Studies Reviewing the Need for Wheelchair Ramps to Reduce Falls

• Journal Listing
• BMJ Open
• v.x(two); 2020
• PMC7045099

BMJ Open up. 2020; 10(2): e034279.

Original research

Factors that influence the adventure of falling after spinal cord injury: a qualitative photograph-elicitation study with individuals that utilize a wheelchair as their principal means of mobility

,^{1, ii} Ballad Y Scovil,^{two, 3} Karen Yoshida,^{1, iv} Sarah Oosman,⁵ Anita Kaiser,^{one, 2, 6} Catharine Chicken,^{one, 2, 7, 8} Susan Jaglal,^{ane, 2, iv, 8} and Kristin E Musselman ^{one, 2, 4, 5}

Hardeep Singh

^ane Rehabilitation Sciences Found, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada,

² Lyndhurst Centre, KITE, Toronto Rehabilitation Institute-Academy Health Network, Toronto, Ontario, Canada,

Carol Y Scovil

² Lyndhurst Centre, KITE, Toronto Rehabilitation Establish-Academy Health Network, Toronto, Ontario, Canada,

³ Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Ontario, Canada,

Karen Yoshida

¹ Rehabilitation Sciences Institute, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada,

⁴ Section of Physical Therapy, University of Toronto, Toronto, Ontario, Canada,

Sarah Oosman

⁵ School of Rehabilitation Science, University of Saskatchewan, Saskatoon, Saskatchewan, Canada,

Anita Kaiser

ⁱ Rehabilitation Sciences Institute, University of Toronto Kinesthesia of Medicine, Toronto, Ontario, Canada,

² Lyndhurst Centre, KITE, Toronto Rehabilitation Plant-University Health Network, Toronto, Ontario, Canada,

⁶ Canadian Spinal Research Organization, Toronto, Ontario, Canada,

Catharine Craven

¹ Rehabilitation Sciences Institute, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada,

ⁱⁱ Lyndhurst Centre, KITE, Toronto Rehabilitation Establish-Academy Health Network, Toronto, Ontario, Canada,

^seven Division of Physical Medicine and Rehabilitation, Faculty of Medicine, Academy of Toronto, Toronto, Ontario, Canada,

^viii Institute of Health Policy, Management and Evaluation, Academy of Toronto, Toronto, Ontario, Canada,

Susan Jaglal

¹ Rehabilitation Sciences Institute, University of Toronto Kinesthesia of Medicine, Toronto, Ontario, Canada,

² Lyndhurst Heart, KITE, Toronto Rehabilitation Plant-University Wellness Network, Toronto, Ontario, Canada,

⁴ Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada,

⁸ Found of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,

Kristin E Musselman

¹ Rehabilitation Sciences Establish, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada,

² Lyndhurst Centre, KITE, Toronto Rehabilitation Institute-University Wellness Network, Toronto, Ontario, Canada,

⁴ Department of Concrete Therapy, University of Toronto, Toronto, Ontario, Canada,

⁵ School of Rehabilitation Science, University of Saskatchewan, Saskatoon, Saskatchewan, Canada,

Received 2019 Sep xiii; Revised 2019 Nov 26; Accustomed 2019 Dec xviii.

Supplementary Materials

Reviewer comments

GUID: 7C18AA5B-EEBB-40D7-B253-1A7198D53B43

Author'due south manuscript

GUID: 8B4E4906-93D5-4814-BDCE-8D42A9A31149

Abstract

Introduction

Falls are a business organisation for wheelchair users with spinal cord injury (SCI). Falls can negatively touch the physical and psychological well-being of fallers. To date, the perspectives of wheelchair users with lived experiences of SCI on the contributors to falls has been understudied. Information about factors that influence fall risk would guide the development of constructive fall prevention strategies.

Objectives

To gain a comprehensive understanding of the factors that influenced the risk of falling as perceived by wheelchair users with SCI.

Design

A qualitative study using photo-elicitation interviews.

Setting

A Canadian SCI rehabilitation hospital and the participants' home/customs environments.

Participants

Twelve wheelchair users living in the customs with chronic SCI.

Methods

Participants captured photographs of situations, places or things that they perceived increased and decreased their risk of falling. Semistructured photograph-elicitation interviews were conducted to talk over the content of the photographs and explore perceptions of fall chance factors. A hybrid thematic analysis and the Biological, Behavioural, Social, Economic, and Ecology model were used as a framework to organise/synthesise the data.

Results

Overall, the findings indicated that the run a risk of falling was individualised, circuitous and dynamic to each person'due south life situation. 4 master themes were revealed in our assay: (1) Falls and autumn risk acquired by multiple interacting factors; (2) Dynamic nature of fall take chances; (iii) Single factors were targeted to reduce falls and autumn-related injuries; and (4) Fall prevention experiences and priorities.

Conclusions

Each wheelchair user encountered numerous fall risk factors in their everyday lives. Information from this study can exist used to fix priorities for fall prevention. Fall prevention initiatives should consider a wheelchair user's fall risks in a holistic manner, acknowledging that a person's current situation, also every bit anticipating their autumn risks and fall prevention needs, will change over time.

Keywords: spinal cord injuries, photograph-elicitation, qualitative inquiry, fall prevention

Strengths and limitations of this study

• Photo-elicitation allowed detailed visual and verbal insights into the factors that influence falls experienced by wheelchair users with spinal cord injury.

• Phone interviews may accept reduced the depth/detail of information collected.

• Photographs captured by caregivers may take influenced the content of the photographs.

• Photo-assignment instructions provided to participants prior to taking photographs may take influenced the photographs captured past participants.

• As the sample is from an urban Canadian surround, the transferability of findings to other environments/contexts is limited.

Introduction

Falls can accept significant adverse consequences such equally fractures, head injuries and a negative impact on an individual's psychological and emotional health.^ane–3 Falls pose a significant complication for community-dwelling wheelchair users with spinal string injury (SCI) as 69% (95% CI threescore% to 76%) will experience at to the lowest degree one fall within a year.^four

Wheelchair users commonly feel falls during transfers, reaching, propelling on an uneven surface, moving in bed and showering.^{1 2 five 6} Depending on the level and severity of their SCI, some individuals primarily utilise a wheelchair for mobility simply tin besides walk brusk distances.^vii Every bit such, some wheelchair users may experience falls while standing and walking.^{one 8} The majority of prior studies examining falls among wheelchair users with SCI used quantitative surveys to assemble information on falls, which limits the breadth of information collected.⁴ There remains a need to proceeds a more detailed understanding of the nature of falls in regard to this particular population.^{2 4} Few studies accept used qualitative or mixed methods to explore the perspectives of wheelchair users with SCI concerning the causes and the impacts of falls.^{1 3 9} An in-depth exploration from the perspectives of wheelchair users can provide insight into priorities and potential strategies for autumn prevention.^{iii 4}

In order to deliver effective fall prevention interventions and minimise the impact of falls and autumn risk on individuals living with SCI, a comprehensive understanding of their fall prevention needs and priorities is needed.¹⁰ I qualitative methodology that enables detailed insight into the perspectives of participants on a particular issue is photo-elicitation interviewing (PEI), which involves the incorporation of photographs into an interview.^{11 12} In a previous written report, PEI was used to examine the perceived causes of falls and impact of fall take chances on the mobility and physical activeness levels of individuals with incomplete SCI.³ However, since the study sample was limited to individuals with motor incomplete SCI (ie, American Spinal String Injury Association Impairment Scale (AIS) grades C and D), more research is needed to understand the factors that contribute to falls in individuals with motor consummate SCI (ie, AIS grades A and B). Photo-elicitation is suited for addressing this knowledge gap. Through photo-elicitation, we can obtain a visual display of the participants' experiences, situations and environments, too as a verbal account of their experiences with falls/fall risk factors.³ Every bit the perspectives of wheelchair users with SCI regarding the factors that increment and decrease their risk of falling remain understudied, here nosotros used PEI to gain a more detailed understanding of: (A) the various risk factors associated with falls and (B) the strategies that tin reduce their fall risk.

Methods

Settings and participants

This interpretive qualitative written report was conducted at the Lyndhurst Eye, Toronto Rehab – University Health Network. This report is part of a larger research report in which we tracked falls for half dozen months in 65 participants with SCI (32 wheelchair users and 33 ambulators).^eight Participants with the post-obit traits were eligible for the larger study: (1) chronic (≥one year postinjury), traumatic SCI with a neurological level between C1 and L1 (AIS grades A–D); (2) customs-dwelling for ≥i month; and (3) ≥18 years of age. To recruit participants for the larger report, HS contacted individuals from the central recruitment database at the Lyndhurst Heart. This database contains a list of individuals with SCI who consented to receive information most enquiry studies.¹³ In addition, recruitment flyers were posted in outpatient rehabilitation clinics, too equally on the SCI Ontario website, social media and magazine. Nosotros also asked participants to share the study information with their peers with SCI. Purposive sampling, whereby participants were 'intentionally selected to represent some explicit predefined traits',¹⁴ was used to select participants for the current study. From the larger written report sample of 32 customs-dwelling wheelchair users with chronic SCI,⁸ purposive sampling^fourteen was used to select participants based on the post-obit predefined traits: (one) used a transmission or power wheelchair for ≥4 hours per twenty-four hours¹⁵ and (two) had ≥1 fall in the past 6 months. Based on previous studies using PEI,^{3 16–18} information technology was determined that 10–12 participants who met the above criteria were needed. Thus, the first fifteen participants that completed the larger study and met the current study's inclusion criteria were invited to participate; 12 participants agreed.

All participants provided informed consent (verbal and written) to participate in this study. Ethical bug related to photography were reviewed with each participant at study kickoff.¹⁹

Patient and public interest

Patients or the public were not involved in the design, reporting or dissemination of our inquiry.

Data collection

As role of the larger written report participants had vii to ix telephone interactions with HS. Participants were provided with verbal instructions to capture photographs of things, places or situations they perceived increased or decreased their take a chance of falling. Participants were provided with the following written photo-assignment instructions. 'Please accept at least ii photographs for each of the following questions: (1) What increases your likelihood of falling? and (2) What decreases your likelihood of falling?'. Participants were as well instructed to refrain from taking pictures of people nether the age of 18 years. They were asked to complete this photo-assignment over 7 consecutive days. If participants had difficulty belongings and/or manipulating the camera, they could inquire a caregiver for assist. Following photograph-taking participants completed an sound recorded interview (face to face (n=9) or phone (n=iii)) with a researcher (HS) who is a female PhD candidate and an occupational therapist with experience in SCI rehabilitation and qualitative research. Photographs were used equally a betoken of reference to facilitate these discussions.²⁰

The SHOWeD framework—a fix of five open-concluded questions—was used to explore the issues presented in the photographs.²¹ The framework effectively facilitates interviews because it moves the discussion nearly the issue from a superficial to deeper level.²² Additional semistructured questions were asked during the interviews to clarify and gain more than details on the factors perceived to contribute to the situations where participants barbarous (see box ane). Interview questions were added or modified to further explore ideas and concepts raised in previous interviews (eg, participants' thoughts on wheelchair safety features).²³

Box 1

Sample photo-elicitation interview questions²¹

SHOWeD interview questions

• What do you See hither?

• What is really Happening here? (Probe: What does the motion-picture show represent to you? What is happening that caused you to take this photograph?)

• How does this relate to Our lives? (Probe: How does this issue or gene affect your life?)

• Why does this situation, concern or forcefulness eastxist?

• What can we Do nearly it? (Probe: How do you think the situation could be improved?)

Semistructured interview questions

• What acquired or contributed to the falls that you have experienced in the past 6 months?

• What strategies do you utilise to prevent falls?

• Please depict any fall prevention training you received while in rehabilitation?

• How can rehabilitation ameliorate set you lot for falls in the community?

• What are your thoughts nearly antitippers and seatbelts for preventing falls?

Data analysis

The audio recorded interviews were anonymised and transcribed past the interviewer (HS) using Dragon Dictation transcription software (Dragon Professional, Nuance, Burlington, Massachusetts, United states of america) and then uploaded into NVivo 12 qualitative data management software (QSR International Ltd). Transcripts were analysed using a hybrid thematic analysis.²⁴ The photographs were used in the data analysis²⁵ to aid the researcher's understanding of the factors that increment or decrease a wheelchair user's chance of falling. HS, KEM and CYS independently reviewed 7 of the 12 transcripts and discussed their interpretations of the inductive coding scheme. KEM is a scientist and licenced concrete therapist with experience in quantitative and qualitative SCI enquiry. CYS is a rehabilitation engineer, SCI knowledge mobilisation specialist and assistive technology consultant. Line-past-line inductive coding was washed for the remaining transcripts by two coauthors (HS and KEM). The relationships and patterns amongst initial codes led to the formation of this report's preliminary themes.²⁴ Lastly, the anterior codes within theme 3 were organised into categories of the Biological, Behavioural, Social, Economical, and Ecology (BBSE) Model.²⁶ This model was used to identify fall-related risk factors in four categories: biological, behavioural, social and economic, and environmental. Biological factors are related to the trunk (ie, intrinsic), whereas behavioural, social and economic, and ecology factors relate to the exterior globe (ie, extrinsic).²⁶

Rigour and brownie

Several methods were integrated throughout our research to raise trustworthiness: (1) multiple data collection sources were used (ie, photographs and exact interviews); (2) the data analysis process involved triangulation whereby multiple authors contributed to theme development; (3) photographs and quotes from participants were used to ensure interpretations were grounded in the data; (iv) our analysis approach was reviewed past coauthors (KY and SO) that were not directly involved in the analysis process to ensure confirmability of interpretations (ie, analytic probing); and (5) an audit trail of the data collection and analysis process was used to heighten transparency and accountability.^27–30

Results

Twelve wheelchair users with chronic SCI participated; 3 participants used power wheelchairs and nine used transmission wheelchairs for their primary means of mobility. While all participants used a wheelchair for their primary ways of mobility, three participants (P1, P6 and P12) ambulated to some extent (eg, short distances in their habitation). Iii participants (P1, P3 and P11) received some assistance from a caregiver for taking photos. Encounter tabular array 1 for participant demographics.

Tabular array i

Participant demographics, wheelchair type, SCI details and the number of falls in the past six months

Participant code	Sex	Type of wheelchair	5-year historic period category	5-year fourth dimension since injury category	Neurological level of injury	AIS	# of falls in by half dozen months
P1	Yard	Ability	55–59	forty–44	Cervical	C	1
P2	F	Manual	20–24	5–9	Thoracic	B	half-dozen
P3	M	Ability	45–49	0–4	Cervical	B	2
P4	F	Manual	40–44	xv–19	Thoracic	A	2
P5	F	Manual	35–39	xv–19	Thoracic	A	i
P6	Grand	Manual	25–29	5–ix	Cervical	C	i
P7	F	Manual	45–49	35–39	Thoracic	B	ane
P8	F	Transmission	45–49	25–29	Lumbar	C	one
P9	F	Transmission	50–54	xxx–34	Thoracic	B	1
P10	F	Transmission	thirty–34	15–19	Thoracic	C	2
P11	Thousand	Power	sixty–64	40–44	Cervical	B	2
P12	F	Manual	xxx–34	5–9	Thoracic	D	2

Overarching theme: Individualised, dynamic and complex fall gamble factors

Participants recognised that their risk of falling was specific to their current state of affairs and that it was dynamic (ie, constantly changing) with respect to changes in their intrinsic and extrinsic environments. To complicate matters, a wheelchair users' hazard of falls was influenced by a complex interplay of multiple factors (come across figure one).

Multifactorial and dynamic fall gamble.

Consequently, the factors that decreased their risk of falling were developed through previous experiences of falls and tailored to their current situation. In addition to the overarching theme, four main themes were revealed: (1) Falls and fall gamble caused by multiple interacting factors; (2) Dynamic nature of fall risk, (3) Single factors were targeted to reduce fall take a chance and fall-related injuries; and (iv) Autumn prevention experiences and priorities (see table 2 and figure 2).

Table two

Themes, subthemes and supporting quotes

Overarching theme: Individualised, dynamic and circuitous autumn gamble factors	Theme one: Falls and fall take a chance caused by multiple interacting factors
	1a. Falls and fall take chances are multifactorial
	(i) 'In that location was a box with 12 bottles in it and I had it in my lap… And and so the box shifted going over this lip and so that caused the chair to tip… my hand that barely works was securing the box and and so my other hand was using the controls on my power chair… I tried to secure the box and I'm shifting my weight forward, and the chair tipped forward'. (P11)
	1b. Consider fall risk associated with their actions
	(i) 'I wouldn't alter my chair… it's up to me to be vigilant in my surroundings… you're constantly monitoring your environments and your behaviour and your actions'. (P8)
	(2) 'I removed [the seatbelt] from my wheelchair because what I plant is if I am hitting something hard enough to throw me out of my wheelchair, the seatbelt is not going to cease me. What it is going to do is bring my wheelchair with me so if I tip over with the wheelchair strapped to me then I am laying on the ground with my wheelchair on top of me that I can't get the seatbelt undone, whereas if I hitting something and autumn out of the wheelchair, it stays upright usually and I can at least get back into information technology'. (P6)
	Theme 2: Dynamic nature of fall run a risk
	(i) 'There was a alter in situation. A alter in concrete situation. Having a weakened arm, I lost grip stability and forcefulness. It became a real problem. It gives upward some times. Information technology just collapses and I just fall mid-transfer'. (P8)
	(ii) 'None of the equipment was new or anything similar that. I was used to doing that transfer merely information technology is internal factors. I was disoriented, I hadn't had plenty sleep, I was a new mother and these are the reasons why I had those falls'. (P4)
	Theme 3: Single factors perceived to reduce falls and autumn-related injuries
	3a. Wheelchair features
	(i) '(Gloves with a safe sole) are the ultimate, ultimate things that I have that decrease my risk of falling… They are a huge safety internet on transfers because of the grip… they assist me transfer onto the floor, on equipment, pushing the wheelchair'. (P6) (see figure 2A)
	two) 'This is just a generic photograph of the anti-tippers. They are a huge safety thing and what decreases the likelihood of falling'. (P6) (see figure 2B)
	3b. Environmental factors
	(i) 'This is the platonic way the pavement gaps should line up… no huge gaping there… this has nil risks for me to fall'. (P4) (see figure 2C)
	(2) 'This proper sidewalk provides the rubber of non having a autumn… (It has) proper cut outs, button placement, no dips or uneven basis. Proper grades and…not having to get backwards off a curb'. (P12) (meet figure 2d)
	3c. Behavioural factors
	(i) 'Trust your feelings. When you experience information technology is not safe don't do it; don't do it because your trunk, your body will tell you when information technology's rubber to practice information technology. If you do something dangerous or if y'all find it'south not safe to practice something only stop yourself there'. (P7)
	3d. Biological factors
	(i) 'I've lost weight and am standing to lose weight so that'due south helping'. (P1)
	3e. Social and economic factors
	(i) 'I but don't walk on my own considering if I need a wheelchair I need it fast and anyone that's assisting me they have been trained to bring my chair for me and to help me to land fairly gently if that's an option'. (P1)
	Theme iv: Autumn prevention experiences and priorities
	4a. Training inappropriate for dynamic needs
	(i) 'The focus was on getting up and getting mobile and not then much the whole fall prevention'. (P1)
	(ii) 'I never thought of having to get dorsum into the chair in a regression… I was taught fall prevention of how to apply a walker and how to apply my walking poles just I guess because we were and then focused on me walking, myself and everyone included, [fall prevention skills] was sort of missed'. (P12)
	4b. Priorities for fall prevention initiatives
	(i) 'You tuck your chin in and you lean forward when you experience yourself going back and that takes practice. And then like it was during basketball and we have access to these huge mats. So my friend had me but get upwards and park my chair without my brakes, and lean back and feel comfy but falling on information technology and getting used to information technology that. And then it'southward putting me in that situation where I'm going to fall no matter what and where I'm making myself fall so if that happens it's muscle memory and not but me going oh my gosh I'k falling and yous know flailing and hitting my head'. (P12)
	(ii) 'Taking people out in the community and going over sidewalks is a good idea. Educational activity them how to do wheelies and navigate steep curves or steep ramps would too forbid them hitting the bottom and flying forward. And so making sure people get out the rehab eye with the confidence to perform a wheelie to get down a steep curb. Also, training people on good transfers in the washroom considering when y'all're wet or slippery or anything like that, you are at a higher risk of falling'. (P5)

Unmarried factors perceived to reduce falls and fall-related injuries. A) Gloves with a condom sole used to increase grip during transfers; B) Anti-tippers on a manual wheelchair; C) Sidewalk with platonic pavement gaps; D) Platonic intersection for safe mobility

Theme i: Falls and autumn risk caused by multiple interacting factors

Falls were primarily caused by an interaction of multiple autumn adventure factors. In addition, participants had to constantly consider fall take chances associated with their actions.

Subtheme 1a: Falls and autumn risk are multifactorial

Previous falls described past participants, as well equally their risk of future falls, were typically influenced by a combination of biological, behavioural, social and economic, and ecology factors, but also wheelchair factors emerged every bit of import for fall adventure. Participants provided several examples of how behavioural factors combined with an environmental hazard resulted in a autumn. All participants agreed that distractions were a common contributor to falls. When rushing or multitasking, participants were distracted and paid less attention to the task and environment. Several participants recalled many experiences of their wheelchairs tripping over cracks, potholes, drainage grates, rocks or branches on the ground when wheeling outdoors while they were not paying attention to the environment. For instance, P5 described how consuming booze combined with a flat tire caused her to fall backwards: 'My flat tire was making me unsteady and then also I had a few drinks… information technology was kind of a combination of the 2'. Similarly, P10 explained that a combination of speed and going through a narrow pathway could cause a fall: 'people but accept to be conscientious with their speed and the width of their chair… (the path) may be too narrow for them to pass over but sometimes when you're not thinking mistakes tin happen'. A power wheelchair user explained that when obstacles or people all of a sudden came into his path this required him to speedily change his behaviour (ie, finish suddenly), increasing his take a chance of falling forward out of his wheelchair.

Participants provided examples of how economic factors combined with ecology factors increased their risk of falling. For case, the high cost of manual wheelchair add-ons (eg, 'shock-arresting' pulley wheels and pause caster forks) made information technology difficult for some participants to add together safety features that could potentially increase the wheelchair's stability when faced with environmental fall hazards (eg, potholes). One participant spoke near price preventing her from improving the accessibility and safety during vehicle transfers as she could not afford a wheelchair vehicle elevator. Another participant spoke virtually the egregious price of home modifications, every bit well as renovation restrictions he had to follow in his rental housing.

Some participants provided examples of the interaction of social and environmental factors that increased their chance of falling. For example, P9 voiced a concern with respect to receiving assistance from members of the public when trying to cantankerous the street in the fourth dimension allotted by the walk signal: 'people come along and say here permit me help you. And they wheel me without tilting me back and they have dumped me out of my wheelchair'.

Participants discussed several factors related to their wheelchair that when combined with other factors (ie, biological, behavioural, social and economic, and environmental) placed them in situations that increased their adventure of falling. A stationary footplate was ane feature perceived to be a tripping hazard when they performed transfers. Due to their size and position, narrow push rims were another characteristic that made information technology difficult for the manual wheelchair user to form a stable grip when performing a transfer or leaning to the side or forward. P6 explained that without a stable grip on the push button rim, 'it'south more likely for [him] to tip over'. Pocket-sized casters were another problematic wheelchair characteristic as they became stuck in small cracks on the ground or caused the wheelchair to get unstable when rolling over debris in the surroundings. Although larger casters were perceived to be more stable than smaller casters, at that place was a general consensus that larger casters reduced, only would not eliminate, their wheelchair tripping over obstacles on the path. Low tire pressure and loose wheelchair brakes became fall hazards during transfers, equally they acquired the wheelchair's middle of gravity to shift. Many participants explained how an ill-fitting wheelchair significantly increased the run a risk of falling. P2 attributed experiencing multiple falls during the early years living with her SCI as her first wheelchair was, 'eight inches too wide' and she was told by the wheelchair prescriber that '[she] would grow into it'.

Subtheme 1b: Consider fall risk associated with their deportment

Participants had to constantly consider autumn gamble associated with their deportment. There were instances where participants were aware that certain activities or decisions could increase their chance of falls, but they still decided to participate in the activeness. For example, most manual wheelchair users did not wear a seatbelt while they were in the wheelchair. As a manual wheelchair user, P9'due south preference for not wearing a seatbelt was related to preventing pressure level injuries: 'I have to elevator myself up for pressure sores. Then if I had a seatbelt on, it would exist an extra burden'. Some other manual wheelchair users believed falling while wearing a seatbelt increased their take chances of injury as the wheelchair would fall on top of them.

Despite supporting antitippers as safety features that could prevent falls, some participants chose not to use them because antitippers restricted their independence/autonomy and their ability to access sure areas inside the community. For example, antitippers restricted the ability to perform wheelies when overcoming high curbs, interfered with going up inclines, and were incompatible with some vehicle lifts. Also, participants described a negative stigma associated with using more adaptive aids, and consequently, many participants decided to remain 'minimalistic' with their use of adaptive devices, despite this decision potentially increasing their fall take a chance. For example, P2 explained that she chose not to use antitippers because of the stigma associated with them. P4 shared that antitippers made a wheelchair user expect like a novice and resembled training wheels on a cycle. Some participants used antitippers during the early on stages of their SCI or when they were adjusting to a new wheelchair. However, in one case they became more comfortable with the wheelchair, the antitippers were removed. Stigma was likewise a barrier to adopting other types of safety equipment. For instance, although P6 recognised that a flip downwards seat would ameliorate the safety of his car transfers, he chose to avert using it: 'the more than equipment I have, the more disabled I experience. I find even if it does aid me, I am still stubborn like that'.

Participants chose to eat alcohol in social situations, despite alcohol leading to decreased balance and inattention to the surroundings, sometimes resulting in a fall. P5 explained: '[alcohol] decreases my coordination… I am just more than relaxed and leaning back and tip over… in 20 years the only time I have hit my head was a few weeks agone and I arraign the red wine'. Similarly, some participants chose to bike on uneven environments during leisure activities, despite uneven basis increasing their adventure of falling. For instance, P1 recalled, 'I've fallen out of my chair a couple of times over the years… doing really ridiculous things similar coming down a grass hill, skidding sideways and stuff similar that'.

For participants that could ambulate brusk distances they described falls related to their legs 'giving out' or their knees buckling unexpectedly while in an upright standing position. Although P1 had poor rest, he continued to ambulate brusk distances every bit it was important for managing his pain, preventing force per unit area injury, maintaining skilful circulation and muscle tone. Similarly, leaning/reaching was required to complete activities of daily living; still, when participants reached in a higher place their head or leaned 'besides far' frontward, backwards or sideways, they could hands fall. Based on their physical abilities, each participant had a unlike notion of what was 'too far'.

Theme 2: Dynamic nature of autumn risk

The dynamic nature of falls was highlighted in many situations described by the participants. For example, at that place was a period of increased falls when participants began using new equipment such as a wheelchair, wheelchair cushion, bed or chair. P10 recalled how gruelling it was to learn and accommodate to the features of her new manual wheelchair: 'every time I have a wheelchair that's new, I commonly have to autumn a couple of times… to figure out where a safe place is to put my easily when I transfer, the weight of the chair, the centre of gravity'.

Based on their previous experiences, participants believed they were at an increased chance of falling when they had a decline in their physical or psychological health. Participants explained that illness or injury could subtract their muscle strength, physical endurance, tolerance and dynamic residual, and these intrinsic factors increased their chances of falling. For case, chronic shoulder issues due to overuse decreased P9's stability and balance during transfers from her manual wheelchair. Furthermore, secondary complications related to ageing with an SCI were perceived to increase the hazard of falling. For example, P1 explained that he experienced a greater number of spasms in his legs as he aged.

Also, fatigue from physical activity, psychological stress and/or a lack of sleep were perceived to contribute to falls considering fatigue increased participants' chances of making errors during motion. P6 found he was at an increased take chances of falling afterward his physiotherapy sessions because he felt, 'fatigued, stretched out' and 'when I become to practice the transfer in my van, [my muscles] are only non quite listening. I'm non as stiff in my core… I don't have the strength or my coordination'.

Theme three: Single factors were targeted to reduce fall risk and fall-related injuries

While the contributors to falls and autumn risk were multifactorial, the strategies suggested to reduce the participants' risk of falling commonly addressed a single factor. Box 2 lists fall prevention strategies based on recommendations and strategies highlighted by participants in this study.

Box 2

Strategies to reduce fall risk from the perspectives of wheelchair users with spinal cord injury

Strategies to reduce the risk of falling related to the wheelchair:

• Regular maintenance of wheelchair (eg, brakes and tire pressure).

• Large diameter casters.

• Stupor absorbing casters.

• Button rims should be broad enough to allow stable grip when reaching/leaning.

• Ensure wheelchair fits user appropriately.

• Increase seating dump if falling forward is a concern.

• Grip gloves to increase stability for transfers and reaching/leaning.

• Use seatbelts and chest straps when using a power wheelchair.

• Explore the benefits and drawbacks of using antitippers and seatbelts; utilize of these safe features should exist an informed option by wheelchair users.

Strategies to reduce the take a chance of falling in the dwelling house environment:

• Ensure grab bars are appropriately positioned in the washroom.

• A roll-in shower with a drain that does not crave sloping tiles.

• An outdoor ramp with drain holes to reduce rain/snow build up.

Behavioural strategies to reduce fall run a risk and minimise injuries:

• Continuously scan the environment and beware of small-scale cracks/uneven spots in pavement.

• Inspect surfaces prior to transfers.

• Accept more time during physical tasks (eg, transfers) to avoid rushing.

• Be enlightened of body signs (eg, levels of fatigue, pain and weakness).

• Advocate for removal of customs fall hazards.

• Tuck chin in when falling backwards to reduce chances of a fall-related injury.

• Twist to the side when falling forrard to reduce chances of a fall-related injury to the hands/wrists.

• Be self-aware of changing care needs due to illnesses/injuries.

• Take the fourth dimension to become familiar with new equipment (eg, a wheelchair, absorber and bed).

• Learn from causes of previous falls (eg, understand what caused the autumn and how to minimise fall risk).

• Inquire a peer for fall prevention tips.

• Understand that fall risk may increment when consuming alcohol.

• Ensure a secure grip on the wheelchair prior to reaching/leaning.

Biological strategies to reduce fall risk:

• Strengthen muscles and maintain range of motion/flexibility.

Socioeconomic strategies to reduce risk of falling:

• Ask for assistance when not confident performing job.

• Abet for trained personal care workers.

Subtheme 3a: Wheelchair features

Manual wheelchair features

In addition to possessing a correctly fitted wheelchair, participants offered several recommendations to reduce autumn gamble while using a transmission wheelchair. Wider push rims enabled the wheelchair user to concur on to the rim for actress back up when they leaned or reached, thereby reducing fall run a risk. Seat 'dump', which is when the rear part of the seat is lower than the front part of the seat, was particularly of import for those with poor core strength or who had recently sustained an SCI. Big-sized casters with a shock absorbing feature that minimised shock when rolling over uneven footing or descending/ascending curbs were also mentioned. A flip up footplate that provided more space for leg clearance when performing a transfer was recommended. Participants besides stressed that it was essential that the wheelchair user regularly maintained their wheelchair (ie, brakes and tire pressure) to reduce mechanical bug, which could contribute to fall-related accidents/injuries. There was give-and-take of how the added weight and/or width made manoeuvrability more than complicated and strenuous. P8 explained,

You gotta get a chair that fits you. Custom to your body shape and function level, that is lite, that yous tin can transfer in and out of your car and do all those things. So it's a toss upward… I could become a tank and take wheels that are five times equally big as this and the chair would weigh 300 pounds, merely that would limit my independence… it'southward a fine balance of having a chair that's lite and fits yous and is mobile.

The majority of manual wheelchair users agreed that installing antitippers on a wheelchair prevented backwards falling; withal, merely three of ix manual wheelchair users used antitippers to varying degrees. Come across figure 2 (photo B) for an prototype of antitippers. P9 explained:

Some people go home and put on some slippers. I switch chairs. And then I have an indoor chair at abode and I accept anti-tippers on information technology… If I'one thousand out in public, I tin can e'er get help to get up. Only if I'thou alone in my home, I wouldn't have anyone to help me get upwards.

P8 had a negative experience wherein the antitippers failed to prevent a autumn: 'I had anti-tip tubes on the back of my chair and I all the same fell out backwards. It didn't work'. P12 feared that falling backwards over her antitippers could lead to severe injuries.

Ability wheelchair features

Seatbelts and chest straps were found to be essential prophylactic features to preclude falls while operating a power wheelchair. P3 customised his wheelchair by adding a button activated tilting system that allowed him to independently regain postural stability later falling forrard. The reclining feature of a ability wheelchair enabled P3 to 'counterbalance' and compensate for positional changes caused when going up or down ramps.

Subtheme 3b: Ecology factors

Accessible spaces

A skilful curb cut at a crosswalk was perceived to reduce the risk of falling for both manual and power wheelchair users. Participants argued that a good crosswalk possessed the following features: a crosswalk button that was within reach of a wheelchair user's arm length, had a smooth ground with gradual incline transitions and provided wheelchair users with ample time to cross the road. In addition, sidewalks must be polish without cracks, potholes or droppings (eg, rocks, branches and snow/ice) to reduce a wheelchair users' risk of falling. P5 proposed 'routine examinations' and making property owners more accountable for cleaning sidewalks around their properties.

Adaptive equipment

Take hold of bars in the washroom were crucial to reducing a wheelchair user'due south risk of falling. P5 explained that the near useful catch bar was the L-shaped grab confined as they were easier to grip than an angled grab bar. In their home, participants applied a multifariousness of strategies to reduce their gamble of falling. After experiencing multiple falls during tub transfers, 1 participant changed her bathtub to a gyre-in shower; she also installed a drain effectually the perimeter of the shower that did non require sloping of the tile floor (ie, Schluter drain). Another strategy used to decrease the risk of a wheelchair shifting during transfers was resting the wheelchair on a non-slip mat.

Subtheme 3c: Behavioural factors

Taking more time

Taking their time when performing tasks provided wheelchair users with more time to notice and avoid a fall hazard. Power wheelchair users maintained that reducing their speed when going over door thresholds was a good preventive strategy. A fall prevention strategy mentioned by two participants when travelling was to call hotels and restaurants in advance to ensure they were easily accessible and fit their specific needs.

Scanning the environment

Constantly scanning the environment was a strategy used by all participants to avoid falls in the community. Beingness continuously cautious and alarm of their surround was of utmost importance to fugitive a fall.

Existence an experienced wheelchair user

Many participants believed that being a more experienced wheelchair user resulted in fewer falls. P9 explained she became better at recognising and fugitive fall chance with experience: 'The likelihood of my falling has reduced considering I've pretty much been through every scenario that I could where I had come up close to falling or really fallen. So you learn from those things'. She went on to say while the number of falls she experienced were fewer than in years past, she withal roughshod occasionally.

Body awareness

Wheelchair users explained that tuning into their current concrete and mental state prior to each physical task decreased their likelihood of falling. A participant who ambulated curt distances explained that his legs reacted differently to each flooring surface (eg, rug, hardwood or tile) requiring him to adjust his walking strategy for each surface to reduce his chances of falling.

Advocating for removal of community fall hazards

Advocating for city council to remove autumn hazards in the community was an constructive strategy previously used past some participants. It was a shared perspective that greater interest of wheelchair users in planning the layout of public spaces would significantly reduce customs autumn adventure and accessibility barriers.

Falling the right way

Since falls were believed to be inevitable, wheelchair users emphasised injury reduction strategies. For instance, several participants spoke about falling in a fashion that prevented a head injury. When falling backward from a manual wheelchair P12 said, 'yous constrict your chin in and you lot lean forward when yous feel yourself going dorsum. And that takes exercise'. About participants developed fall prevention strategies through receiving assistance from a therapist and drawing on prior fall experiences. P8 explained:

I was lucky that when I was in (deidentified rehabilitation centre), we were such a big group… we were simply going out to effort to have fun… we would flip out of our chairs and that was function of simply learning to exist in a chair. And we learned very quickly what to do if you autumn out of your chair… I remember my physiotherapist saying if you fall, put your head downwardly and fall backwards, scroll out of your chair and also how to become dorsum in information technology.

Subtheme 3d: Biological factors

There was express word on biological fall prevention strategies. The fall prevention strategies discussed by participants pertaining to intrinsic factors included improving strength, flexibility and losing weight every bit doing so would make it easier to perform transfers.

Subtheme 3e: Social and economic factors

Having easy admission to assistance and experienced/trained personal care workers were 2 aspects pertaining to social and economic factors that reduced wheelchair users' risk of falling. To reduce fall take chances, many participants asked for supervision or help from social supports or members of the public when they were not confident in performing a task. P1 advised, 'non to go besides proud to enquire for assist and take someone supervise while you lot're walking'.

Theme 4: Fall prevention experiences and priorities

Participants explained that the fall prevention training they had received was no longer advisable for their dynamic needs and discussed priorities for fall prevention initiatives.

Subtheme 4a: Training inappropriate for dynamic needs

Many of the participants felt they did not receive comprehensive fall prevention training later on sustaining an SCI. Despite being provided with fall prevention education, several participants ignored the communication they were given because they believed it was non applicative to their state of affairs or a concern for them until they savage. For some participants, the fall prevention didactics they received became inappropriate due to changes in their concrete abilities and role, such every bit transitioning from a ability to manual wheelchair or from being convalescent to using a wheelchair. Instead, P12 explained that autumn prevention skills were learnt from a peer with SCI: 'what my peer did was like getting those mats and didactics me how to autumn backwards properly'.

Subtheme 4b: Priorities for autumn prevention initiatives

According to the participants, the aims of fall prevention initiatives should be to inform people with SCI about fall risk factors, how they could acquire from previous falls and provide them with practical autumn prevention training. Wheelchair users would do good from educational activity about diverse wheelchair safety features, but their pick not to employ safety features should be respected. In addition, participants would similar autumn prevention training to include strategies to avoid falls when using their wheelchair and during transfers and to acquire how to mitigate common fall hazards in the home and community environments. P12 explained that the goal of fall prevention education was to teach wheelchair users how to minimise injury when falling; she explained in particular the 'tuck and roll' manoeuvre to protect the caput. Well-nigh importantly, participants argued since 'everyone is dissimilar' fall prevention grooming programmes should take private differences into account.

Discussion

Photo-elicitation interviews were used to meliorate understand the factors that increased and decreased autumn run a risk according to wheelchair users with chronic SCI. Findings from this written report suggest that each wheelchair user had a unique set of fall hazard factors based on an interaction of multiple fall hazard factors inside their specific situation, and their risk of falling was dynamic (ie, autumn prevention needs change over time). When addressing a wheelchair user'south fall take a chance, the individualised, dynamic and circuitous nature of fall risk and their dynamic autumn prevention needs should be considered. Participants besides discussed priorities for fall prevention training, also as multiple fall prevention strategies that they developed through their past experiences of falling.

Although individualised fall prevention approaches have been previously well supported and recommended for use with older adults,^{31 32} they have been less recognised for the SCI population. The need for individualised fall prevention is not a surprising finding given that individuals with SCI avowal a wide range of physical and functional abilities.³³ Our findings suggest a need for fall prevention initiatives to exist available throughout an individual'south life and adapted to reflect one's changing needs and life circumstances.

While previous literature reports that falls are a greater concern for younger, more than active individuals with SCI,³⁴ participants in the current report highlighted ageing-related factors that increased their risk of falling. Too, changes in a person's state of affairs, such every bit a temporary illness or more than permanent comorbidities, impacted their fall run a risk.

Contrary to previous studies,^{3 4} we found that the BBSE model was not advisable to categorise perceived fall gamble in the SCI population because falls are influenced past multiple and dynamic fall hazard factors that spanned across multiple categories of the model. In dissimilarity, when participants described factors or strategies that reduced their chances of falls, these often fit within a single category of the BBSE model. When developing fall prevention interventions, attention should move beyond unmarried gene solutions to account for the multifactorial nature of falls. Findings from a prior written report back up this approach to fall prevention as the authors found seventy% of falls were caused past more than ane autumn attribution.¹ In clinical practice, healthcare practitioners should consider whether individuals with SCI who are primarily wheelchair users also ambulate curt distances, as wheelchair users can experience falls during standing/walking.^{1 8} Providing these individuals with fall prevention strategies that address their fall risk related to wheelchair use besides as upright activities (eg, continuing/walking) may be beneficial. Furthermore, healthcare practitioners should acknowledge the multiple and interacting factors that influence a wheelchair user'southward fall take a chance that may span beyond multiple categories of the BBSE model. Doing so would direct the customisation of fall prevention programmes that encounter each person'due south private needs.

In add-on, several crucial fall hazards pertaining to wheelchairs were identified. It is critical for wheelchair designers, vendors and therapists to exist enlightened of the features that are perceived to increment and subtract the gamble of falling when designing or prescribing wheelchairs to individuals with SCI. Therapists and vendors should include the perspectives and concerns of wheelchair users in the blueprint and customisation of wheelchairs to account for an individual's needs and preferences.

Box ii lists fall prevention strategies based on recommendations and strategies highlighted by participants in this study. This information tin inform the development of multifactorial fall prevention strategies/education. Future research should further explore realistic and feasible autumn prevention techniques/strategies that a wheelchair user can easily utilize in their habitation and community environment.

Although an action or decision may increase the hazard of falling, participants may continue to participate in certain activities. Individuals 'make choices that take the greatest personal benefit and relevance to their lives'.³⁵ When because daily activities and the risk of falling, this decision-making approach was adopted by participants. For instance, despite recommendations encouraging the employ of seatbelts for manual wheelchairs,³⁶ the majority of wheelchair users in this study chose non to use seatbelts. Furthermore, the utilize of antitippers amid wheelchair users with SCI was variable considering antitippers were seen as limiting their independence. Interestingly, this is not the first fourth dimension wheelchair users have expressed a dislike for seatbelts and antitippers.³⁷ Every bit plant in the current study, safety features that raise a wheelchair's stability have also been previously recognised to interfere with functioning and manoeuvrability,³⁸ and when making decisions, wheelchair users may choose non to utilise antitippers for this reason. Making appropriate judgements to the hazard of falls presented in an action is important to subtract fall risk. To accost this, the utility of a self-management approach to autumn prevention that targets problem-solving and controlling skills has previously been highlighted.³⁵

Like to findings in previous studies,^{3 39} wheelchair users tend to develop autumn prevention strategies based on their life experiences. Thus, it might be worthwhile to explore whether practising practical fall prevention techniques in a controlled and safe setting reduces falls and/or fall-related injuries. In this study, information technology was suggested that peers, along with therapists, may exist a valuable combination for delivering fall prevention training. Peer mentoring has been employed in interventions for individuals with SCI^{xl 41} but has not yet been explored every bit a potentially viable fall prevention preparation method. Future enquiry should investigate the utility of peer mentoring in autumn prevention.

The limitations of this study are important to consider. Our first limitation is the apply of phone interviews. Although nosotros used telephone interviews to suit the participants that could not attend in person, nosotros recognise that the absence of visual cues in phone interviews may have reduced the depth/detail of information collected in those interviews.⁴² 2d, the participants that had difficulty holding and/or manipulating the camera asked a caregiver for assistance. It is possible that the caregivers may have influenced the photograph content.¹⁰ Third, although the researchers refrained from providing participants with examples of how they could reply to the photo-consignment, it is possible that the verbal photo-taking and photograph-assignment instructions provided could accept unintentionally influenced the content photographed by the participants. For instance, participants may have photographed fall adventure factors that they causeless the researchers would be interested in rather than what they idea was well-nigh meaningful.¹⁰ Fourth, the unequal distribution of manual and power wheelchair users is important to consider. Since there were more than manual wheelchair users in our sample, at that place was a greater focus on autumn take chances factors related to using a manual wheelchair. Fifth, the sex distribution of our sample (33% men and 67% women) did not represent that of the Canadian traumatic SCI population,⁴³ which could bear upon the trustworthiness of the data. However, the high proportion of women in our sample was as well a strength as women tend to be nether-represented in SCI inquiry.⁴⁴ Finally, since this written report presents the perspectives of participants that reside in an urban Canadian surround, the findings may take limited transferability to other environments/contexts.

Conclusion

In determination, multiple and dynamic factors influenced a wheelchair user's risk of falling. A need for peer-led autumn prevention/management education was highlighted in our study. To effectively address a wheelchair user's risk of falls, the complex nature of fall risk factors must exist accounted for. Findings from this study concord utility for multiple stakeholders (ie, wheelchair users with SCI, clinicians, researchers, vendors and wheelchair designers) and can inform individual approaches to understanding a wheelchair user'south risk of falling, also as autumn prevention strategies. Hereafter research should actively involve participants in the development of comprehensive and effective fall prevention interventions.

Supplementary Material

Acknowledgments

We would like to thank the participants for dedicating their time to this report.

Footnotes

Contributors: HS participated in study blueprint, nerveless and analysed the information and wrote the first typhoon of the manuscript. CYS participated in data analysis and manuscript writing. KY participated in information analysis and manuscript editing. SO participated in data assay and manuscript editing. AK participated data collection and manuscript editing. CC participated in report design, data drove, and manuscript editing. SJ participated in study design, data drove, and manuscript editing. KEM participated in the study design, analysis and manuscript writing. All authors read and approved the final manuscript.

Funding: This work was supported by the Craig H. Neilsen Psychosocial Research Grant (grant number 440070) to KEM, consulting fees paid to CYS from the Craig H. Neilsen Psychosocial Research Grant (grant number 440070) and a student scholarship from the Toronto Rehab Institute-University Health Network to HS.

Disclaimer: The funders did not have a function in the study's design, execution, analyses and interpretation of the data.

Competing interests: None declared.

Patient consent for publication: Not required.

Provenance and peer review: Not deputed; externally peer reviewed.

Information availability statement: No data are available.

References

1. Sung J, Trace Y, Peterson EW, et al. . Falls among total-time wheelchair users with spinal cord injury and multiple sclerosis: a comparing of characteristics of fallers and circumstances of falls. Disabil Rehabil 2019;41:389–95. ten.1080/09638288.2017.1393111 [PubMed] [CrossRef] [Google Scholar]

2. Forslund Eastward, Jørgensen V, Franzén Eastward, et al. . High incidence of falls and autumn-related injuries in wheelchair users with spinal cord injury: a prospective study of risk indicators. J Rehabil Med 2017;49:144–51. 10.2340/16501977-2177 [PubMed] [CrossRef] [Google Scholar]

3. Musselman KE, Arnold C, Pujol C, et al. . Falls, mobility, and physical activity subsequently spinal cord injury: an exploratory study using photo-elicitation interviewing. Spinal Cord Ser Cases 2018;4:39 10.1038/s41394-018-0072-ix [PMC gratis commodity] [PubMed] [CrossRef] [Google Scholar]

iv. Khan A, Pujol C, Laylor Thou, et al. . Falls later on spinal string injury: a systematic review and meta-analysis of incidence proportion and contributing factors. Spinal String 2019;57:526–39. x.1038/s41393-019-0274-4 [PubMed] [CrossRef] [Google Scholar]

5. Nelson AL, Groer S, Palacios P, et al. . Wheelchair-related falls in veterans with spinal cord injury residing in the customs: a prospective accomplice written report. Curvation Phys Med Rehabil 2010;91:1166–73. 10.1016/j.apmr.2010.05.008 [PubMed] [CrossRef] [Google Scholar]

vi. Nelson A, Ahmed South, Harrow J, et al. . Fall-related fractures in persons with spinal cord harm: a descriptive analysis. SCI Nurs 2003;20:30–seven. [PubMed] [Google Scholar]

8. Singh H, Flett H, Hitzig South. A comparison of falls between wheelchair users and ambulators with spinal cord injury [Poster presentation]. ACRM Annual Conference. Chicago, Il, 2019. [Google Scholar]

ix. Jannings West. A quality improvement project to investigate the circumstances of lower limb fractures in non-ambulant persons with spinal cord injury. JARNA 2017;xx:14–18. [Google Scholar]

10. LaVela SL, Balbale S, Hill JN. Experience and utility of using the participatory enquiry method, Photovoice, in individuals with spinal cord injury. Top Spinal String Inj Rehabil 2018;24:295–305. x.1310/sci17-00006 [PMC free commodity] [PubMed] [CrossRef] [Google Scholar]

11. Harper D. Talking nigh pictures: a case for photograph elicitation. Visual Studies 2002;17:xiii–26. 10.1080/14725860220137345 [CrossRef] [Google Scholar]

12. Clark-IbáÑez 1000. Framing the social world with Photo-Elicitation interviews. Am Behav Sci 2004;47:1507–27. x.1177/0002764204266236 [CrossRef] [Google Scholar]

13. Verrier K, Carson J, Brisbois L, et al. . Describing the feasibility, and planning for the scalability of central recruitment for patients with subacute SCI in tertiary academic rehabilitation centres. J Spinal Cord Med 2012;35:419–78. [Google Scholar]

14. Luborsky MR, Rubinstein RL. Sampling in qualitative inquiry: rationale, issues, and methods. Res Aging 1995;17:89–113. 10.1177/0164027595171005 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

fifteen. Rushton Prisoner of war, Kirby RL, Miller WC. Transmission wheelchair skills: objective testing versus subjective questionnaire. Curvation Phys Med Rehabil 2012;93:2313–8. 10.1016/j.apmr.2012.06.007 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

16. Fritz H, Lysack C. "I run into information technology at present": Using photo elicitation to sympathise chronic affliction self-management: 50'usage de la méthode de photo-interview cascade mieux comprendre l'autogestion des maladies chroniques. Can J Occup Ther 2014;81:247–55. [PMC free commodity] [PubMed] [Google Scholar]

17. Beat L. Photograph-Elicitation with Autodriving in research with individuals with balmy to moderate Alzheimer's disease: advantages and challenges. Int J Qual Methods 2014;xiii:170–84. 10.1177/160940691401300106 [CrossRef] [Google Scholar]

eighteen. Johnson CM, Sharkey JR, Dean WR, et al. . It'south who I am and what nosotros eat. Mothers' food-related identities in family unit nutrient pick. Appetite 2011;57:220–8. 10.1016/j.appet.2011.04.025 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

19. Lal S, Jarus T, Suto MJ. A scoping review of the Photovoice method: implications for occupational therapy research. Tin J Occup Ther 2012;79:181–ninety. ten.2182/cjot.2012.79.three.8 [PubMed] [CrossRef] [Google Scholar]

twenty. Torre D, Tater J. A different lens: changing perspectives using Photo-Elicitation interviews. Educ Policy Anal Arch 2015;23:111 10.14507/epaa.v23.2051 [CrossRef] [Google Scholar]

21. Wang CC. Photovoice: a participatory activity research strategy applied to women's health. J Womens Wellness 1999;8:185–92. 10.1089/jwh.1999.viii.185 [PubMed] [CrossRef] [Google Scholar]

22. Liebenberg L. Thinking critically about Photovoice: achieving Empowerment and social change. Int J Qual Methods 2018;17:1609406918757631. [Google Scholar]

23. Byrne Thousand. Interviewing every bit a data drove method. AORN J 2001;74:233–5. ten.1016/S0001-2092(06)61533-0 [PubMed] [CrossRef] [Google Scholar]

24. Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods 2006;5:80–92. 10.1177/160940690600500107 [CrossRef] [Google Scholar]

25. Catalani C, Minkler M. Photovoice: a review of the literature in health and public health. Health Educ Behav 2010;37:424–51. x.1177/1090198109342084 [PubMed] [CrossRef] [Google Scholar]

26. CPSI Reducing falls and injuries from falls 2015.

27. Krefting L. Rigor in qualitative research: the cess of Trustworthiness. Am J Occup Ther 1991;45:214–22. 10.5014/ajot.45.3.214 [PubMed] [CrossRef] [Google Scholar]

28. Tobin GA, Begley CM. Methodological rigour within a qualitative framework. J Adv Nurs 2004;48:388–96. 10.1111/j.1365-2648.2004.03207.x [PubMed] [CrossRef] [Google Scholar]

29. Thorne SE. Interpretive description: qualitative enquiry for applied practice. New York, NY: Routledge, 2016. [Google Scholar]

30. Lincoln YS, Guba EG, Pilotta JJ. Naturalistic enquiry. 9 Beverly Hills, CA: Sage, 1985: 438–ix. x.1016/0147-1767(85)90062-8 [CrossRef] [Google Scholar]

31. Sihvonen Southward, Sipilä S, Taskinen South, et al. . Fall incidence in fragile older women afterwards individualized visual Feedback-Based rest grooming. Gerontology 2004;50:411–6. ten.1159/000080180 [PubMed] [CrossRef] [Google Scholar]

32. Lord SR, Tiedemann A, Chapman K, et al. . The upshot of an individualized autumn prevention program on autumn adventure and falls in older people: a randomized, controlled trial. J Am Geriatr Soc 2005;53:1296–304. ten.1111/j.1532-5415.2005.53425.x [PubMed] [CrossRef] [Google Scholar]

33. Somers MF. Spinal cord injury: functional rehabilitation. 2nd edn Upper Saddle River, N. J.: Pearson Didactics, 2001. [Google Scholar]

34. Jørgensen V, Butler Forslund E, Franzén Eastward, et al. . Factors associated with recurrent falls in individuals with traumatic spinal cord injury: a multicenter report. Arch Phys Med Rehabil 2016;97:1908–sixteen. 10.1016/j.apmr.2016.04.024 [PubMed] [CrossRef] [Google Scholar]

35. Pohl P, Sandlund One thousand, Ahlgren C, et al. . Fall take a chance awareness and condom precautions taken by older community-dwelling women and Men—A qualitative study using focus group discussions. PLoS One 2015;ten:e0119630 ten.1371/journal.pone.0119630 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

36. Fast A, Sosner J, Begeman P, et al. . Forces, moments, and acceleration acting on a restrained dummy during simulation of three possible accidents involving a wheelchair negotiating a curb: comparison betwixt lap chugalug and four-signal belt. Am J Phys Med Rehabil 1997;76:370–7. 10.1097/00002060-199709000-00004 [PubMed] [CrossRef] [Google Scholar]

37. Chen W-Y, Jang Y, Wang J-D, et al. . Wheelchair-related accidents: relationship with wheelchair-using beliefs in active community wheelchair users. Arch Phys Med Rehabil 2011;92:892–8. x.1016/j.apmr.2011.01.008 [PubMed] [CrossRef] [Google Scholar]

38. Kirby RL, Ackroyd-Stolarz SA, Brown MG, et al. . Wheelchair-related accidents acquired past tips and falls amid noninstitutionalized users of manually propelled wheelchairs in nova Scotia. Am J Phys Med Rehabil 1994;73:319–30. 10.1097/00002060-199409000-00004 [PubMed] [CrossRef] [Google Scholar]

39. Jørgensen V, Roaldsen KS. Negotiating identity and self-image: perceptions of falls in ambulatory individuals with spinal string injury – a qualitative study. Clin Rehabil 2017;31:544–54. 10.1177/0269215516648751 [PMC complimentary article] [PubMed] [CrossRef] [Google Scholar]

40. Gainforth HL, Latimer-Cheung AE, Davis C, et al. . Testing the feasibility of preparation peers with a spinal string injury to learn and implement brief action planning to promote concrete activity to people with spinal cord injury. J Spinal Cord Med 2015;38:515–25. 10.1179/2045772314Y.0000000239 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

41. Ljungberg I, Kroll T, Libin A, et al. . Using peer mentoring for people with spinal cord injury to enhance self-efficacy beliefs and prevent medical complications. J Clin Nurs 2011;20:351–eight. 10.1111/j.1365-2702.2010.03432.10 [PubMed] [CrossRef] [Google Scholar]

42. Garbett R, Mccormack B. The experience of practice development: an exploratory telephone interview study. J Clin Nurs 2001;ten:94–102. x.1046/j.1365-2702.2001.00455.x [PubMed] [CrossRef] [Google Scholar]

43. Guilcher SJT, Munce SEP, Couris CM, et al. . Health care utilization in non-traumatic and traumatic spinal cord injury: a population-based report. Spinal String 2010;48:45–l. 10.1038/sc.2009.78 [PubMed] [CrossRef] [Google Scholar]

44. Krause JS, Broderick L. Outcomes after spinal cord injury: comparisons as a function of gender and race and ethnicity. Arch Phys Med Rehabil 2004;85:355–62. 10.1016/S0003-9993(03)00615-4 [PubMed] [CrossRef] [Google Scholar]

---

Articles from BMJ Open are provided here courtesy of BMJ Publishing Grouping

---

haneypereve.blogspot.com

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7045099/

Share this post