without walking problems. See Table 2.6 for the results in detail. Table 2.7 indicates that 74 % of the experts agreed that there was no need to add another items to the questionnaire, 52% agreed that there was no need to delete any items; and 52% agreed that there was a need to modify some items in the questionnaire. Table 2.8 presents examples of the major changes of the A S C Q items. Comparing the 1 s t and 2 n d survey results, the 2 n d survey showed approximately a 10% to 20% increase in the agreement that there was no need to add, delete, or modify the A S C Q items. 2.5 Discussion The A S C Q was created for the purpose of detecting ambulation problems among older adults. Several studies suggest that one's level of confidence is a strong indicator of their level of performance (Bandura, 1977, 1992, & 1997; Shwarzer & Renner; Panjanes, 2002). Additionally, identifying and modulating an individual's level of confidence by experiencing a necessary ski l l ; learning vicariously through others; and receiving support, training, and feedback from others and clinicians may lead to a better outcome. 30 We believe that this self-efficacy theory is directly applicable to the identification and remediation of ambulatory problems. The A S C Q is a tool that w i l l allow clinicians to assess their patients' ambulation confidence in their l iving environment. This may provide clinicians with crucial information for working with their patients. Patients who do not typically report high confidence while reflecting on performance of the assessed ambulation activities may benefit from rehabilitation consultation about their worries in order to better understand and overcome their ambulation difficulties before they return to their home and community. This study provides the foundation for the development of a questionnaire that w i l l enable clinicians and researchers to identify individuals who have issues related to their ability to walk around their home and community that may not be readily perceived using current standard clinical methods. We were pleased that most of experts who completed the content validity surveys for the A S C Q (Version 3) showed an average or above average, score of 3 (agree), on the 4-point Likert scale for the clarity, appropriateness, importance, and discrimination ability of the A S C Q items. More than 50% of the experts also agreed that there was no need to add, delete, or modify the A S C Q items. A broad cross-section of experts was selected in order to assist in developing the questionnaire. In particular, we selected community-dwelling older adults who could recount personal experiences regarding confidence while walking about their home and community with or without ambulation problems. Furthermore, this group was able to provide feedback from a user's perspective. Conversely, we sampled clinical and academic experts who are interested ambulation to determine whether the items in the 31 questionnaire adequately captured the content of interest. Overall, this sample provided important feedback to create a better version the A S C Q . The original A S C Q contained 22 items that were based on the investigator's experience, review of the literature; and other similar instruments. A total of five items among the original 22 were modified or replaced by the items suggested by our experts. Items were deleted for three major reasons: 1) the items focused on assessing an individual's functional ability other than ambulation skills; 2) experts speculated that the items would be performed infrequently by test-takers; and 3) experts suggested the possibility of an alternative method capture the intended performance. Some of the A S C Q items were novel to the field. Our experts and investigators considered the influence of environmental, social, and personal factors on an individual's ambulation in their l iving environment. Examples of those items include walk while carrying groceries, walking in the dark, walking and talking at the same time. These items include a different aspect of interaction that an individual has to deal with when they are walking at home or in the community with or without a companion. Incorporating these items make our A S C Q unique compared to other tools with similar goals. Table 2.8 provides a summary of the major changes of the A S C Q items. Three commonly used response formats for self-efficacy measures, a 1-10, 0-10, and 0-100% scale, were presented to the experts in the first survey to determine the format best suited to the A S C Q . Although the simple "yes/no" or "confidence/no-confidence" response format offers the benefits of being direct and easy to understand (Legters, 2002), it was not included as part of the A S C Q response format selections 32 because the format was criticized for its limitation to detect variability in the degree of confidence or fear as expressed by Lawrence et al. (1998) and Howland et al. (1993). The majority, more than 50% of the experts, selected a maximal score of 10 for the A S C Q . For this reason, we decided to use a maximum score of 10 for the A S C Q . Despite the fact a 1-10 response format was selected as the most popular choice by the participants, when assessing the minimum anchor score for the A S C Q we decided to use 0 as this more truly represented the construct of zero or "no" confidence. Betz and Hackett (1981 & 1998) used a combination of a "yes/no" confidence question and 1-10 scale in the construction of their Occupational Self-Efficacy Scale. For this format, i f respondents answered "yes" to the first section, they were asked to rate their level of confidence using a scale from one to ten and the researchers assumed that a response format of "No confidence" was equal to "0". They also created and tested the same confidence scale using only a 0-9 scale. 0 indicating "no confidence at a l l " and 9 indicating "complete confidence". The authors suggested that both formats were acceptable ways to conduct self-efficacy assessments. We feel that our 0-10 response format provides a good representation of the total spectrum of scores. On the other hand, it is also interesting to acknowledge that each existing confidence scale has a different response format. For example, the original Falls Efficacy Scale has a 1-10 response category; modified F E S has a 1 -4 response category; and the A B C (which was designed to improve the FES) created by Powell & Myers (1995) has a 0-100 % response format because of its wider range of item difficulty and more detailed descriptors. Further research that could be considered in this area, investigating effectiveness of a difference 33 response format, could be studies such as a pilot study using the tool with a broad range of older adults might be useful for future development. There are some limitations to this study. Firstly, our sample of experts was not randomly selected. Moreover, both older adults and other experts were selected primarily from three geographic areas (Montreal, Vancouver, and some part of Ontario). Therefore, some of them (participants from Vancouver) may not be exposed to the extremes in weather or to the suburbia environment and some items that cover the outdoor environment would be missed. Environmental factors such as the climate, design of a rural vs. urban city, or influence from the community are different depending on where an individual lives. The types of questions need to be asked to assess an individual's confidence in their ambulation in the real-living environment might have been varied i f we had experts from each province of Canada or even from different countries. A second limitation was failure to include older adults in the study who may have had a higher level of ambulation disability, particularly because the A S C Q is designed to be answered by them and to identify those who have ambulation problems in their l iving environment. None of our older adult experts reported that they used any type of walking aid. Hence, our older adults may have been "too healthy" to fully represent the diversity of North American (older) adults who have ambulation problems. Older. adults who regularly use a walking aid may possess more significant levels of ambulation disability that reduces their level of confidence in ambulation. Thus, having older adult experts who used walking aids in the study might have been beneficial in broadening the type of feedback that we drew upon when creating the questions for the A S C Q . It may have also 34 been a good idea to get a focus group together to ask what walking activities they feel less confident performing or were more important to include in the A S C Q . 2.6 Conclusion and Future Research The results of this study culminated in the development of a new tool that is designed to assess ambulation confidence. The A S C Q w i l l facilitate the assessment of walking-related issues that arise in elderly populations in North America. Evaluating the test-retest reliability, internal-consistency and validity of the A S C Q is a mandatory next step. It is also possible that during this enquiry we may identify redundant issues (using internal consistency). The results of the next study wi l l be used to create the final version of the A S C Q . 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Accessed from: http://www.phac-aspc.gc.ca/seniors-aines/pubs/factoids/2001/intro e.htm 38 Table 2.1 - Demographic of Al l Participants Characteristics Older Adults (n = 13) Professionals & Students (n = 18) Mean age 75.6 35.7 Gender % Male 41.7 55.6 Years of experience Not applicable 11.3 % Walk aid user 46.2 Not applicable 39 Table 2.2 - Occupational and Educational Background of All Clinicians, Academics, and Students Characteristics Professionals & Students (n = 18) Occupation % # Medical Doctor ( M D ) 33.3 6 Physiotherapist (PT) 33.3 6 Occupational Therapist (OT) 5.6 1 Recreational Therapist (RT) 5.6 1 Exercise Physiologist (EP) 16.7 3 Researcher 5.6 1 Type of Work % # Clinical 44.4 8 Research 16.7 3 Clinical & Research 11.1 2 Clinical & Research Student 27.8 5 Highest Education Completed or Currently Pursuing % # B-.Sc/B .A. 38.9 7 M . D . 27.8 5 M . S c . / M . A . 22.2 4 Ph.D. 11.1 2 40 Table 2.3 - The Results of Survey I: Item Clarity and Appropriateness (n = 31) The A S C Q Strongly Disagree Agree Strongly Disagree Agree Item Clarity 1 0 6 9 16 2 0 2 10 19 3 0 1 8 22 4 0 1 8 22 5 0 1 9 21 6 0 1 10 20 7 0 1 9 21 8 1 2 9 19 9 0 2 7 22 10 3 3 10 15 11 3 4 9 15 12 2 3 10 16 13 2 1 11 17 14 1 0 7 23 15 0 2 8 21 16 1 1 7 22 17 1 1 6 23 18 1 4 7 19 19 1 7 4 19 20 I 3 10 17 41 21 22 2 1 6 9 22 20 The A S C Q Appropriateness 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Strongly Disagree 0 1 0 0 0 0 0 1 0 0 1 0 0 1 1 0 1 0 Disagree Agree 0 0 1 1 2 0 0 0 2 4 4 7 6 7 7 7 8 7 7 5 6 5 9 6 10 7 5 5 5 Strongly Agree 24 24 23 23 22 23 24 23 24 21 21 21 24 19 22 25 24 23 42 19 1 4 7 19 20 2 2 9 18 21 0 4 7 20 22 0 3 7 21 43 Table 2.4 - The Results of Survey I: the ASCQ "Yes or No" Questions (n = 30) Questions Yes N o N o Response Do you wish to add any item? 15 16 0 Do you wish to delete any item? 8 22 1 Do you wish to modify any item? 19 11 1 Is the A S C Q instruction easy to understand? 27 3 1 Is the A S C Q instruction appropriate? 28 1 2 Do you wish to modify the A S C Q instruction? 14 16 1 Do you wish to modify the A S C Q response format? 5 25 1 44 Table 2.5 - The Results of Survey I: the ASCQ Response Format Preference (n Response Format n 1 - 1 0 16 0 - 1 0 8 0 - 1 0 0 % 7 45 Table 2.6 - The Results of Survey II: Item Clarity, Importance, and Disacrimination (n=27) The A S C Q Strongly Disagree Disagree Agree Strongly Agree Item Clarity 1 0 2 4 21 2 0 2 4 21 3 0 1 4 22 4 0 1 4 22 5 1 . 2 2 22 6 0 1 6 20 7 0 1 6 20 8 0 1 6 20 9 0 1 6 20 10 0 2 3 22 11 0 2 7 18 12 0 1 4 22 13 0 3 3 21 14 0 1 6 20 15 0 2 6 19 16 0 1 9 17 17 1 1 4 21 18 1 0 4 22 19 1 1 2 23 20 1 0 3 23 21 ! 0 7 19 46 22 1 0 2 24 The A S C Q Strongly Disagree Agree Strongly Disagree Agree Importance 1 0 1 6 20 2 0 1 6 20 3 0 1 5 21 4 0 1 5 21 5 3 6 8 10 6 0 3 7 17 7 0 3 7 17 8 0 2 3 22 9 0 1 5 21 10 0 2 8 17 11 1 7 8 11 12 1 1 5 20 13 2 3 4 18 14 0 2 4 21 15 2 1 4 20 16 1 1 9 16 17 2 5 2 18 18 2 0 3 22 19 2 2 2 21 20 2 2 8 15 47 21 1 2 6 18 22 1 1 7 18 The A S C Q Strongly Disagree Agree Strongly Disagree Agree Discrimination 1 0 3 5 19 2 0 4 5 18 3 0 2 8 17 4 0 3 8 16 5 2 5 8 11 6 0 2 9 16 7 0 2 10 15 8 2 1 5 19 9 1 2 3 21 10 1 5 6 15 11 1 7 8 11 12 1 1 5 20 13 2 5 8 12 14 1 1 9 16 15 1 2 7 17 16 1 4 7 15 17 3 4 6 14 18 3 0 3 21 19 3 3 1 20 48 20 2 2 8 15 21 2 3 3 19 22 2 3 8 14 49 Table 2.7 - The Results of Survey II: the ASCQ "Yes or No" Questions (n = 27) Questions Yes N o N o Response Do you wish to add any item? 5 20 2 Do you wish to delete any item? 10 14 3 Do you wish to modify any item? 14 12 1 Is the A S C Q instruction easy to understand? 22 2 3 Is the A S C Q instruction appropriate? 23 1 3 Do you wish to modify the A S C Q instruction? 8 17 2 Do you wish to modify the A S C Q response format? 7 19 1 50 Table 2.8 - A Brief Summary of the primary changes in the ASCQ Original Item Decision Primary Reasons Get in your transportation and sit down Modification -> Get in and out of a car Deletion Requirement of additional skills such as balance Get on and off a bus Deletion Requirement of additional skills such as balance Get up from your seat and get out your transportation Modification -> Walk to your seat and sit down on a moving bus Deletion Requirement of additional skills such as balance Stand up from your seat and walk to the door of a moving bus Deletion Requirement of additional skills such as balance Walk on a moving bus Deletion Infrequency Enter and leave your apartment Deletion Inter-personal issues Walk independently Modification -> Walk without a cane, walker, or holding on to someone Deletion Too easy and respondents are allowed to consider the use walking aid. Walk in a crowd Modification Similarity to other items -> walk though a crowded place Addition Common and important item 51 Walk on flat/level Ground Deletion Similarity to other items Walk and talk at the same time Addition common and important item Walk in the dark Addition common and important item -Minor modifications including changes in wording and additions of examples were also performed using experts' responses and suggestions. -> indicates deletion, addition, or modification of the A S C Q item 52 Recruitment -Posters at the university and community centres -Referrals from students and professors -51 invitation letters were sent 31 potential participants were recruited -Mail ing out the 1 s t survey 2 and 4 week later -Mai l ing out reminder letters .31 participants completed the first survey -Revision of the A S C Q -Development of the 2 n d Survey -Mail ing out the 2 n d Survey 2 and 4 week later -Mai l ing out reminder letters r 4 participants did not return the 2 n d survey 27 participants completed the 2ns Survey -Final revision of the A S C Q Figure 2 - Protocol 53 Chapter 3: Reliability and Validity of the Ambulatory Self-Confidence Questionnaire 3.1 Introduction Canadians are getting older, as the average age of the population rapidly increases inline with the longevity of the population. It is estimated that by 2051, the proportion of adults over 65 years old w i l l reach approximately 20% of the entire Canadian population (Statistics Canada, 2001; H R D C , 2003). Amongst these older adults mobility is reported to be the most common disability (Statistics Canada, 2001; H R D C 2003). 70 to 80% of Canadian adults aged 65 and over report having a mobility disability. Ambulation,defined as the ability to 'walk ' (Kreservic et al., 1997), is one of the most important aspects of mobility as a whole. Ambulation is necessary in order to maintain a healthy lifestyle, as well as a good quality of life (Lawton 1999, Shumway-Cook et al., 2002). Regaining and maintaining ambulation is one of the major goals for older adults who go though hospitalization and rehabilitation (Lerner-Frankiel et al., 1986; Hirschberg, 1976). A s a result, effective and efficient assessment tools designed to evaluate ambulation are critical, so that clinicians can provide the best treatment for their patients. The most popular method to assess an individual's ambulation is through the use of a performance-based test, such as a walk, gait, or balance test. These tests, however, often require a large testing area, and adequate energy levels, as well as demanding a relatively large amount of patient and clinician time. In addition, these tests are usually carried out in a safe and controlled environment that seldom reflects an individual's actual l iving circumstances. 54 Self-report questionnaires are also a popular method for functional assessments and they have the advantage of being able to capture an individual's perception of their ability. Moreover, such questionnaires are considered to be time and cost effective, as well as a valid and reliable method of data collection (Guccione, 2000). Perceived self-efficacy, defined as personal action control or agency (Schwarzer & Renner, 2000), is one of the most commonly used theories for assessing and enhancing an individual's behavior or performance. Studies have shown that an individual's belief in their ability is a powerful predictor of whether they can perform a behavior such as walking, regardless of whether they have the ability or not. For example, a study conducted by Taylor et al. (1985) demonstrated that post coronary patients' cardiovascular recovery was improved by patients' belief in their physical performance and cardiac function. Holman and Lorig (1992) also found that by increasing rheumatoid arthritis patients' perceived self-efficacy, their patients were more motivated to participate in regular physical activities. Likewise, an individual's perception or cognitive appraisal is believed to influence their decision to engage in a particular behavior or activity, and how well they perform the activity under given conditions (Bandura, 1977, 1982, & 1997; Bandura & Adams, 1977). Thus, perceived self-efficacy is considered to be an important factor in determining actual performance (Bandura, 1997). Some older adults avoid venturing out into the community, and limit the distance they walk based on their belief they are not capable of anything better (Shmuway-Cook et al., 2004; 2005) The A S C Q is a 22 item self-report questionnaire designed to assess an individual's ambulation confidence in different l iving settings. The results of the previous study (chapter 2) suggest that the A S C Q has excellent support for its content validity, assessed 55 by 31 experts. A s the A S C Q may be able to assess an individual's perception of their ambulation ability, i f the A S C Q is found to be reliable and valid, it may be used by clinicians and patients to identify psychological aspects of ambulation that require attention for patients to walk safely and independently in their community and perform the normal activities of daily living. To date there is no method of assessing an individual's confidence to ambulate. To address this problem, the Ambulation Self Confidence Questionnaire ( A S C Q ) was developed. 3.2 Purpose The purpose of the study was to assess the psychometric properties of the A S C Q . The specific objectives were to assess the: 1) internal consistency; 2) two-week test-retest reliability; and 3) construct validity of the A S C Q among community-dwelling older adults. We hypothesized that the A S C Q w i l l have: 1) high internal consistency (Crobach's alpha = 0.90); 2) high two-week test-retest reliability (ICC = 0.90); and 3) moderate (Spearman's rho = 0.40) to high (rho = 0.80) correlation with other self-report questionnaires and performance-based tests. 3.3 Methods 3.3.1 Design The design was a descriptive methodological study using follow up data for reliability and cross-sectional data for validity. 56 3.3.2 Participants A total of 101 participants (see Appendix IV for the sample size rationale) were recruited between October 2004 and February 2005. Specifically a convenience sample was drawn from the following eight locations in Vancouver: 1) the West End Community Centre (Be-Well Program); 2) the Lion 's Den Adults Day Centre; 3) the Chown Adults Day Centre; 4) the Arbutus, Shaughnessy, Kerrisdale Friendship Society Adult Day Centre; 5) the Geriatric Out-Patient Clinic at the St. Paul's Hospital; 6) the Geriatric Out Patient Cl inic at the Vancouver General Hospital's Monrone clinic; 7) Kerrisdale Community Center (Osteoporosis Workshop) and 8) a specialized older adult private practice. Participants who were referred from senior day centres and clinics to the study (by their centre coordinators, therapists, and doctors) had physical and/or psychological health conditions diagnosed by their doctors and/or therapists. Thus, the aforementioned group of participants (sites 2, 3, 4, 5, 6, and 8) who were referred by doctors, therapists, nurses, and adult day centre coordinators was expected to be more frail than the group of participants who were referred by the community senior program coordinators (sites 1 and 7). In order to participate in the study, participants had to: 1) be > 65years of age; 2) be able to speak and read English; 3) have no cognitive impairment (Folstein's M i n i Mental State Exam ( M M S E ) score > 24); and 4) be capable of walking a minimal distance (10 meters) with or without a walking aid. The M M S E was reported to be reliable and valid tool to detect cognitive impairment in elderly populations (Tombough & Mclntyre, 1992; Folstein et al., 1975). The participants were excluded i f they: 1) were living in a long term care facility; and/or 2) reported that they had suffered a major illness 57 or accident that required serious medical attention and/or hospitalization between baseline and follow up. 3.3.3 Protocol The participants who fulfilled the inclusion criteria were referred to the investigator by their therapists, doctors, or day centre coordinators. A t the time of recruitment, the study protocol was explained prior to obtaining informed consent. A l l the participants who consented to participate in the study were asked to complete several questionnaires and performance-based measures. The order of the questionnaires and performance-based tests was randomized to control for order effects. A two-minute rest was provided between performance-based tests. A l l the questionnaires and performance-based measures were explained and/or demonstrated to the participants prior to data collection. A l l measurements were administered according to the assigned standardized protocols and Appendix V and V I presents our performance-based tests protocol and Appendix VII , VIII, and I X presents copies of questionnaires. During the first data collection session, socio-demographic information including age, sex, number of medications, comorbidities, and falls (over the past 12 months), highest level of education completed, marital status, use and type of walking aid and contact information was collected, in addition to all the walk tests and questionnaires. The baseline data collection was performed at the community centre, day centre, or day hospital and clinic of the participant's choice. When the participants were unable to come to one the aforementioned centers for their first session, a home-visit data-collection was offered to them. A t follow up, only data from the A S C Q was collected. This information 58 was captured by having the participant complete the A S C Q at their home and mail it back to the investigator. A l l participants received a reminder phone call 13-15 days from the first session in order to remind them to complete and mail the A S C Q . When participants completed the A S C Q at their home they were also asked i f they had major illness, injury, or accident that required serious medical attentions over the past 14 days. If participants had serious medical conditions or accidents, they were also asked how many days over the past 14 days they needed to stay in bed or to avoid participating regular activities that they were involved. The study protocol was reviewed and approved by the University of British Columbia's Behavioral Ethic Review Board. Figure 3 presents the protocol in detail. 3.3.4 Measures The 6-Minute Walk Test (6MWT) The 6 M W T is a measure of the individual's physiological or cardiovascular function and reflects the functional exercise level for daily physical activities ( A T S , 2002; Torrey, 2002) and mobility related function among older adults (Harada et al., 1999). The test has been reported to have high reliability with coefficients of I C C = 0.88-0.95 (Rikl i & Jones, 1998; Steffen et al., 2002) and moderate correlation (r=0.71) with older adults' overall physical performance assessed by treadmill performance (Rik l i & Jones, 1998). The 6 M W T was also found to have high correlation (r=0.97) with older adults' sum-maximal exercise VO2 (kervio et al., 2002) and moderate correlation (r=-0.73 and 0.61) with mobility assessed using the gait speed test (Harada et al., 1999) and with functional ability assessed using the physical function scale (Bean et al., 2002) respectively. 59 Furthermore, Lord et al. (2002) demonstrated that there were statistically significant correlation, ranged from weak to moderate, with older adults' physical, psychological, and health status. To complete this test participants walked back and forth around a cone on a 10 meter path for six minutes at their own comfortable pace. The goal of the test was for the participant to walk as far as possible for six minutes. The total distance that participants walked in meters to the nearest meter was recorded. A n y time during the test, participants are allowed to take a rest or decide to stop the walk test. The Timed "Up & Go" Test (TUG) The T U G assesses basic mobility (Podsiadlo & Richardson, 1991). The participant was asked to stand from a seated position, walk three meters, turn around a cone, return to their seat and sit down. A standard chair with arms was used for this test. A n investigator demonstrated the test for the participants before their trial. The time was recorded to the nearest 10 of second. The T U G has excellent inter-rater (r=0.99) and test-retest reliability (ICC=0.98) among older adults (Podsiadlo & Richardson, 1991). In addition, the T U G has good construct validity through correlation with gait speed (r = 0.75), Functional Stair Test (r = 0.59), and performance-based balance measure (Berg Balance Scale, r = -0.76) (Steffen et al., 2002) in an older adult population. 60 The Activity-specific Balance Confidence Scale (ABC) The A B C is a 16-item scale designed to measure balance confidence in performing daily activities. It is scored from 0% (no confidence) to 100% (complete confidence) and a total score is derived by calculating a mean score. The A B C has high two-week test-retest reliability (ICC = 0.92) and high internal consistency (Cronbach's alpha = 0.96) (Powell & Myers, 1995). Support for construct validity has been demonstrated through correlations with Physical Self-Efficacy Scale (r = 0.49) and high correlation with the F E S (r = 0.84) (Powell & Myers, 1995) in an older adult population. Instrumental Activities of Daily Living Scale (IADL) The I A D L scale is an eight-item scale designed to assess an individual's ability to perform instrumental activities of daily l iving (such as banking, gardening, or preparing meals). Its total score ranges from 0 (not independent) to 8 (independent). The I A D L was shown to be valid and reliable tool for use in community-dwelling older adult population with high reproducibility (Latwon & Brody, 1969) and statistically significant correlation with the cognitive impairment classification (Cromwell et al., 2002). The I A D L was also reported to have high correlation (r=0.72) with the Functional Assessment Questionnaire (Pferre et al., 1982). The Ambulatory Self-Confidence Questionnaire (ASCQ) The A S C Q contains 22 items. Each item is scored from 0 (not at all confident) to 10 (extremely confident) and a total score is derived by calculating a mean score. The participants are asked to report how confident they are in their ability to walk in different 61 situations at home such as "walk from one room to another in your home" and in the community such as "crossing a street with a timed cross walk (walk signal)". The previous chapter (study) assessed content validity of the A S C Q and the results suggested that the A S C Q was found to have good content validity. We believe that individuals' level of confidence in their ambulation could be an excellent indicator of their ambulation performance. Accordingly, the A S C Q was created based on the self-efficacy theory (Bandura, 1977 & 1996) for the purpose of assessing individuals' confidence in their ambulation at their home and community environment. The A S C Q items were carefully selected by conducting literature reviews and a study assessing the content validity of the A S C Q with the experts (including academics and clinicians in the field of rehabilitation sciences or medicine and community dwelling older adults), so the information collected using the A S C Q can capture individuals' level of confidence in ambulation in their real l iving environment that might be influenced by personal and environmental factors. Appendix III presents a sample of the A S C Q . 3.3.5 Data Analysis Descriptive data is presented as means, standard deviations and proportions. Two-week test-retest reliability and the item by item test-retest reliability were evaluated using intra-class correlation coefficients (ICC1, 1) which were calculated using one-way ANOVA. The standard error of measurement (SEM) and F-value were also reported. The S E M is the standard deviation of the measurement error which reflects the range of score that can be expected on retesting. The S E M also provides the minimal amount of change that would be required to indicate a satisfactory different score when testing over two 62 different periods of time. The F-value tells i f there was a satisfactory different mean value between time-1 and time-2. Internal consistency was calculated using Cronbach's Alpha. Spearman's Product Moment Correlation Coefficients were used to calculate correlations between each of the performance-based measures and the A S C Q . We hypothesized that the A S C Q would have: 1) high internal consistency (alpha = 0.90); 2) high test-retest reliability (ICC=0.80-0.90); and 3) moderate to high construct validity with A B C (rho=0.70-0.80), I A D L (rho=0.40), T U G (rho=-0.60 to -0.80) and 6 M W T (rho=0.60 to 0.80). P O . 0 5 was considered statistically significant for this study. A l l data entry and analysis was performed using SPSS Windows 11.5. 3.4 Results During the first session, 91 participants (validity sample) completed the A S C Q . Two weeks later, 67 participants (reliability sample) completed the follow-up A S C Q at their home. The average age of the 91 participants (validity sample) was 77.6 ± 7.5 years, of whom 72.5% were female and 30.8% used walking aid regularly. There were no statistically significant differences between the reliability and validity samples with regard to age, gender, number of medications, comorbidities, and falls (over the past 12 months), highest level of education completed, and use of walking aids. Participants who did not complete the A S C Q on the two different occasions (n=24) were slightly older and scored an M M S E slightly lower than those who (n=67) completed the A S C Q twice; however, the differences were not statistically significant; except for two variables: 1) use of walking aid; and 2) marital status. There were an 63 additional 10% of participants using walking aids, and less than 10% were married amongst those who did not complete the follow-up A S C Q . Among 24 participants who did not complete the follow up A S C Q : two reported to have medical treatments and/or hospitalizations during the two weeks test-retest period; nine did not complete the A S C Q ; and 13 did not return the A S C Q . Those two who reported to have a major medical or health condition had: 1) nine days of bed-rest with morphine treatments due to a fall and pain caused by the incident six days after the initial data-collection; and 2) four to five days bed-rest due to the arthritis condition and pain. The average A S C Q score at time 1 for the validity sample was 8.52 ± 1.74 (S.D.). The average score of the A B C was 83.7 ± 18.9% (S.D.), the I A D L was 7.59 ± 0.99 (S.D.), the T U G was 11,9 ± 7.7s (S.D.), and the 6 M W T was 310.3 ± 112.9m (S.D.). A total of 10 participants were excluded from the study for the following two reasons: 1) Seven participants scored M M S E < 24 (indicating some level of cognitive impairments); and 2) three participants did not complete the A S C Q at the initial data collection. Table 3.1 and 3.2 presents a summary of the participant characteristics and measures. Internal Consistency of the ASCQ The resulting Cronbach's alpha was 0.95. Scaling using stepwise deletion of each item did not change the overall alpha with the exclusion of any single item. See table 3.3 for the complete results. Test retest Reliability of the ASCQ 64 Among 91 participants who completed their initial session, a total of 24 participants did not complete the follow-up session (two participants for a medical reason, nine participants for the A S C Q incompletion; and 13 for the withdrawal). 67 participants (73.6% of total) with a mean age of 77.3 ± 7.9 years completed the A S C Q on two occasions. O f these, 28.4% of those were male, 31.3%. were married, and 71.6% did not use a walking aid. For this reliability sample (n=67), the mean A S C Q score was 8.52 ± 1.59 at time 1 and 8.46 ± 1.61 at time 2. The I C C for the mean A S C Q score was ICC= 0.92 (95% confidence interval (CI) 0.87, 0.95), F=12.95, p< 0.001 with the SEM=0.49. The item by item two-week test retest reliability ranged from 0.56 (95% CI 0.28, 0.73) for item u (walk a short distance without stopping) to 0.94 (95% CI 0.90, 0.96) for items f (walk down a flight of stairs) and q (use an escalator). There were two participants whose score noticeably changed over the two-week period between the initial and follow-up date. See Appendix 3 for the complete results. Construct Validity of the ASCQ A total sample (91 participants) completed the A S C Q and the I A D L . O f those 88 completed the A B C , 86 completed the T U G , and 77 completed the 6 M W T . Our sample size was slightly different for the tests; however, there were no significant differences in socio-demographics and other measures between those who gave complete versus partial information. The A S C Q was highly correlated with the A B C (r = .87), and moderately negative correlated T U G (rho = -.46) and the 6 M W T (rho = .36), and did not correlate highly with the I A D L (rho=.27) (Table 3.4). Our construct validity results matched the 65 direction of the relationships that we expected. Although the magnitudes of the relationship between the A S C Q and the walk tests were slightly lower than expected. Scatter plots of these relationships ( A S C Q vs. A B C , I A D L , T U G , and 6 M W T ) can be found in Figure 3.2. 3.5 Discussion The importance of understanding the relationship between personal and environmental factors that influence ambulation disability for older adults is becoming increasingly recognized (McDonnough et al., 1995; Patla & Shumway-Cook, 1999; Shumway-Cook et al., 2002 & 2003). A better understanding of this relationship and successful implementation of this acquired information into the rehabilitation sciences may help older adults retain their independence and satisfaction with their lives. The barriers leading to ambulation disability include issues related to environmental, physical and psychological factors. While a considerable amount of research has investigated issues concerning physical factors such as strength and balance, less is known about the psychological parameters. While evidence regarding psychological factors is currently limited, we do know that confidence is important as studies have demonstrated. For example, efficacy beliefs predicted just moderate performance; whereas with C O P D patients who received a cognitive behavior therapy, they gained confidence in their own exercise capabilities (Kaplan et al., 1984). The A B C scale study also suggested that assessing an individual's balance confidence was a moderate reflection of their true balance-performance (Pal, 2004). Rehabilitation scientists and practitioners know very little about how confidence with ambulation affects 66 an older adults' life, primarily because no one has been able to measure this construct. The A S C Q is a new tool for this exact purpose. This study assessed the reliability and validity of this new self-confidence measurement tool, designed to assess an individual's confidence of their ambulation skill in their home and community environment. Internal-Consistency The anticipated A S C Q items' high internal consistency (alpha = 0.95) may indicate a high item redundancy (Boyle, 1991). Andersen (2000) suggested that alpha 0.80 and above indicates the excellent internal consistency and she did not suggest a cut off point for the item redundancy of the scale. Streiner and Norman (2003) also stated that a minimum value of 0.80 is expected to support internal consistency of the scale. The number of items can increase the alpha and therefore there may be room to drop some of the A S C Q items. However, our analysis supports that there is no difference in alpha i f any single A S C Q item is deleted from the A S C Q . Additionally, the results of our previous study, which assessed the content validity of the A S C questionnaire with 25 experts, support that all the A S C Q items are thought to provide useful information. High internal consistency may be explained by the item redundancy demonstrated by similarities between some of the items such as 'walk up' & 'walk down' or the number of items. It is possible that we have item similarity statistically; however, clinically there can be important differences, such as the use of eccentric versus concentric contractions -going up and down stairs and ramps. 67 Test-Retest Reliability It is recommended that I C C should be above 0.75 (Andersen, 2000) to support the precision of the questionnaire. The A S C Q total score showed a high I C C value, supporting the excellent test-retest reliability. When the A S C Q individual items test retest reliability was assessed, one item among the 22 showed moderate individual I C C (ICC = 0.55). Looking at the particular item (the A S C Q item u, "walk a short distance without stopping"), of 67 test-retest reliability participants (who completed both initial and follow-up A S C Q ) , there were two participants whose score dramatically changed over the two-week period between the initial and follow-up date, particularly for the item u. However, there were no significant incidence such as a serious medical condition, accident, or hospitalization reported during this period of time by these participants. The unreported medical incidence or accident, presence of other individuals such as family members or friends or absence of the tester while completing the A S C Q , and environmental differences between data collection centres and home were considered to be possible reasons for the finding. Construct Validity The results of the correlation analyses suggest there is support evidence to the validity of the A S C Q . It was interesting to discover that the T U G test demonstrated a higher correlation (Spearman's rho= -0.46) than the 6 M W T (rho=0.36). We speculated that the walking distance (that an individual is able to walk for 6-minutes) would be a better predictor of an individual's ambulation confidence than the walking speed. The results of the A S C Q may be an indicator of not only the distance that individuals can 68 walk, but also their comprehensive ambulation skil l , including the walking speed, balance, and strength. We expected that the correlation between the A S C Q and A B C would be high; however, the result was higher what we had anticipated. It appears that there is a shared variance of 70% between the A S C Q and A B C . These results might not be that surprising i f we consider that the balance confidence would be an important component of ambulation confidence; for instance, when thinking about confidence to "walk a short distance without stopping: for example from your home to a car" or "walk a long distance without stopping: for example from your home to a bus stop" (the A S C Q items u & v, respectively) an individual may contemplate whether they have the energy, strength and balance to complete the task. The correlation result with the I A D L (r = 0.27) was lower than the other selected measures in this study. We included the I A D L measure, in part, to provide us with an idea of the activity limitation of the sample. However, the high mean score reported by the sample suggests that most had few limitations, despite our attempts to select a cross-section of individuals with functional ability. Maybe a different method should be used or maybe the construct of general disability and ambulation confidence simply are not closely related. In today's society, an individual does not have to be ambulatory to pay the bills or make a phone call. Limitations of the Study In Canada, it is reported that 60% of older adults aged 74-84 years and 70% of older adults over the age of 84 are female. 56% of the senior population aged 74 years and over is married and approximately 60% never completed high school. Furthermore, 69 76% of older adults take medication, and 83% still l iving at home reported at least one chronic health condition (Health Canada, Government of Canada 2001 & 2002). Our sample reflected the population of older Canadians based on sex, considering the average number of chronic conditions and their dependency on medication. However, the majority of our participants were better educated and fewer were married. It is difficult to determine whether this constitutes a bias in the sampling or not. It was relatively difficult to recruit for the study as we were hoping to target a range of community-dwelling individuals, who would not only reflect the older adult population, but also represent those who would and would not potentially have difficulties with confidence in their ambulation. Our study tried to target senior day centres and geriatric day clinics to capture more individuals who would have reduced ambulatory confidence, and therefore we did not use a random sample. Further studies might consider random sampling techniques. Another possible limitation of the study is that at the baseline we collected information in person, while at follow up, the A S C Q was completed without the presence of an investigator. Although investigators did not interfere with the completion of the A S C Q during time one, there was no way to control the influence of the participant's friends or family at time two. Implications The A S C Q can be a tool for clinical and research use that assesses a novel construct: ambulatory self-efficacy or confidence. This is important because of the multi-facetted reasons for ambulation disability. Therefore future studies might assess how important this construct is, and i f it influences participation in the community and in social 70 activities. If it is determined to be as important as we expect, treatments or programs can be examined to evaluate our ability to improve and maintain ambulation functions. The A S C Q w i l l also enable us to describe and examine ambulation confidence, as well as the relationship with other factors that influence ambulation performance, such as balance and lower limb strength. 3.6 Conclusion and Future Research Clinicians and researchers in rehabilitation need to develop, evaluate, and use effective and efficient assessment tools in order to provide the best available treatments for older adult patients. Measuring ambulatory confidence is important to help patients regain and maintain necessary skills to safely return to their community. The A S C Q was found to be a reliable tool and support for validity was observed for this sample of community-dwelling older adults. Future research, assessing discriminate and predictive validity and responsiveness, as well as its application to disease specific populations, is highly recommended to strengthen our knowledge of the psychometric characteristics of the A S C Q . 3.7 Acknowledgements The authors thank all the participants, the West End Community Centre's Be-Wel l Program (Ms. Lois Blair and M s . Bonnie McKinnon) , the Lion 's Den Adults Day Centre (Ms. Carolyn Innes), the Chown Adults Day Centre (Ms. Nancy Jackson), the Arbutus, Shaughnessy, Kerrisdale Friendship Society Adult Day Centre (Ms. Christine Stardom and M s . Tanis Watson), the Geriatric Out-Patient Cl inic at the St. Paul's Hospital (Ms. Julie Cheng, M s . Karen Gilbert and Dr. Wendy Cook), the Geriatric Out 71 Patient Cl inic at the Vancouver General Hospital's Monrone Cl inic (Dr. Roger Wong), the Kerrisdale Community Center's Osteoporosis Workshop (Ms Annie Hess) and a specialized older adult private practice (Dr. John Sloan) who all made this project possible. 72 3.8 References American Thoracic Society (2002). A T S statement: Guidelines for the Six-Minute Walk Test. American Journal of Respiratory and Critical Care Medicine, 166, 111-117. Andersen, E . M . (2000). Criteria for assessing the tools of disability outcomes research. Archives of Physical Medicine and Rehabilitation, 81(S2): S15-S20. Bandura, A . (1977). Self-Efficacy: Toward a unifying theory of behavior change. Psychological Review, 84(2), 191-215. Bandura, A . (1982). Self-efficacy mechanism in human agency. American Psychologist, 37(2), 122-147. Bandura, A . (1997). Self-efficacy: the exercise of control. N e w York: Freeman. Bandura, A . , & Adams, N . E . (1977). 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Journal of the American Academy of Family Practices, September: 904-906. 76 Table 3.1 - Sociodemographics of All Participants Characteristics Validity Sample fn=91) Reliability Sample (n=67) Mean age (SD) 77.6 (7.5) 77.3 (7.9) % M a l e 27.5 28.4 % Faller (the past 12months) 27.5 26.9 Median # Fall/s 0 0 Median # Medications 1 1 Median # Cormobidities 3 3 % Use of Walking Aid None 69.2 71.6 Cane 13.2 16.4 Walker 11.0 6.0 Cane & Walker 6.6 6.0 % Highest Education Completed < High school 17.6 19.4 High school 34.1 32.8 College 8.8 7.5 > University 31.9 35.9 N o Response 7.7 4.5 % Marital Status Single 26.4 25.4 Married 28.6 31.3 Widowed 45.1 43.3 77 % Recruitment Location Community Centre 49.5 56.7 Day Centre/Clinic 50.5 43.3 78 Table 3.2 - Results of the Self-Report Questionnaires and Performance-Based Tests Measurement N Mean SD M i n -Max. Score A S C Q 1 91 8.52 1.74 2 . 0 0 - 10.00 A S C Q 2 67 8.69 1.61 3.45- -10.00 A B C (%) 88 83.7 18.9 13.13 - 100 I A D L 91 7.59 1.00 4 - 8 T U G (seconds) 86 11.9 7.7 5.53- -51.38 6 M W T (meters) 77 310.3 112.9 43.0- -579.0 79 Table 3.3 - Internal Consistency (N = 91) and Test Retest Reliability (N=67) of ASCQ A S C Q Alpha i f the item I C C 95%CI Item# was deleted 7 0.95 6~93 0.86-0.95 b 0.95 0.91 0.88-0.95 c 0.95 0.92 0.65-0.87 d 0.95 0.78 0.58-0.84 e 0.95 0.74 0.89-0.96 f 0.95 0.93 0.90-0.96 g 0.95 0.94 0.73-0.90 h 0.95 0.83 0.78-0.92 i 0.95 0.87 0.65-0.87 j 0.95 0.78 0.86-0.95 k 0.95 0.91 0.79-0.92 1 0.95 0.87 0.60-0.85 m 0.95 0.75 0.60-0.85 n 0.95 0.75 0.77-0.91 o 0.95 0.86 0.79-0.92 p 0.95 0.87 0.69-0.88 q 0.95 0.81 0.89-0.96 r 0.95 0.94 0.75-0.91 s 0.95 0.83 0.72-0.90 t 0.95 0.71 0.54-0.82 80 u 0.95 0.56 0.28-0.73 v 0.95 0.92 0.88-0.95 A S C Q Total 0.95 0.92 0.87-0.95 81 Table 3.4 - Correlation of the ASCQ with Other Study Measures A S C Q A B C I A D L T U G 6 M W T A S C Q 1 .27* -.46** .36** A B C 1 .36** . 48** .35** I A D L 1 -.42** .40** T U G 1 -.82** 6 M W T 1 * P<0.05 and **P<0.001, significant at 0.05 level (2-tailed) The number of the participants are different depending on the test. A S C Q - Ambulatory Self Confidence questionnaire A B C - Activities specific Balance Confidence scale I A D L - Instrumental Activities of Daily L iv ing scale T U G - Timed "Up and G o " test 6 M W T - 6 Minutes Walk test 82 Recruitment -Pamphlets and posters at the recruitment locations -Referral from doctors, therapists, and centre coordinators -Referral from potential participants 101 participants were recruited -Consent and screening ( M M S E ) -Socio-demographics 7 participated were excluded - M M S E < 24 94 participated in the study -Initial data collection 91 participants completed the A S C Q & other measures including the A B C , I A D L , T U G , and the 6 M W T I 3 participated were excluded - A S C Q incompletion Reminder Phone Cal l 13-15 days after their initial data collection date 24 participated were excluded - 9 A S C Q missing data 13 withdrew 2 were too sick 67 participants completed the second A S C Q for the test-retest reliability study gure 3.1 - Protocol 83 ASCQ vs IADL ASCQ vs ABC o m < ASCQ ASCQ vs 6MWT ASCQ vs TUG P. a & ,"v ASCQ 1 — 1 30.00^ O 1-ASCQ gure 3.2 - Scatter Plots of the Relationships between the A S C Q and Other Measures 84 Chapter 4: General Discussion and Conclusion 4.1 Overview The objectives of this study were to assess the reliability, content and construct validity of the Ambulatory Self-Confidence Questionnaire ( A S C Q ) The results of this study provide support for the reliability and validity of the A S C Q . 4.2 General Findings Older Adult Population and Ambulation Ambulation is a basic yet important skill for older adults to maintain healthy lifestyle and quality of life (Lawton, 1999, Shumway-Cook et al., 2002). Furthermore, ambulation problems are reported to be the most common disability among North American older adults (Statistics Canada, 2001) yet the demand to maintain independent ambulation varies for every older adult has a different requirement to ensure maintenance for his/her independent ambulation. Helping older adult patients, during their hospitalization or rehabilitation process, regain necessary mobility skills, such as ambulation, to ensure their safe return to home and community is the primary goal for clinicians and researchers in the field of rehabilitation science. To meet this goal of providing effective and sufficient rehabilitation programs, it is important for rehabilitation science researchers and practitioners to create and use reliable and valid assessment tools. Unfortunately, defining and measuring an individual's l iving environment and the related ambulation demands is difficult. In addition, Lerner-Frankel et al. (1987) suggest that there is a gap between the tests used to assess hospitalized older adult patients' ambulation and actual ambulation requirements in their home and community. Application of Self-Efficacy Theory Bandura's self-efficacy theory (1977) suggests that an individual's perception or cognitive appraisal (such as confidence) is a strong indicator of their activity performance. For example, the results of a study conducted by Hatch et al. (2003) show that an individual's confidence in their activity specific balance skil l is a strong indicator 85 under the hypothesis that assessing an individual's confidence with their ambulation wi l l be a strong indicator of their ambulation performance. A review of the literature indicates that there is no self-report questionnaire that assesses an individual's confidence with their ambulation confidence taking into consideration the environment. Thus, the A S C Q is a novel questionnaire that should provide unique information about the potential problems an individual may experience with their ambulation. The Content Validity of the ASCQ The first and one of the most important steps of creating a new scale is testing its content (Gable, 1986, Beck & Gable, 2001). Chapter 2 introduced results of our study assessing the content validity of the A S C Q . The A S C Q template was created by professors at University of British Columbia based on a review of the literature and their knowledge and experience related to the area of mobility ability. In order to expand and refine this initial work we conducted two surveys with 31 experts (academics, clinicians, and community-dwelling older adults) across Canada to identify additional and assess the appropriateness of the items for the A S C Q . We asked the panel of experts to evaluate i f each existing A S C Q item was appropriate and important for the A S C Q , whether the items were clearly described, and whether the item would discriminate between people with and without ambulation disabilities using a 4-point Likert Scale. In addition, the panel members were asked whether items should be deleted, modified or whether additional should be included. Rationalization for suggested changes was requested as well . After completing the two surveys and two revisions over 60% of the panel members agreed the final revised A S C Q content was sufficient with regards to the appropriateness, clarity, importance of the items. Moreover they agreed that the items would discriminate between people with and without ambulation problems. The Reliability and Construct Validity of the ASCQ Assessing the reliability and validity is the next recommended step for creating a new scale (Gable, 1986, Beck & Gable, 2001). In Chapter 3 we present the results of a study that examined the psychometric properties (internal consistency, two-week test retest reliability; and construct validity) of the A S C Q among 91 community dwelling 86 older adults. The results suggest that the A S C Q has excellent internal consistency (Cronbach's alpha - 0 . 9 5 ) and two-week test retest reliability (ICC = 0.92). One might argue that our alpha is too high, thus, it may indicate item redundancy (Streiner & Norman, 2003) however, the results of the stepwise item deletion analysis revealed that deleting any item from the A S C Q did not influence its internal consistency; therefore all of the 22 items were retained in the current version of the A S C Q . Assessment of the construct validity revealed that the A S C Q was well correlated with the A B C (rho = 0.87), moderately correlated with the T U G (rho = -0.46) and the 6 M W T (rho = 0.36). A weak correlation with the I A D L (rho = 0.27) was observed (Portney & Watkins, 2000). The strong correlation between the A S C Q and the A B C may be considered too high (Fisher, 1992). This may be explained by the similarity of the items and the constructs overall. Moreover, it seems likely that the participants were unable to differentiate between the questionnaire items. Alternatively, approximately 25% of the variation between the constructs remained unexplained. Therefore the correlation was less than perfect and it seems likely that each of the questionnaires taps different information. 4.3 Limitations There are several factors that influence the content validity, reliability, and construct validity of the A S C Q . These factors include the participants, the tester, and the environment. We did our best to standardize the protocol to minimize measurement error, however it is impossible to eliminate error related to these factors entirely. Study Sample One of our study limitations was related to sampling. Our sample was recruited from particular a variety of centers and clinics designed to ensure a mixture of two older adult populations; healthy, functionally independent older adults, recruited from community centers in Vancouver, B . C . , and frail older adults who were recruited from out-patient day centers and geriatric clinics. Thus, the study is not necessarily representative of the general older adult population. 87 Older Adults' Cognition: Self-Confidence and Insight Cognitive impairment is one of the important issues to consider when a study is conducted among older adults. This is especially critical for this study given that the A S C Q relies on self-report data. Although we used the M i n i Mental State Exam (Folstein et al., 1975) to screen for the presence of cognitive impairment in the study participants' cognitive impairment, one might argue that insight, might interfere with the study results. Insight, defined as older adults' realization of a problem (Trottier, 2003), may interfere with their perceived confidence (Clark, 2003). It is because older adults who have cognitive impairments may have a problems understanding or judging their situation, related problems, and the potential solution(s) to the problem(s), or their ability to overcome the issue (Clark, 2003). However, according to Bandura's self-efficacy theory (1977; 1994), an individual's self-belief or confidence, whether accurate or not, is a strong indicator of whether an individual w i l l engage in an activity regardless of their insight. Therefore, insight should not interfere with the judgment of confidence. Measurement and Study Environment Another limitation of our study relates to data collection. The initial testing, occurred in a variety of different locations. Each testing location was unique, for example, in some of the centres we were provided with private space while in other centres we used a common space to collect data under the observation of everyone in the centre. In addition, our follow-up testing was conducted at each participant's home since we used a take-home mail-back questionnaire to collect the test-retest reliability data. It seems plausible that the different testing environments may have influenced the participants' reporting of their ambulation confidence. For instance, the presence of family or friends may have altered responses to the individual A S C Q items, as subjects could have asked others for their impression. We tried to control for this problem by instructing our participants to complete the questionnaires by themselves, however absolute control exceeded our grasp. Our study exceeded the minimum sample size requirements, (67 for reliability and 91 for validity); however, the sample size is relatively small. For example, Cronbach suggests that reliability requires samples of 200 or more (Cronbach, 1951). In addition, 88 our entire sample was from the lower mainland. A lack of a homogeneous sample and small sample may be a problem, because it causes heterogeneity inflates the I C C values. 4.4 Study Implications We believe that given the unique construct measured by the A S C Q that it w i l l be an invaluable tool for clinicians and researchers alike. Future research with a larger sample and a sample with ambulation disabilities such as individuals who regularly use walking aid w i l l be useful to strengthen and improve the quality of the A S C Q . The ultimate goal of the A S C Q is to be able to identify ambulation problems of people living in their environment, to discriminate between older adults with and without ambulation problems, and to detect the effectiveness of rehabilitation treatments and programs prescribed to reduce older adults' ambulation disabilities. Hence, assessing discriminate, predictive validity, and responsiveness of the A S C Q and its application to disease specific populations, are highly recommended to increase our knowledge of the psychometric characteristics of the A S C Q . Item response theory (IRT) is a psychometric theory that suggests that an individual's performance on the test can be predicted by a set of factors (such as abilities or traits) and the relationship between those can be defined by an item characteristic curve (ICC), i f the two assumptions of IRT (1. the data are unidimentional and 2. probability of answering any item in a positive direction is not related to the probability of answering any other item positively for individuals with the same amount of trait) are met (Embretson & Reise, 2000; Lord, 1980). The IRT and its models, especially Rasch analysis may be one parameter (unidimentional) logistic model to scale item response data to find a trait and looks at the weighting of the individual items as well . The A S C Q is a measurement tool, designed to assess an individual's confidence, hoping and hypothesizing that an individual's test response (perceived confidence) can be a predictor of another factor (walk test performance). In addition, our unreported data based on principal component analysis demonstrates that the A S C Q is a 22-item unidimensional tool (Appendix XII). Thus, for the future research, it w i l l be worthwhile to expose the A S C Q to the IRT and R M . 89 4.5 Final Thoughts Ambulation and emotional wellness are crucial aspects to the health, level of independence and quality of life of community l iving older adults. The A S C Q may provide vital missing information that enables rehabilitation practitioners and researchers to explore and understand the inter-relationship between individuals' personal factors (confidence), environmental factors (living environment), and behaviour (ambulation performance). Thereby helping to improve and maintain older adult patients' daily l iving and further advance rehabilitation sciences. 90 4.6 References Bandura, A . (1977). Self-Efficacy: Toward a unifying theory of behavior change. Psychological Review, 84(2), 191-215. Bandura, A . (1982). Self-efficacy mechanism in human agency. American Psychologist, 37(2), 122-147. Bandura, A . (1997). Self-efficacy: the exercise of control. N e w York: Freeman. Bandura, A . , & Adams, N . E . (1977). Analysis of self-efficacy theory of behavior change. Cognitive Therapy and Research, 1(4), 287-310. Beck, C.T. , & Gable, R . K . (2001). Ensuring content validity: A n illustration of the process. Journal of Nursing Measurement, 9 (2), 201-215. Clark, C. (2003). Biomarks of dementia and cognitive impairment. Chicago Workshop on Biomarker Collection in Population-Based Household Surveys of Older Adults. Conference proceedings. Cronbach, L . J. (1951). Coefficient alpha and the internal structure of tests. Psychometrika, 16, 297-333. Fisher Jr., W . (1992). Progress in rehabilitation medicine. Rasch Measurement Transactions, 6 (2), 214. Gable, R . K . (1986). Instrument Development in the Affective Domain. M A : Kluwer Academic Publishers. Gregory, R.J . , (1996). Validity and test development. Psychological testing: History, principles, and applications. Boston, M A : A l l y n & Bacon. Guccione, A . A . (Ed.). (2000). Geriatric Physical Therapy (2 n d edition). St. Louis, M O : Mosby-Year Book Inc. Lawton, M . P . , Winter, L . , Kleban, M . H . , Ruckdeschel, K . (1999). Affect and quality of life: objective and subjective. Journal of Aging and Health, 11 (2): 169-198. Lerner-Frankiel, M . B . , Vargas, S., Brown, M . B . , Krusell , L . , & Schoneberger, W . (1986). Functional community ambulation: What are your criteria? Clinical Management, 6 (2), 12-15. Portney, L . G . & Mary, P .W. (2 n d Ed.) (2000). Foundations of Cl inical Research: Applications to Practice. New Jersey; Prentice-Hall, Inc. 91 Statistics Canada (2001). Aging seniors: statistical snapshots of Canada's seniors. Accessed from: http://vv^vvv.phac-aspc.gc.ca/seniors-aines/pubs/factoids/2001/intro e.htm Shumway-Cook, A . , Patla, A . E . , Stewart, A . , Ferrucci, L . , C i o l , M . A . , & Guralnik, J . M . (2002) . Environmental demands associated with community mobility in older adults with and without mobility disabilities. Physical Therapy, 82 (7), 670-681. Shumway-Cook, A . , Patla, A . E . , Stewart, A . , Ferrucci, L . , C i o l , M . A . , & Guralnik, J . M . (2003) . Environmental components of mobility disability in community-living older persons. Journal of the American Geriatrics Society, 51 (3): 393-8. Shumway-Cook, A . , Patla, A . E . , Stewart, A . , Ferrucci, L . , C i o l , M . A . , & Guralnik, J . M . (2005). Assessing environmentally determined mobility disability: self-report versus observed community mobility. Journal of the American Geriatrics Society, 53 (4): 700-4. Streiner, D . L . , & Norman G.R. (2003). Health Measurement Scales: A Practical Guide to their Development and Use (3 r d edition). N Y : Oxford University Press Inc. Trottier, L . (2003). The current state of insight research. Canadian Undergraduate Journal of Cognitive Science, Fal l : 1-16. 92 Appendix I: The A S C Q - Version 1 The Ambulatory Self-Confidence (ASC)Questionnaire This is a questionnaire that looks at how confident you are with your ability to walk in different situations both in the home and the community. For each of these scenarios, consider the use of your regular walking aid. Please rate each item using the following scaling system. 1 : 2 3 4 5 6 7 8 ~~9 10 Not at all confident Somewhat confident Extremely confident On a scale from 1-10, how confident are you that you are able to . . . 1. step up to a standard height sidewalk curb? 2. step down from a standard height sidewalk curb? 3. walk up a flight of stairs (12 steps)? 4. walk down a flight of stairs (12 steps)? 5. ride an escalator? 6. walk up a ramp (mild incline)? _7. walk down a ramp (mild incline)? 8. cross an intersection (2 lanes - 15 meters)? 9. cross an intersection where there is a timed cross-walk? 10. get in your transportation (bus/car) and sit down on your seat? 11. stand up from your seat and get out of your transportation (bus/car)? 12. walk a short distance from a parking lot/bus stop to the closest store/bank/restaurant (50 meters)? 13. walk through a supermarket or shopping mall (300 meters)? 14. stop suddenly while walking? _15. carry a small item (<2.0kg) when walking? 16. walk on uneven or bumpy ground? 17. walk on slippery ground (icy or wet surfaces)? 18. walk independently (without an aide such as cane or walker)? 19. enter and leave your home/apartment? 20. walk from one room to another in your home/ at your doctor's office? 21. walk in a crowd? 22. walk on flat/level ground? 93 Appendix II: The A S C Q - Version 2 The Ambulatory Self-Confidence (ASC)Questionnaire This is a questionnaire that looks at how confident you are with your ability to walk in different situations both in the home and the community. For each of these scenarios, consider the use of your regular walking aid. Please rate each item using the following scaling system. 0 2 3 4 5 6 7 8 9 10 Not at all confident Somewhat confident Extremely confident On a scale from 1 - 1 0 , how confident are you that you are able to . . . 1. step onto a curb? 2. step off a curb? 3. walk up a flight of stairs (4 steps or more) with a handrail? 4. walk down a flight of stairs (4 steps or more) with a handrail? 5. walk and talk at the same time? 6. walk up a ramp (mild incline)? 7. walk down a ramp (mild incline)? 8. cross a street without a timed cross walk (walk signal)? 9. cross a street with a timed cross walk (walk signal)? 10. use an escalator? 11. walk on a moving sidewalk: for example one at airport? 12. walk on a moving bus? 13. walk in the dark or at night? 14. walk a short distance without stopping: for example from your home to a car? 15. walk a long distance without stopping: for example from your car at a parking lot to a supermarket? 16. suddenly stop walking to avoid an oncoming vehicle? 17. carry small items while walking: for example a carton of milk? 18. walk on an uneven sidewalk? 19. walk on slippery ground: for example icy or wet surfaces? 20. walk on grass? 21. walk through a crowded place: for example a busy street? 22. walk from one room to another in your home? 94 Appendix III: The A S C Q - Version 3 The Ambulatory Self-Confidence Questionnaire (ASCQ) This questionnaire measures how confident you are in your ability to walk. If you normally walk with a walker or cane, assume you have your walking aid with you when answering each question. Please answer all items. If activities do not apply to you please guess how you would feel to perform the activity. Please answer each question using the following 0-10 scale: 0 1 2 3 4 5 6 7- 8 9 10 Not at all Completely Confident Confident On a scale of 0 - 10, how confident are you that you are able to... a. step up onto a curb? b. step down off a curb? c. walk up a ramp (mild incline)? d. walk down a ramp (mild incline)? e. walk up a flight of stairs (4 steps or more) with a handrail? f. walk down a flight of stairs (4 steps or more) with a handrail? _g. cross a street with a timed cross walk (walk signal)? h. cross a street without a timed cross walk (walk signal)? i. walk on an uneven sidewalk? j . walk on grass? _k. walk on slippery ground: for example icy or wet surfaces? I. walk in the dark or at night when it is difficult to see your feet? m. walk through a crowded place: for example a busy street? n. walk and talk to a companion at the same time? p. carry small items while walking: for example a carton of milk? p. stop walking suddenly to avoid an oncoming vehicle? q. use an escalator ? r. use a moving sidewalk (one at an airport)? s. walk on a moving bus? t. walk from one room to another in your home? u. walk a short distance without stopping: for example from your home to a car? v. walk a long distance without stopping: for example from your home to a bus stop? 95 Appendix IV: Sample Size Calculation 1. Reliability Sample According to Gable (1986, p.147), a typical value for good cognitive related measures for reliability is expected to be in high 0.80s to low 0.90s. Thus, the minimum acceptable intraclass correlation coefficient (ICC) for the proposed study is set at 0.70 and expected at 0.90. Dormer and Eliaziw (1987) published tables to estimate sample size for the reliability study using a one way A N O V A to calculate an ICC. The sample size was derived based on testing the hypothesis of detecting a significant difference between a minimal standard and expected rho at a pre-selected alpha level (0.05) and beta (0.20). Using figure 4 from Dormer and Eliaziw's work (1987, p.446), a minimum of 40-45 participants are required for this proposed study. 2. Construct Validity Sample In order to examine the construct validity of the A S C Q based on acquiring the speculated correlation between the A S C Questionnaire and the T U G (r>0.50; based on the relatively similar work by Bean et al. 2002) and the A S C Questionnaire and the 6 M W T (r>0.50; based On the relatively similar work by R i k l i and Jones, 1998), a minimum of 29 participants are required for this proposed study. This number was acquired using a sample size calculation Table published by Hulley and Cummings (1988, P.218) with an alpha=0.05 (two tailed) and power=0.80. Over sampling to comprise attrition of 10% of the largest total sample size required for the proposed study, a total of 50 participants w i l l be required. 96 Appendix V - The 6 Minute Walk Test Protocol Equipments: Tape measure, masking tape, a chair, a stop watch or timer, marking cones, (lap counter i f possible) Note: • Subjects w i l l be asked to walk from end to end of the walking path for 6 minutes. • The walk should be carried out in an area with minimal traffic that is 10-m in length. • The length of corridor should be marked every 1 -m. • Manually take the participant's heart rate before each measurement Protocol: 1. The following instructions w i l l be given to subjects: "The purpose of this test is to find out how far you can walk in 6 minutes. You will start from this point (indicate marker at one end of the path/course) and follow the hallway to the marker at the end, then turn around and walk back. When you arrive back at the starting point, you will go back and forth again. You will go back and forth as many times as you can in 6 minute period. If you need to, you may stop and rest. Just remain where you are until you can go on again. However, most important thing about the test is that you walk as much as you can during the 6 minutes. I will tell you the time, and I will let you know when the 6 minutes are up. When I say 'stop', please stand right where you are." 2. Then you demonstrate (demonstrate one lap)... "Now I am going to show you. Please watch the way I turn without hesitation." 3. After you explain/demonstrate the test, make sure (ask) subjects understand the instruction... "Are you ready to do the walk test? " 4. Position the subject at the starting line. A n investigator should also stand near the starting line during the test. 5. A s soon as the subject starts to walk, start the stop watch. 6. Do not talk to anyone during the walk test. Use an even tone of voice when using the standard phrase of encouragement with 30 second notification: " You are doing well, you have 5 and half minutes left"; " Keep up the good work, you have 1 minute, left"; "You are doing fine, you have only 1 and half minutes left" Do not use other words of encouragement. 97 7. When the timer is 15 seconds from the completion, say this: "In a moment I am going to tell you to stop. When I do, just stop right where you are and I will come to you." 8. A t 6-minute say this: " Stop!" then walk over to the subject and mark the stop by placing a bean bag or a piece of tape on the floor. 9. Post-test: Record the distance that the subject walks in 6 minutes w i l l be recorded. (Duration of time spent resting wi l l also be recorded.) 10. Congratulate the subject on good effort and offer a drink of water. 98 Appendix V I : The Timed "Up & G o " Test Protocol Note: • Subjects w i l l be asked to stand up from a chair, walk 3 meter, take a turn, walk back 3 meter and sit down on a hair. • The walk should be carried out in an area with minimal traffic that is 3-m in length. 1. The following instructions w i l l be given to subjects: "The purpose of this test is to measure how long you take to complete following tasks: Standing up from the chair, walking 3-meter, taking a turn, walking back 3-meter, and sitting down. When you are ready, I will say "Go", as soon as you hear my "Go" you will start the test" 2. Then you demonstrate (demonstrate one lap)... "Now I am going to show you. Please watch the way I perform the test" 3. After you explain/demonstrate the test, make sure (ask) subjects understand the instruction... "Are you ready to do the walk test? " 4. Place the subject at seated position at the start line. A n investigator should also stand near the starting line during the test. 5. When you say " G o " as a start sign, you should start the stop watch. • Do not talk to anyone during the walk test. • Do not say any encouragement. 6. A s soon as the subject sits down on the chair, you press the stop watch. 7. Post test: Record the time in seconds that the subject takes to complete the test. 8. Congratulate the subject on good effort. Standing & Sitting Turning Protocol: 99 Appendix VII : A sample of the A B C Scale For each of the following activities, please indicate your level of self-confidence by choosing a corresponding number from the following rating scale. Answer all items even i f there are activities you would not do or are unsure about. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Not Completely confident confident How confident are you that you w i l l not lose your balance or become unsteady when you A) walk around the house? % B) walk up and down stairs? % C ) pick up a slipper from the floor? % D) reach at eye level? _% E) reach while standing on your tiptoes? % F) stand on a chair to reach? % G) sweep the floor? % H) walk outside to nearby car? % I) get in and out of a car? % J) walk across a parking lot? % K) walk up and down a ramp? % L ) walk in a crowded mall?__ % M ) walk in a crowd or get bumped? % N) ride an escalator holding the rail? % O) ride an escalator not holding the rail?_ % P) ....walk on icy sidewalks?__ % 100 Appendix VIII: A sample of the I A D L Scale Please check the box that most applies for each activity: Ability to Use Telephone: • Operates telephone on own initiative (examples: look up and dial numbers). • Dials a few well know numbers. • Answers telephone but does not dial. • Does not use telephone at all . Shopping: • Take care of all shopping needs independently. • Shops independently for small purchases. • Needs to be accompanied on any shopping trips. • Completely unable to shop. Food Preparation: • Plans, prepares, and serves adequate meals independently. • Prepares adequate meals i f supplied with ingredients or heats meals on wheels. • Prepares meals but does not maintain an adequate diet. • Needs to have meals prepared and served. Housekeeping: • Maintains house alone or with occasional assistance (e.g. heavy work, gardening). • Performs light daily tasks such as dish washing, bed making. • Performs light daily tasks but cannot maintain acceptable level of cleanliness. • Needs help with all home maintenance tasks. • Does not participate in any housekeeping tasks. Laundry: • Does personal laundry completely. • Launders small items. • A l l laundry must be done by others. Mode of Transportation: • Travels independently on public transport or drives own car. • Arranges own travel via taxi, but does not otherwise use public transportation. • Travels on public transport when accompanied by another. • Travels limited to taxi or vehicle with assistance of another. • Does not travel at all . Responsibility for Own Medication: • Is responsible for taking medication in correct dosage at correct time. • Take responsibility i f medication is prepared in advance in separate dosages (might need reminder) • Is not capable of dispending own medication Ability to Handle Finances: • Manages financial matters independently (e.g. paying bills, going to bank). • Manages day-to-day purchases, but needs some help with banking, major transactions. • Incapable of making financial decisions or handling money. 101 Appendix I X : A sample of Folstein's M M S E This is instructions for the M M S E . Please see/use the Score sheet attached after the 2-page instruction. (The M M S E is an 11 item brief assessment of the person's orientation to time and place, recall ability, short-term memory, and arithmetic ability providing insight into cognitive loss.) You , an investigator, ask several questions to the subjects and rate each answer. If the subject can answer the question correctly give 1 point, i f not give 0 point. Orientation: a. What is the year? Score b. What is the season? Score c. What is the date? Score d. What is the day? Score e. What is the month? Score f. Which province are we in? Score g- Which country are we in? Score h. Which city are we in? Score i. Which hospital are we at? Score J- Which floor are we on? Score Score (max 10) Registration: Y o u wi l l give the following instruction to the subject, then name three words. "Please listen carefully, I am going to say 3-words. You say them back after I stop. Are you ready? Here they are... (i.e. car, house, ocean)" Give 1 point for each correct answer. Then repeat them until he or she learns all 3. Count trials and record. Score (max 3) #of trials Attention and Calculation: Y o u w i l l give the following instruction to the subject. Give 1 point for each correct answer and stop after 5 answers. "I would like you to count backward from 100 by sevens." (93, 86, 79, 72, 65,...). If the subject cannot or w i l l not perform this task, ask him or her to spell the word (i.e. W O R L D ) backwards. The score is the number of letter in correct order, (i.e. i f subject answered D L O R W , he or she gets 3 point). Score (max 5) 102 Recall: Y o u w i l l give the following instruction to the subject. " Earlier I told you the names of three things. Can you tell me what those are?" Give 1 point for each correct answer. Score (max 3) Naming: Y o u wi l l show the two simple objects (such as a pen or a wrist watch) to the subject, and ask him or her to name them. Give 1 point for each correct answer. Score (max 2) Repetition: Y o u w i l l ask the subject to repeat the sentence ( N O ifs ands or buts) after you. Only one trial is allowed. Give 1 point for the correct answer. Score (max 1) 3-stage Command: Y o u w i l l give the subject a piece of blank paper and ask him or her to complete tasks. "Take the paper in your hand, fold it half, and put it on the floor." Give 1 point for each task correctly performed. Score (max 3) Reading: Y o u wi l l give the subject a written instruction (sentence) then ask him or her to read the sentence and perform what it says. "Please read this and do what it says" (i.e. close your eyes) Give 1 point for each task (reading and performing) correctly performed. Score (max 2) Writing: Y o u w i l l give a blank piece of paper and ask the subject to write a sentence for you. The sentence must contain a subject and verb and be sensible. Correct grammar and punctuation are not necessary, "Make up and write a sentence. It must contain a noun and verb." Give 1 point for the performance. Score 103 Copying: Y o u wi l l give the subject a blank piece of paper and ask him or her to draw the symbol (see the score on next page). A l l the 10 angles must be presented and two must be intersect. "Please copy this picture" Give 1 point for the performance. Score 104 Appendix X : Socio-demographics and measurement outcomes categorized by the type of recruitment location Characteristics Community Day Centre Centre (n=45) & Clinic (n=46) Mean age (S.D.) 74.1 (6.2) 81.0 (7.1) % M a l e 20.0 34.8 % Faller (the past 12months) 27.8 ' 47.0 Median # Fall/s 0 0 Median # Medications 1 1 Median # Cormobidities 2 3.5 % Use of Walking A i d None 91.1 47.8 Cane 4.4 21.7 Walker 2.2 19.6 Cane & Walker 2.2 10.9 % Highest Education Completed < High school 13.3 21.7 High school 28.9 39.1 College 8.9 8.7 > University 44.4 19.6 N o Response 4.4 10.9 % Marital status Single 35.6 17.4 Married 33.3 23.9 Widowed 31.1 58.7 Measurement Outcomes Measures (Mean/SD)ASCQ ABC IADL TUG 6MWT Community Centre 8.98 (1.76) 89.5 (15.6) 7.98 (0.15) 9.20 (6.83) 364.8 (96.1) Day Centre/Clinic 8.07(1.61) 78.0 (20.3) 7.22(1.30) 14.95 (7.55) 237.7 (91.3) T-test Significance p<0.01 p<0.01 p<0.01 p O . O l p O . O l Min-Max Score 0-10 0-100 0-8 - -Unit % - seconds meters A S C Q : The Ambulatory Self-Confidence Questionnaire A B C : The Activities-specific Balance Confidence Scale I A D L : The Instrumental Activi ty of Dai ly L iv ing Scale T U G : The Timed "Up & G o " Test 6 M W T : The 6 Minute Walk Test 105 Appendix X I : Socio-demographics and measurement outcomes categorized by the non-fallers and fallers Characteristics Non-Fallers (n=61) Fallers (n=25) Mean age (SD) 76.6(7.2) 80.1 (7.8) % Male 24.2 36.0 Median # Medications 1 1 Median # Cormobidities 3 3 % Recruitment Location Community Centre 56.1 32.0 Day Centre & Clinic 43.9 68.0 % Use of Walking A i d None 69.7 68.0 Cane 12.1 16.0 Walker 13.6 4.0 Cane & Walker 4.5 12.0 % Highest Education Completed < High school 16.7 20.0 High school 28.8 48.0 College 9.1 8.0 > University 35.4 16.0 N o Response 9.0 4.0 % Marital status Single 22.7 36.0 Married 31.8 20.0 Widowed 45.5 44.0 Measurement Outcomes Measures (Mean/SD)ASCQ ABC IADL TUG 6MWT Non-Fallers 8.71 (1.63) 86.1 (17.4) 7.61 (0.94) 11.65 (8.16) 316.8 (112.7) Fallers 8.01(1.95) 77.9(21.4) 7.56(1.16) 12.66 (6.55) 291.8 (114.0) T-test Significance NSS NSS NSS NSS NSS Min-Max Score 0-10 0-100 0-8 - -Unit % seconds meters N S S : Not statistically significant difference (p<0.05) between two groups A B C : The Activities-specific Balance Confidence Scale I A D L : The Instrumental Activity of Dai ly L iv ing Scale T U G : The Timed "Up & G o " Test 6 M W T : The 6 Minute Walk Test 106 Appendix XII : Principal Component Analysis ASCQ Item Fl F2 F3 Step up onto a curb .753 -.454 .147 Step down off a curb .802 -.415 .140 Walk up a ramp .719 .218 .551 Walk down a ramp .692 .262 .496 Walk up a flight of stairs .710 -.634 .060 Walk down a flight of stairs .693 -.657 .025 Cross a street with a timed cross walk .735 .257 -.061 Cross a street without a timed cross walk .765 .258 -.289 Walk on an uneven sidewalk .748 .179 -.210 Walk on grass .812 .005 -.198 Walk on slippery ground .692 -.148 -.304 Walk in a dark or at night .753 .322 -.273 Walk though a crowded place .837 -.044 .059 Walk and talk to a companion at the same time .781 -.311 -.010 Carry small items while walking .774 -.078 -.089 Stop walking suddenly to avoid an oncoming car .696 .518 -.155 Use an escalator .806 -.130 .122 Use a moving sidewalk .738 .206 -.020 Walk on a moving bus .688 -.180 -.352 Walk from one room to another .638 .288 .422 Walk a short distance without stopping .655 .439 .113 Walk a long distance without stopping .640 .255 -.157 F l : Factor 1 F2: Factor 2 F3: Factor 3 107 Appendix X I V : A Sample Survey -1 Please rate each item in the Ambulation Self Confidence Questionnaire by using the following scale for: a) Item clarity: "is this question easy to understand?" and b) Item appropriateness: " is this question appropriate for the A S C Questionnaire?" 1 2 3 4 Strongly Disagree Agree Strongly Disagree Agree The Followings are 22 items of the ASC Questionnaire: On a scale from 1-10, how confident are you that you are able to . 1. step up to a standard height sidewalk curb? 2. step down from a standard height sidewalk curb? 3. walk up a flight of stairs (12 steps)? 4. walk down a flight of stairs (12 steps)? 5. ride an escalator? 6. walk up a ramp (mild incline)? 7. walk down a ramp (mild incline)? 8. cross an intersection (2 lanes - 15 meters)? 9. cross an intersection where there is a timed cross-walk? 10. get in your transportation (bus/car) and sit down on your seat? 11. stand up from your seat and get out of your transportation (bus/car)? 12. walk a short distance from a parking lot/ Bus stop to the closest store/bank/restaurant (50 meters)? 13. walk through a supermarket or shopping mall (300 meters)? 14. stop suddenly while walking? 15. carry a small item (<2.0kg) when walking? 16. walk on uneven or bumpy ground? 17. walk on slippery ground (icy or wet surfaces)? 18. walk independently (without walking aide such as a cane or walker)? 19. enter and leave your home/apartment? 20. walk from one room to another in your home/at your doctor's office? 21. walk in a crowd? 22. walk on flat/level ground? Item # Clarity Appropriateness 1 2 3 10 11 12 13 14 15 16 17 18 19 20 21 22 109 Appendix X V : A Sample Survey - II Please rate each item in the Ambulation Self Confidence Questionnaire by using the following 1-4 scale for: c) Item clarity: "is this question easy to understand?" d) Item importance: "is this question important for the Questionnaire?" e) Item distinguishes: "can this item distinguish between people with and without walking problems?" 1 2 3 4 Strongly Disagree Agree Strongly Disagree Agree The Followings are revised 22 items of the Questionnaire: 1 step onto a curb? 2. step off a curb? 3. walk up a flight of stairs (4 steps or more) with a handrail? 4. walk down a flight of stairs (4 steps or more) with a handrail? 5. walk and talk at the same time? 6. walk up a ramp (mild incline)? 7. walk down a ramp (mild incline)? 8. cross a street without a timed cross walk (walk signal)? 9. cross a street with a timed cross walk (walk signal)? 10. use an escalator? 11. walk on a moving sidewalk: for example one at airport? 12. walk on a moving bus? 13. walk in the dark or at night? _14.walk a short distance without stopping: for example from your home to a car? _15.walk a long distance without stopping: for example from your car at a parking lot to a supermarket? 16. suddenly stop walking to avoid an oncoming vehicle? 17. carry small items while walking: for example a carton of milk? 18. walk on an uneven sidewalk? 19. walk on slippery ground: for example icy or wet surfaces? 20. walk on grass? 21. walk through a crowded place: for example a busy street? 22. walk from one room to another in your home? Item rclar]ty^~ Importance Distinguish 1 | I 1 2 1 1 3 [4 [ \ i 6 r 7 | 1 8 I (9 10 — " 11 f 12 1 1 3 I 14 ! 15 1 16 [ [17 I 1 I 19 I 20 1 • i 21 [~ i 22 [ 110 Appendix X V I I : A Sample Information and Consent Form Vancouver :oastalHealth W Pramefisg ! K l « Emum§ core. The University of British Columbia School of Rehabilitation Sciences Faculty of Medicine SUBJECT INFORMATION AND CONSENT FORM Development of a New Self-Report Questionnaire: The Ambulatory Self-Confidence Questionnaire (ASCQ) Principal Investigator: Dr. B i l l Mi l le r , PhD, OT Assistant Professor, Divis ion of Occupational Therapy, School o f Rehabilitation Sciences, University of British Columbia Co-Investigator: Miho Asano, BSc (CEP) Master Student, Divis ion of Occupational Therapy, School of Rehabilitation Sciences, University of British Columbia Invitation to Participate: Y o u are being invited to participate in this study because we wish to study the quality of a self-report questionnaire that assesses older adults' perceived confidence in their ambulation (walking) skil l and you are identified as a possible potential subject. Your Participation is Voluntary: Your participation in this study is entirely voluntary. This consent form w i l l explain to you about the study and it is important for you to understand what the study involves. If you wish to participate, you w i l l be asked to sign this consent form. If you do decide to take part in this study, you may still refuse to participate or withdraw from the study at anytime. If you do not wish to participate, you do not have to provide any reason for your decision nor w i l l you lose the benefit of any medical care to which you are entitled or are presently receiving. Who is Conducting the Study? 112 This study is a research project for a graduate thesis of M s . Miho Asano. It is conducted by Dr. B i l l Mi l l e r and M s . Miho Asano. Background: Older adults often demonstrate mobility (walking) problems as a result of age-related physical changes. Walking safely and independently is one of the basic yet most important parts of daily living. Currently, there is no self-reported questionnaire that focuses on assessing one's perceived confidence in their walking ski l l . What is the Purpose of the Study? The purpose of the proposed study is to assess the quality (reliability and validity) of a new self-report questionnaire, the Ambulatory Self-Confidence Questionnaire (ASCQ) . The A S C Q is designed to evaluate how confident individuals are with their ability to walk at home and within the community. The A S C Q contains 22 questions and takes about 10 to 15 minutes to complete. Who Can Participate in the Study? Potential subjects who can participate in the study include those who are: 1. older than 65 years of age 2. able to read, write, speak, and understand English 3. able to walk minimum of 10 meters with or without walking aides (examples: a walker or a cane) at home and in the community 4. l iving in their home What Does the Study Involve? Overview of the study: If you agree to jo in the study, we wi l l collect information from you at 2 different times. The study w i l l initially take place in G F Strong Research Lab where data w i l l be collected. Then you w i l l be asked to complete one questionnaire (the A S C Q ) at your home and mail it back using a prepaid-envelope 14 days after the first data collection. If you agree to take part in this study, the procedures that you can expect w i l l include the following: Session 1 at your Day Center or home: The study co-ordinator w i l l explain how the study is conducted and answer any questions that you have regarding the study. If you agree to participate in the study, informed consent w i l l be obtained from you. A l l the subjects who consent to participate in the study w i l l perform M i n i Mental State Exam followed by 3 brief questionnaires: the first one looks at confidence in balance ski l l , the second one looks at your ability to perform some activities of daily l iving, and the third one looks at confidence in walking ability. M i n i Mental State Exam is an exam that assesses an individual's orientation, attention, immediate and short-term recall, and language, and the ability to follow simple verbal and written commands. Y o u need to score higher than 24 on this exam in order to participate in the study. Lastly, we w i l l examine your walking ability by asking you to perform 3 walk tests: the L test, the Timed "Up & G o " Test and the 6 Minute Walk Test. 113 For the walk tests, you wi l l be asked to walk a simple path (6-meters and 20-meters and for 6-minutes). The study co-ordinator w i l l record the time it takes you to walk a path for the Timed "Up & G o " Test and the L Test and the distnace that you w i l l walk for the 6 Minute Walk Test. A l l the questionnaires and the walk tests w i l l be explained and/or demonstrated to you before the official measurement. Y o u may decide to use your walking aide (such as cane or walker) and to take a rest during the walk test i f you feel it is necessary. Y o u w i l l also be given adequate rest between testing and your heart rate w i l l be monitored manually before each walk test. Your socio-demographic information such as age, gender, number of falls in the past 12 months, any major medical condition (i.e. arthritis, heart condition) and use of a walking aide (i.e. walker, cane) w i l l be collected. A peson with first aid w i l l be present in case you fall during the walk tests. The entire session w i l l take approximately 30 to 45 minutes of your time. Session 2 at your home: When you complete the session 1 at your Day Center or home, you w i l l be given a take-home questionnaire package. The package includes a second Ambulatory Self-Confidence Questionnaire, an information letter, and a prepaid return envelope. Y o u w i l l be asked to complete the questionnaire at your home 14 days after your first session (session 1 at your Day Center or home) and mail your completed questionnaire back to us using our prepaid envelope. Y o u w i l l also receive a phone call 14 days after your first session to remind you to f i l l in the questionnaire. The entire session w i l l take approximately 10 to 15 minutes of your time at your home. What are the Possible Harms and Side Effects of Participating? We do not anticipate any harm or side effect of participating in the study. However, during testing, you can stop participating at any stage and you do not have to finish any of the tests i f you don't want to. What are the Benefits of Participating in this Study? N o one knows whether or not you w i l l benefit from this study. There may or may not be direct benefits to you from taking part in this study. We hope that the information learned from this study can be used in the future to benefit other older adults with a similar condition. If you wish to obtain the results from this study, we w i l l be happy to give you a copy of the overall results after the entire study is finished. What Happens if I Decide to Withdraw My Consent to Participate? Your participation in this study is entirely voluntary, and you may refuse to participate or withdraw from the study at any time. Y o u may also refuse to answer any question that you do not wish to answer any time during the study. If you decide to enter the study and to withdraw at any time in the future, there wi l l be no penalty or loss of benefits to which you are otherwise entitled, and your future medical care w i l l not be affected. The study investigators may decide to withdraw you from the study at any time, i f they feel that it is in your best interests. If you choose to enter the study and then decide to withdraw at a later time, all data collected about you during your enrolment in the study w i l l be retained for analysis. 114 Development of a New Self-Report Questionnaire: The Ambulatory Self-Confidence Questionnaire (ASCQ) Consent Form • I have read and understood the subject information and consent form. • I have had sufficient time to consider the provided information and had the opportunity to ask questions. • I have had the opportunity to ask questions and have had satisfactory responses to my questions. • I understand that all the information obtained w i l l be kept confidential and that the results w i l l only be used for scientific objectives. • I understand that my participation in this study is entirely voluntary and I am completely free to refuse to participate or withdraw from this study at any time without changing in any way the quality of care that I receive. • I understand that I am not waiving any of my legal rights as a result of signing this consent form. • I have been told that I w i l l receive a dated and signed copy of this form. • I read this form and I freely consent to participate in this study. Printed name of subject Signature Date Printed name of witness Signature Date Name of principal investigator/designated representative Signature Date 116 

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