DEVELOPMENT OF A NEW SELF-REPORT QUESTIONNAIRE:

THE AMBULATORY SELF-CONFIDENCE QUESTIONNAIRE (ASCQ)

by

MIHO ASANO

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

REQUIREMENTS FOR T H E D E G R E E OF

M A S T E R OF SCIENCE

in

F A C U L T Y OF G R A D U A T E STUDIES

(Rehabilitation Sciences)

T H E U N I V E R S I T Y OF BRITISH C O L U M B I A

October 2005

© M i h o Asano, 2005
Abstract

Ambulation is one o f the most important aspects o f mobility as a whole.

Difficulty with ambulation is a common problem among older adults i n North America.

Accordingly, maintaining or regaining their ambulation, at home and i n the community,

is a major goal and a great concern for older adults i n rehabilitation programs. For

researchers and clinicians i n rehabilitation sciences, major goals and challenges include

developing and using sufficient and effective measurement tools. Measurement tools that

assess ambulation are an essential form o f 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 skill can be predictive o f 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 o f this study included assessment of: 1) content validity o f the A S C Q by a

panel o f experts; and 2) reliability and construct validity o f the A S C Q among older

adults. The results o f 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 ASCQ

demonstrated excellent internal-consistency and test-retest reliability; and 3) the support

for construct validity was evident for a sample o f older adults.

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Table of Contents

Abstract • • 11

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

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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

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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 " U p & G o " Test 99

Appendix VII: The Activity specific Balance Confidence Scale. 100

Appendix VIII: The Instrumental Activity o f Daily L i v i n g Scale 101

Appendix I X : The Folstein's M i n i Mental State E x a m 102

Appendix X : Socio-demographics and measurement outcomes categorized by the type o f

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 Follow-Up Questionnaire Ill

Appendix X V I I : A Sample Information and Consent Form 112

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List of Tables

Table 1: Characteristics o f Selected Measures o f Walking 20

Table 2.1: Demographic o f A l l Participants 39

Table 2.2: Occupational and Educational Background o f A l l Clinicians, Academics, and

Students 40

Table 2.3: The Results o f Survey I: Item Clarity and Appropriateness. 41

Table 2.4: The Results o f Survey I: the A S C Q " Y e s or N o " Questions 44

Table 2.5: The Results o f Survey I: the A S C Q Response Format Preference 45

Table 2.6: The Results o f Survey II: Item Clarity, Importance, and Disacrimination 46

Table 2.7: The Results o f Survey II: the A S C Q " Y e s or N o " Questions 50

Table 2.8: A B r i e f Summary o f the primary changes in the A S C Q 51

Table 3.1: Sociodemographics o f A l l Participants 77

Table 3.2: Results o f the Self-Report Questionnaires and Performance-Based Tests 79

Table 3.3: Internal Consistency and Test Retest Reliability o f A S C Q 80

Table 3.4 - Correlation o f the A S C Q with Other Study Measures 82

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List of Figures

Figure 1.1: Theoretical M o d e l for the Proposed Study 22

Figure 1.2: I C F M o d e l & 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

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Acknowledgements

Great appreciations to my thesis committee, Dr. B i l l M i l l e r , D r . Catherine

Backman, Dr. Janice E n g , and Dr. Roger W o n g for their support and invaluable input.

A special thank you to my graduate supervisor, Dr. B i l l M i l l e 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 o f 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.

viii
Chapter 1: Introduction

1.1 Overview of the Thesis

This thesis is comprised o f four chapters: 1) an introduction, rationale, and

purpose o f the proposed study; 2) a manuscript examining the content validity o f a new

measure o f ambulation confidence; 3) a manuscript examining the reliability and

construct validity o f a new measurement o f ambulation confidence; and 4) overall

conclusions and future implications o f the study.

1.2. Purpose

The overall aims o f 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 o f the new questionnaire using a panel o f experts (academics,

clinicians, and professional or graduate level students, and older adults) and to assess the

reliability and construct validity o f 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 o f daily living (Shumway-Cook et al., 2002) and a key determinant of their

quality o f life (Spector et al., 1987; O ' B o y l e , 1997). In older adults, mobility can become

impaired as a result o f 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 A g i n g " reported that as many as 19% o f the 26,4 million "non-

institutionalized adults", older than 65 living in the United Sates had difficulty with

walking (Havilk et al., 1987). More recently, i n 2001, Human Resources Development

Canada ( H R D C ) reported that 39.5% o f Canadian adults between 75 and 84 years o f age,

and 57.7% o f 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 o f older adults in North America (Guccione, 1993; Moore et al., 1997;

R i k l i & Jones, 1997). Therefore, maintaining control o f 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 o f having a tool to assess patients' conditions and prescribe appropriate

rehabilitation programs, best suited for use in everyday practice o f rehabilitation sciences,

has been stressed for some time (Ware et al. 1981; Jette, 1989). Consequently,

remarkable amounts o f research designed to quantify an individual's ability to function

have been reported (Applegate et al. 1990). A number o f valid and reliable measurement

tools have been developed to evaluate an individual's handicap, impairment, or diability

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and to assess change over time (Sherman et al., 1998). Even though it is widely agreed

that this kind o f screening o f 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 o f information for researchers and clinicians,

because they have been shown to be predictive o f the ability to perform activities o f 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 o f 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

" U p & G o " test ( T U G ) , and the 6-Minute Walk Test ( 6 M W T ) . The T U G is an

assessment o f many o f the components o f 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 o f the distance that an individual is able to walk at his or her "normal"

speed in a given amount o f time (American Thoracic Society, 2002). The 6 M W T

measures the global responses o f 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 o f 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 o f 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 living 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 i n 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 skill

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 o f their ability. Perception has been found to be particularly important for

predicting performance, more so than an individual's skill or ability (Bandura, 1997;

Pajanes, 2002).

1.4 Theory and Concept behind the Proposed Study

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 In 1977, Bandura introduced self-efficacy theory and social cognitive theory to

the world o f psychology (Bandura, 1977). Since then, these theories have been used to

support many investigations i n 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 o f action required to manage perceptive situation" (Bandura,

1977& 1986; Bandura & Adams, 1977). In other words, self-efficacy addresses the

question o f " C a n 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 o f activities and

environmental settings regardless o f 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 o f (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 o f information that influence an individual's self-efficacy:

1) performance attainment, 2) vicarious experience, 3) verbal and social persuasion, and

4) physiological state.

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 Performance attainment, such as experience o f learning skills, is believed to be

the most powerful source o f 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 o f the process. W i t h or without

difficulties and obstacles, performance attainment experience can ultimately help

individuals master the necessary skills.

Vicarious experiences are the second principal source o f 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 o f 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 o f 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 o f 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 o f 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.

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 The aforementioned four sources o f self-efficacy are crucial factors to be

considered and implicated in the field o f rehabilitation sciences. If the theory is applied

correctly i n the field, we can assess individuals' ambulation skills using a self-report

scale o f ambulation confidence that is more cost, space, and time effective, as well as

less o f 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 o f 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 o f actual performance or achievement levels (Gage et al., 1994; Bandura,

1997). For instance, one o f the commonly-used scales in the rehabilitation sciences, the

Activity-Specific Balance Confidence ( A B C ) Scale, was developed to include the

concept o f self-efficacy (Powell & Myers, 1995). The A B C measures perceived-balance

ability while an individual is performing a series o f specific activities. The A B C has

revealed the degree to which an individual believes they are capable o f participating in

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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 o f their actual

performance (Hatch et al., 2003).

The International Classification of Functioning, Disability and Health (ICF) model

of Functioning and Disability

The International Classification o f Functioning, Disability and Health (ICF)

model was created by the World Health Organization ( W H O ) to assist health

professionals define and classify elements o f 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 I C F model and defines

the primary components. For our study, we focused on two important factors that may

influence an individual's level o f activity (such personal factors and environmental

factors). A m o n g 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, i n their living

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 o f the individual and personal

resources, which might be influenced by Environmental Factors and Activity

(ambulation). W e recognize the importance o f personal and environmental factors and

8
health conditions as predictors or determinants o f 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) o f ambulatory in various living settings. The

ASCQ reflects level o f confidence (personal factor) and it takes into context o f

environment and should be an indicator o f 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 skill.

The Influence of the Environment on Activity Performance

More recently, in addition to the W H O ' s notion o f 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 o f

understanding the association between the environment and an individual's ambulatory

(mobility) skill has been emphasized for both prevention and rehabilitation o f 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 o f 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 skill i n 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 o f collecting standardized

functional status information from an individual ( M c D o w e l l & N e w e l 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. W i t h 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 living arrangements, this type o f 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 o f 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 o f older adults' ambulation. In addition, a

manual search o f reference lists o f those articles identified by the electronic database

search was also conducted. We introduce few existing questionnaires used i n an older

adult population i n this chapter. These questionnaires include the Environmental Analysis

of Mobility Questionnaire ( E A M Q ) that assesses the frequency o f encounter and

avoidance o f 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 o f 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 o f 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 o f meters) using a 'yes or no' answering

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system; thus, they may not encompass all the necessary elements o f home and

community ambulation. The items o f the Walking A b i l i t y Questionnaire (WAQ),

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 o f the W A Q reported in the study. Table 1 presents an additional summary o f

self-report walk or mobility questionnaires.

None o f 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 & M i l l e r , 2005;

Leyden et al., 2003; M i l l e 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 o f

confidence is a reliable predictor o f their performance (Bandura, 1977, 1992, & 1997;

Panjanes, 2002). Therefore, we speculated that successful assessment o f an individual's

confidence (self-efficacy) in environmental ambulation may provide clinicians and

researchers i n 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 living in their homes

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and communities safely and independently. Table 1 presents a summary o f the self-report

waling scales.

A t present there is no self-report questionnaire that focuses on the assessment of

confidence in ambulation i n an individual's real living situation. In order to address this

shortcoming the primary purpose o f this study was to develop a self-report questionnaire

of ambulation confidence.

1.5 Study Objectives and Hypotheses

The objectives o f this study are to: 1) develop a questionnaire that records

information about an individual's perception o f confidence while walking in different

environments; 2) assess the content validity o f the questionnaire using a panel o f experts;

and 3) assess the reliability and the construct validity o f 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). W i t h age, many

13
individuals have ambulatory-related disabilities, and this can lead to an increasing

likelihood o f the hospitalization o f older adults for medical and functional issues.

Requirements for the independent ambulation in a real living situation can differ

depending on an individual. A s the concept o f environmental ambulatory skill is difficult

to define or measure, there are no questionnaires or preferred performance-based

measures to directly assess an individual's ambulatory skill in his or her real living

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 o f an individual's perceived ambulatory skill in his or her living situation, the

use o f the questionnaire may assist researchers and clinicians in their efforts to measure

ambulatory function. More importantly, the ASCQ may help clinicians target

individuals/patients who need additional treatment to improve their confidence ultimately

their participation i n daily activities.

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1.7 References

Alexander, N . B . , Guire, K . E . , Thelen, D . G . , Ashton-Miller, J . A . , Schults, A . B . ,

Grunawalt, J.C., Giordani, B . (2000). Self-reported walking ability predicts functional
mobility performance in frail older adults. Journal o f the American Geriatrics Society,
48(11), 1408-1413.

American Thoracic Society (2002). A T S statement: Guidelines for the Six-Minute Walk
Test. American Journal o f Respiratory and Critical Care Medicine, 166, 111-117.

Bandura, A . (1977). Self-Efficacy: Toward a unifying theory o f behavior change.

Psychological Review, 84(2), 191-215.

Bandura, A . , & Adams, N . E . (1977). Analysis o f self-efficacy theory o f behavior change.

Cognitive Therapy and Research, 1(4), 287-310.

Bandura, A . (1982). Self-efficacy mechanism in human agency. American Psychologist,

37(2), 122-147.

Bandura, A . (1986). Social Foundations o f Thoughts and Action: A Social Cognitive

Theory. N e w Jersey: Prentice-Hall, Inc.

Bandura, A . (1997). Self-efficacy: the exercise o f control. N e w York: Freeman.

Bennett , K . J . (2000). Exercise programs offset age-related disabilities. Geriatrics and

Aging, 3,12.

Browne, J.P., O'Boyle, C . A . , M c G e e , H . M . , Joyce, C . R . , M c D o n a l d , N . J . , O'Malley, K . ,

Hiltbrunner, B . (1994). Individual quality o f life in the healthy elderly. Quality o f Life
Research, 3(4):235-44.

Cohen, J.J., Sveen, J.D., Walker, J . M . , & Brummel-Smith, K . (1987). Establishing

criteria for community ambulation. Topics in Geriatric Rehabilitation, 3 (1), 71-77.

Collins, T . C . , Suarez-Almazon, M . , Petrsen, N . J . , O ' M a l l e y , K . J . (2004). A Spanish

translation o f the Walking Impairement Questionnaire was validated for patients with
peripheral arterial disease. Journal o f Clinical Epidemiology, 57(12), 1305-1315.

Enright, P . L . , McBurnie, M . A . , Biter, V . , Tracy, R.P., McNamara, R., Arnold, A . , &

Newman, A . B . (2003). The 6-min Walk Test: A quick measure o f functional status in
elderly adults. Chest, 123(2), 387-398.

Fougeyrollas, P., Cloutier, R., Bergaton, H . , Cote, J., & St M i c h e l , G . (1999). The
Quebec classification: Disability Creation Process. International Disability Process,
Canada.

15
Fougeyrollas, P., Noreau, L . , & Boschen K . (2002). Interaction o f Environment with
individual characteristics and social participation: Theoretical perspectives and
applications in persons with spinal cord injury. Topics in Spinal Cord Injury
Rehabilitation, 7 (3), 1-16.

Fries, J.F. (1980). A g i n g , natural death, and the compression o f mobility. The N e w
England Journal o f Medicine, 303, 130-135

Gage, M . , N o h , S., Polatajko, H . J . , Kaspar, V . (1994). Measuring perceived self-efficacy

in occupational therapy. The American Journal o f Occupational Therapy, 48 (9), 783-
790.

Gauthier-Gagnon, C , Grise, M . C . , Lepage, Y . (1998) The Locomotor Capabilities index:

content validity. Journal o f Rehabilitation Outcome Measurements, 2, 40-46.

Gray, D . B . , & Hendershot, G . E . (2000). The I C I D H - 2 : Developments for a new era o f

outcomes research. Archives o f Physical Medicine and Rehabilitation, 81(S2), S10-S15.

Guccione A A . Physical therapy diagnosis and the relationship between impairment and
function. Physical Therapy 1991; 71: 499-504

Guccione, A . A . (Ed.). (2000). Geriatric Physical Therapy ( 2 nd

edition). St. Louis, M O :
Mosby-Year Book Inc.

Guralnik, J . M . , Ferrucci, L . , Simonsick, E . M . , Salive, M . E . , & Wallace, R . B . (1995).

Lower-extremity function in persons over the age 70 years as a predictor o f subsequent
disability. N e w England Journal o f Medicine, 332, 556-561.

Harada, N . D . , Chiu, V . , & Stewart, A . L . (1999). Mobility-related function i n older adults:

Assessment with a 6-Minute Walk Test. Archive o f Physical Medicine and
Rehabilitation, 80, 837-841.

Hatch, J., G i l l - B o d y , K . M . , Portney, L . G . (2003). Determinants o f balance confidence in

community-dwelling elderly people. Physical Therapy, 83 (12): 1072-79.

Havilk, R.J., L i u , B . M . , & Kover, M . G . (1987). Health statistics on older persons, United
States, 1986. Washington, D . C . : National Center for Health Statistics, Public Health
Service, U . S . Government Printing Office.

Human Resources Development Canada (2003). A profile o f disability in Canada, 2001.

Ottawa, Ontario: Statistics Canada.

Jette, A . M . (1989). Diagnosis and classification by physical therapist: A special

Communication. Physical Therapy, 69(11), 967-969.

16
Katz, S., Branch, L . G . , Branson, M . H . , Papsidero, J . A . , Beck, J.C., & Greer, D . S . (1983).
Active life expectancy. The N e w England Journal o f Medicine, 309, 1218-1224

Legro, M : W . , Reiber, G . D . , Smith, G . D . , del Agulia, M . , Larsen, J., Boone, D . (1998).

Prosthesis Evaluation Questionnaire for persons with a lower limb amputation: assessing
prosthesis-related quality o f life. Archives o f Physical Medicine and Rehabilitation, 79,
931-938.

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.

Leyden, K . M . (2003). Social Capital and the Built Environment: The Importance o f
Walkable Neighborhoods. American Journal o f Public Health, 93(9), 1548-1551.

Lorig K , Stewart A , Ritter P, Gonzalez V , Laurent D , L y n c h J. (1996). Outcome

Measures for Health Education and other Health Care Interventions. California: Sage
Publications, Inc

M c D o w e l l , I., & N e w e l l C . (1996). Measuring health: A guide to rating scales and

questionnaires, ed.2. Oxford, Oxford University Press.

Moore, E . G . , Rosenberg, M . W . , & McGuinness, D . (1997). Growing O l d in Canada:

Demographic and Geographic Perspectives. Ontario. Canada: International Thomson
Publishing.

Myers, A . M . , Holiday, P.J., Harvey, K . A . , & Hutchinson, K . S . (1993). Journal o f

Gerontology: Medical Sciences, 48(5), M 1 9 6 - M 2 0 6 .

Nair, M . G . (1999). Clinical exercise specialist manual. San Diego, C A : American

Council on Exercise.

Noreau, L . , Fougeyrollas, P., & Vincent C . (2002). The L I F E - H : Assessment o f the

quality o f social participation. Technology and Disability, 14(3), 113-118.

O'Boyle, C A . (1997). Measuring the quality o f later life. Philosophical Transactions o f

the Royal Society o f London - Series B : Biological Sciences, 352(1363): 1871-9.

Pajanes, F. (2002). Emory University. Overview o f social cognitive theory and o f self-
efficacy. Accessed from: www.des.emory.edu/mff/eff.html.

Perry, J., Garrett, M . , Gronley, J . K . , Mulroy, S.J. (1995). Classification o f walking

handicap in the stroke population. Stroke, 26, 982-989.

17
Podsiadlo, D . , & Richardson, S., (1991). The timed " U P & G o " : A test o f basic
functional mobility for frail elderly persons. Journal o f the American Geriatrics Society,
39(2), 142-148.

Powell, L . E . , & Myers, A . M . (1995). The Activity-specific Balance Confidence ( A B C )

Scale. Journal o f Gerontology: Medical Sciences, 50A (1), M 2 8 - M 3 4

Richardson, J., L a w , M . , Wishart, L . , Guyatt, G . (2000). The use o f a simulated

environment (easy street) to retrain independent living skills in elderly persons: a
randomized controlled trial.
Journals o f Gerontology Series A - B i o l o g i c a l Sciences & Medical Sciences.
55(10):M578-84,

R i k l i , R . E . , & Jones, C . J . (1997). Assessing physical performance in independent older

adults: Issues and Guidelines. Journal o f A g i n g and Physical Activity, 5, 244-261.

R i k l i , R., & Jones, J. (1998). The reliability and validity o f a 6-Minute W a l k Test as a
measure o f physical endurance in older adults. Journal o f A g i n g and Physical Activity, 6,
363-375.

Robinett, C . S., & Vondran, M . A . (1988). Functional ambulation velocity and distance
requirements in rural and urban communities. Physical Therapy, 68 (9), 1371-1373.

Rudberg M A , Parzen, M . I . , Leonard, L . A . , Cassel, C . K . (1996). Functional limitation

pathways and transitions in community-dwelling older persons. Gerontologist, 36: 430-
440.

Sherman, S.E., & Reuben, D . (1998). Measures o f functional status in community-

dwelling elders. Journal o f General Internal Medicine, 13, 817-823.

Schmid, A . H . (1991). The deficiency model: A n exploration o f current approaches to

latelife disorders. Psychiatry, 54, 358-367.

Shumway-Cook, A . , Brauer, S., Woollacott, M . (2000). Predicting the probability o f falls

in community-dwelling older adults using the Timed U p & Go test. Physical Therapy,
80(9): 896-903.

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.

Spector, W . D . , Katz, S., Murphy, J.B., & Fulton, J.P. (1987). The hierarchical
relationship between Activities o f Daily L i v i n g and Instrumental Activities o f Daily
Living. Journal o f Chronic Disease, 40(6), 481 -489.

18
Steffen, T . M . , Hacker, T . A . , & Mollinger, L . (2002). A g e - and gender-related test
performance in community-dwelling elderly people: Six-Minute Walk Test. Berg
Balance Scale, Timed U p & G o Test, and gait speed. Physical Therapy, 82 (2), 128-137.

Suzuki, T., Yoshida, H . , K i m , H . , Yukawa, H . , Sugai, M . , Furuta, T., Nishizawa, S.,

Kumagai, S., Shinkai, S., Ishizaki, T., Watanabe, S., & Shibata, H . (2003). Walking
speed as a good predictor for maintenance o f I - A D L among the rural community elderly
in Japan: a 5 year follow-up study from T M I G - L I S A . Geriatrics and Gerontology
International, 3, 1-6.

Tager, I.B., Swanson, A . , & Satariano, W . A . , (1998). Reliability o f physical performance

and self-reported functional measures in an older population. Journal o f Gerontology:
Medical Sciences, 5 3 A (4), M 2 9 5 - M 3 0 0 .

Viosca, E . , Lafuente, R., Martinez, J.L., Almagro, P.L., Gracia, A . , Gonzalez, C . (2005).
Walking recovery after an acute stroke: assessment with a new functional classification
and the Barthel Index. Archives o f Physical Medicine and Rehabilitation, 86(6), 1239-
1244.

Voorriops, L . E . , Ravelli, A . C . , Dongelmans, P.C., Deurenberg, P., V a n Stareren, W . A .

(1991). A physical activity questionnaire for the elderly. Medicine and Sciene in Sports
and Exercise, 23 (8), 974-979.

Wagstaff, S. (1989). The use o f the 'International Classification o f Impairments,

Disabilities and Handicaps' in Rehabilitation. Physiotherapy, 68(7), 233-235.

Ware, J.E., Brook, R . H . , Davie, A . R . , & Lohr, K . N . (1981). Choosing measures o f health
status for individuals in general populations. America Journal o f Public Health, 71(6),
620-625.

World Health Organization. (2001). International Classification o f Functioning,

Disability and Health. Geneva: World Health Organization.

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Table 1. Characteristics of Selected Measures of Walking

Instrument Item # Conceptual Focus Population Purpose

Scale Format
EAMQ 24 items Walking Capacity Older adults Assesses the frequency o f encounter
Shumway-Cook et al., 2003 Likert scale and avoidance of physical obstacle in eight
dimensions (density, attention, terrain,
postural transition, physical load, ambient,
template, and distance dimention)

FACHS 6-level Lower-extremity Older adults Assesses the performance by lower

Viosca et al., 2005. Classification performance Stroke extremity j oint movements
observation

Neighbourhood Walkability scale 10 items Walking Capacity General Assesses the capability to walk in a
Leyden et al., 2003. Likert scale neighbourhood

HPAQ 22 items Physical activity Older adults Assesses walking frequency, distance,
Vorrips et al., 1991. (total) & walking and duration
3 items performance
(walking)
Metric system

Rosow-Breslau scale 3 items Walking Capacity Older adults Assesses basic walking ability
Alexander et al., 2000. 'yes/no'
questions
PEQ-MS 13 items Perceived Prosthetic Assesses the perceived mobility
Legroet al., 1998. Likert scale mobility (amputation) capability
Capability

PPA-LCI 11 items Transfer & Prosthetic Assess the ability to perform selected
Gauthier-Gagnon et al., 1998. Likert scale ambulation (amputation) loco-motor activities such as transferring, or
Capacity climbing stairs

WAQ 19 items Walking Capability Older adults Assesses an individual's social limitations
Perry et a l , 1995. Category due to his or her walking disabilities
response

WIQ 14 items Walking Capacity Young adult Assesses an individual's degree o f

Collins et al., 2004. Likert scale (55< age) difficulty to walk by distance,
speed, stair climbs, and more.

E A M Q - Environmental Analysis o f Mobility Questionnaire

F A C H S - Functional Ambulation Classification o f Hospital at Sagunto

H P A Q - Habitual Physical Activity Questionnaire

P E Q - M S -Prosthetic Evaluation Questionnaire Mobility Subscale

P P A - L C I - the Prosthetic Profile o f the Amputee Locomotor Capabilities Index

W A Q - Walking Ability Questionnaire

W I Q - Walking Impairment Questionnaire

 Behaviour

Personal Factors Environmental Factors

(Cognitive, affective, and biological)

Figure 1 . 1 - Theoretical M o d e l for the Proposed Study

22
 Health Condition

Body Functions and Activities Participations

Structures

1
Environmental Factors Personal Factors

Body Functions - the physiological and psychological functions of body system

Body Structures - anatomical parts o f 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 - I C F M o d e l & Definition

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Chapter 2: Content Validity of the Ambulatory Self-Confidence Questionnaire

2.1 Introduction

Older Adults & Ambulation Problems

A g i n g 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 o f the most important skills to

maintain quality o f life (Shumway-Cook et al., 2002; Lawton, 1999; Spector et al., 1987).

Moreover, difficulty with ambulation is one o f the most common problems seen in older

adults living i n North America (Havilk et al., 1987; H R D C , 2003). Approximately 70%

to 80% o f Canadian adults aged 65 years or older reported having ambulation problems

related to disability (Statistics Canada, 2001). In the field o f rehabilitation sciences,

maintaining or regaining independent mobility, at home and in the community, is often

identified as one o f 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 o f 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 ( M c D o w e l l & Newell, 1996). A recent review o f the literature

24
revealed that there is no self-report questionnaire that exclusively focuses on the

assessment o f 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 o f the promising instrument (Gregory, 1996). Assessing content

validity is considered to be one o f 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 i n 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 o f this study was to assess the content validity o f a new self-report

questionnaire, the Ambulatory Self-Confidence Questionnaire ( A S C Q ) , with experts

including academics and clinicians; students in the field o f rehabilitation science and

medicine; and community-dwelling older adults.

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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 o f the

questions and which response format they preferred.

2.3.2 Participants

The participants included academics and clinicians in the field o f rehabilitation

sciences and medicine, and professional or graduate-level students who: 1) were familiar

with the assessment o f 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 o f older adult

judges included individuals who: 1) were > 65 years o f age; 2) could comprehend

English; and 3) were capable o f walking with or without a walking aid.

A variety o f 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 o f 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 o f 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 o f 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 o f experience and specialty was collected from the practitioner/researcher

participants. A g e , sex, use and type o f walking aid information was collected from the

older adult participants. If no response was received within 10 days o f 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 o f 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 o f British Columbia's Behavioral Ethic Review

Board. Figure 2 presents the protocol in detail.

2.3.4 Measures

The survey that accompanied version 1 o f the A S C Q asked i f the item was: 1)

clearly worded; 2) appropriate as a factor o f 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 o f 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 o f 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 M i l l e r at the

University o f British Columbia. A copy o f the A S C Q version 1, version 2, and version 3

(final version) are presented in Appendix I, and Appendix II is i n Appendix III,

respectively.

2.3.5 Data Analysis

Data analysis was performed using descriptive statistics using SPSS Windows

11.5. The number o f participants responding were reported for each question. Agreement

on suitability o f an A S C Q item was inferred i f >50% o f 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 o f academic, clinician, and student,

participant (8 females and 10 males) had an average o f 11.3 ± 10.4 years experience in

their field o f specialty. The group o f the community-dwelling older adults (7 females and

6 males) had an average age o f 75.6 ± 7.4 years. Approximately 46 % o f older adults

reported to be a regular walking aid user. Tables 2.1 and 2.2 present a summary o f the

participant characteristics.

28
The first survey

The results o f the first survey questions are shown in Table 2.3. Results are

grouped by question (i.e. clarity and appropriateness o f the A S C Q items). For the clarity,

appropriateness, and importance section, the experts commonly agreed (> 50% o f

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% o f the experts agreed that there was no need

to add further items to the questionnaire; 7 1 % agreed that there was no need to delete any

items from the questionnaire; and 6 1 % agreed that there was need to modify some items

in the questionnaire (Table 2.4). In addition, 90% o f 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 o f 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 i n and out o f transportation and sitting down and up from a

seat should be classified as a balance and strength skill rather than as an ambulation skill.

Accordingly these questions were removed from the original version o f the A S C Q . A s for

riding an escalator-type items, the infrequency o f the use o f the escalator or the option o f

using a different method such using an elevator were suggested by several experts; thus,

29
this type o f item was removed from the original version o f the A S C Q . The revised

version o f 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 o f 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 % o f 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 o f the major changes o f the A S C Q items. Comparing the 1 st

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 o f detecting ambulation problems among

older adults. Several studies suggest that one's level o f confidence is a strong indicator o f

their level o f performance (Bandura, 1977, 1992, & 1997; Shwarzer & Renner; Panjanes,

2002). Additionally, identifying and modulating an individual's level o f confidence by

experiencing a necessary skill; 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 o f ambulatory problems. The A S C Q is a tool that w i l l allow clinicians to

assess their patients' ambulation confidence i n their living 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 o f 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 o f

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 o f experts who completed the content validity surveys

for the A S C Q (Version 3) showed an average or above average, score o f 3 (agree), on the

4-point Likert scale for the clarity, appropriateness, importance, and discrimination

ability o f the A S C Q items. More than 50% o f the experts also agreed that there was no

need to add, delete, or modify the A S C Q items.

A broad cross-section o f 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 o f 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 o f the literature; and other similar instruments. A total o f 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 o f an alternative method capture the intended performance. Some o f the

A S C Q items were novel to the field. Our experts and investigators considered the

influence o f environmental, social, and personal factors on an individual's ambulation in

their living environment. Examples o f those items include walk while carrying groceries,

walking in the dark, walking and talking at the same time. These items include a different

aspect o f 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 o f 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 o f being direct and easy to understand

(Legters, 2002), it was not included as part o f the A S C Q response format selections

32
because the format was criticized for its limitation to detect variability i n the degree o f

confidence or fear as expressed by Lawrence et al. (1998) and Howland et al. (1993).

The majority, more than 50% o f the experts, selected a maximal score o f 10 for

the A S C Q . For this reason, we decided to use a maximum score o f 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 o f zero or "no" confidence. Betz and

Hackett (1981 & 1998) used a combination o f a "yes/no" confidence question and 1-10

scale i n the construction o f their Occupational Self-Efficacy Scale. For this format, i f

respondents answered "yes" to the first section, they were asked to rate their level o f

confidence using a scale from one to ten and the researchers assumed that a response

format o f " N o 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 o f the total spectrum o f scores. O n 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 F E S ) created by Powell & Myers (1995) has a 0-100 % response format

because o f its wider range o f item difficulty and more detailed descriptors. Further

research that could be considered in this area, investigating effectiveness o f 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 o f experts was not

randomly selected. Moreover, both older adults and other experts were selected primarily

from three geographic areas (Montreal, Vancouver, and some part o f Ontario).

Therefore, some o f them (participants from Vancouver) may not be exposed to the

extremes i n 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 o f 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 o f 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 o f 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 living

environment. None o f our older adult experts reported that they used any type o f 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 o f ambulation disability

that reduces their level o f confidence in ambulation. Thus, having older adult experts who

used walking aids i n the study might have been beneficial in broadening the type o f

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 o f this study culminated in the development o f a new tool that is

designed to assess ambulation confidence. The A S C Q w i l l facilitate the assessment o f

walking-related issues that arise in elderly populations in North America.

Evaluating the test-retest reliability, internal-consistency and validity o f 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 o f the next study w i l l

be used to create the final version o f the A S C Q . Importantly, we w i l l be able to explore

the dimensionality o f the tool among the target population - community-dwelling older

adults.

2.7 Acknowledgement

Authors thank all the participants, Dr. Catherine Backman, Dr. Roger Wong, and

Catherine Donnelly who assisted us in developing and revising the A S C Q .

35
2.8 References

Alexander, N . B . , Guire, K . E . , Thelen, D . G . , Ashton-Miller, J . A . , Schultz, A . B . ,

Grunawalt, J.C., Giordani, B . (2000). Self-reported walking ability predicts functional
mobility performance in frail older adults. Journal o f the American Geriatrics Society, 48:
1408-13.

Bandura, A . (1977). Self-Efficacy: Toward a unifying theory o f 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 o f control. N e w Y o r k : Freeman.

Beck, C . T . , & Gable, R . K . (2001). Ensuring content validity: A n illustration o f the

process. Journal o f Nursing Measurement, 9 (2), 201-215.

Bennett , K . J . (2000). Exercise programs offset age-related disabilities. Geriatrics and

Aging, 3, 12.

Betz, N . & Hackett, G . (1981). The relationship o f career-related self -efficacy

expectations to perceived career options in college men and women. Journal o f
Counseling Psychology, 28, 399-410.

Betz, N . E . , & Hackett, G . (1998). Ohio State University. Manual for the Occupational
Self-Efficacy Scale. Accessed from: http://seamonkey.ed.asu.edu/~gail/occsel.htm.

Fries, J.F. (1980). Aging, natural death, and the compression o f mobility. The N e w
England Journal o f Medicine, 303, 130-135

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 nd

edition). St. Louis, M O :
Mosby-Year Book Inc.

Guralnik, J . M . , Ferrucci, L . , Simonsick, E . M . , Salive, M . E . , & Wallace, R . B . (1995).

Lower-extremity function in persons over the age 70 years as a predictor o f subsequent
disability. N e w England Journal o f Medicine, 332, 556-561.

36
Guralnik, J . M . , Leveille, S.G., Volpato, S. (2004, in press) Targeting high risk older
persons into exercise programs for disability prevention. Journal o f A g i n g and Physical
Activity.

Havilk, R.J., L i u , B . M . , & Kover, M . G . (1987). Health statistics on older persons, United
States, 1986. Washington, D . C . : National Center for Health Statistics, Public Health
Service, U . S . Government Printing Office.

Howland, J., Peterson, E . W . , Levin, W . C . (1993). Fear o f falling among the community-
dwelling elderly. Journal o f A g i n g and Health, 5: 229-43.

Human Resources Development Canada (2003). A profile o f disability i n Canada, 2001.

Ottawa, Ontario: Statistics Canada.

Katz, S., Branch, L . G . , Branson, M . H . , Papsidero, J.A., Beck, J.C., & Greer, D . S . (1983).
Active life expectancy. The N e w England Journal o f Medicine, 309, 1218-1224

Lawrence, R . H . , Tennsted, S.L., Kasten, L . E . (1998). Intensity and correlated o f fear o f

falling and hurting oneself in the next year: baseline findings from a Royal Center fear o f
falling intervention. Journal o f A g i n g and Health, 10: 267-86.

Lawton, M . P . , Winter, L . , Kleban, M . H . , Ruckdeschel, K . (1999). Affect and quality o f

life: objective and subjective. Journal o f A g i n g and Health, 11 (2): 169-198.

Legters, K . (2002). Fear o f falling. Physical Therapy, 82(3): 264-72.

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.

M c D o w e l l , I., & N e w e l l C . (1987). Measuring health: A guide to rating scales and

questionnaires, ed.2. Oxford, Oxford University Press.

Nair, M . G . (1999). Clinical exercise specialist manual. San Diego, C A : American

Council on Exercise.

Pajanes, F. (2002). Emory University. Overview o f social cognitive theory and o f self-
efficacy. Accessed from: www.des.emory.edu/mff/eff.html.

Perry, J., Garrett, M . , Gronley, J . K . , Mulroy, S.J.(1995). Classification o f walking

handicap in the stroke population. Stroke, 26 (6): 982-989.

Powell, L . E . , & Myers, A . M . (1995). The Activities-specific Balance Confidence ( A B C )

Scale. Journals o f Gerontology Series A - B i o l o g i c a l Sciences & Medical Sciences,
50A(l):M28-34.

37
Pvichardson, J., L a w , M . , Wishart, L . , Guyatt, G . (2000). The use of a simulated
environment (easy street) to retrain independent living skills i n elderly persons: a
randomized controlled trial. Journals of Gerontology Series A - B i o l o g i c a l Sciences &
Medical Sciences. 55(10):M578-84.

Rosow, I. & Breslau, N . (1966). A Gutman Health Scale for the aged. The Gerontology
Society, 21: 556-9

Shwarzer, R. & Renner, B . Freie Universitait Berlin. Health-specific self-efficacy scales.

Accessed from: www.ralfschwarzer.de/

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 i n 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 o f 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.

Specter, W . D . , Katz, S., Murphy, J.B., & Fulton, J.P. (1987). The hierarchical
relationship between Activities of Daily L i v i n g and Instrumental Activities of Daily
L i v i n g . Journal o f Chronic Disease, 40(6), 481 -489.

Statistics Canada (2001). A g i n g seniors: statistical snapshots o f Canada's seniors.

Accessed from: http://www.phac-aspc.gc.ca/seniors-aines/pubs/factoids/2001/intro e.htm

38
Table 2.1 - Demographic of All Participants

Characteristics Older Adults (n = 13) Professionals & Students (n = 18)

Mean age 75.6 35.7

Gender % Male 41.7 55.6

Years o f experience N o t 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.Sc./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 2 6 22

22 1 9 20

The A S C Q Strongly Disagree Agree Strongly

Disagree Agree
Appropriateness

1 0 0 7 24

2 1 0 6 24

3 0 1 7 23

4 0 1 7 23

5 0 2 7 22

6 0 0 8 23

7 0 0 7 24

8 1 0 7 23

9 0 2 5 24

10 0 4 6 21

11 1 4 5 21

12 0 9 21

13 0 6 24

14 1 10 19

15 1 7 22

16 0 5 25

17 1 5 24

18 0 5 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 No 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

1-10 16

0-10 8

0-100% 7

45
Table 2.6 - The Results of Survey II: Item Clarity, Importance, and Disacrimination
(n=27)
The A S C Q Strongly Disagree Agree Strongly
Disagree 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 No 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 o f a car Deletion Requirement o f additional

skills such as balance

Get on and off a bus Deletion Requirement o f additional

skills such as balance

Get up from your seat and get out Modification

your transportation

-> Walk to your seat and sit down Deletion Requirement o f additional
on a moving bus skills such as balance

Stand up from your seat and walk Deletion Requirement o f additional

to the door of a moving bus 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 Deletion Too easy and respondents
holding on to someone 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 o f examples were also

performed using experts' responses and suggestions.

-> indicates deletion, addition, or modification o f 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

-Mailing out the 1 survey
st

2 and 4 week later

- M a i l i n g out reminder letters

.31 participants completed the first survey

-Revision o f the A S C Q
-Development o f the 2 Survey n d

2 and 4 week later

-Mailing out the 2 Survey
n d

- M a i l i n g out reminder letters

4 participants did not return

r the 2 survey
n d

27 participants completed the 2ns Survey

-Final revision o f 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 o f the population rapidly increases

inline with the longevity o f the population. It is estimated that by 2051, the proportion o f

adults over 65 years old w i l l reach approximately 20% o f 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% o f

Canadian adults aged 65 and over report having a mobility disability.

Ambulation,defined as the ability to ' w a l k ' (Kreservic et al., 1997), is one o f the

most important aspects o f mobility as a whole. Ambulation is necessary i n order to

maintain a healthy lifestyle, as well as a good quality o f life (Lawton 1999, Shumway-

Cook et al., 2002). Regaining and maintaining ambulation is one o f 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 o f patient and clinician time. In addition, these tests are usually

carried out i n a safe and controlled environment that seldom reflects an individual's

actual living circumstances.

54
 Self-report questionnaires are also a popular method for functional assessments

and they have the advantage o f being able to capture an individual's perception o f their

ability. Moreover, such questionnaires are considered to be time and cost effective, as

well as a valid and reliable method o f data collection (Guccione, 2000).

Perceived self-efficacy, defined as personal action control or agency (Schwarzer

& Renner, 2000), is one o f 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 o f whether they can perform a behavior such as

walking, regardless o f 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 o f 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 living settings. The results o f 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 o f 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 o f ambulation that require

attention for patients to walk safely and independently in their community and perform

the normal activities o f daily living.

To date there is no method o f 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 o f the study was to assess the psychometric properties o f 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 o f the A S C Q among community-dwelling older

adults. W e 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 ( I C C = 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 o f 101 participants (see Appendix I V 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 E n d Community

Centre (Be-Well Program); 2) the L i o n ' 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 Clinic 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 o f 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 o f

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 o f age; 2)

be able to speak and read English; 3) have no cognitive impairment (Folstein's M i n i

Mental State E x a m ( M M S E ) score > 24); and 4) be capable o f 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 o f

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 o f 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 o f questionnaires.

During the first data collection session, socio-demographic information including

age, sex, number o f medications, comorbidities, and falls (over the past 12 months),

highest level o f education completed, marital status, use and type o f 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 o f 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 o f

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 o f 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 o f I C C = 0.88-0.95 (Rikli

& Jones, 1998; Steffen et al., 2002) and moderate correlation (r=0.71) with older adults'

overall physical performance assessed by treadmill performance ( R i k 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, L o r d 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 o f the test was for the

participant to walk as far as possible for six minutes. The total distance that participants

walked i n 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 o f 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 ( I C C = 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) i n 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 o f daily living (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 i n 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 o f 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 o f confidence in their ambulation could be an

excellent indicator o f their ambulation performance. Accordingly, the A S C Q was created

based on the self-efficacy theory (Bandura, 1977 & 1996) for the purpose o f assessing

individuals' confidence i n 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 o f the A S C Q with the experts (including academics and

clinicians in the field o f 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 i n ambulation in their real living environment that might be influenced by

personal and environmental factors. Appendix III presents a sample o f 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 o f measurement ( S E M ) and F-value were also reported. The

S E M is the standard deviation o f the measurement error which reflects the range o f score

that can be expected on retesting. The S E M also provides the minimal amount o f change

that would be required to indicate a satisfactory different score when testing over two

62
different periods o f 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 o f 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 o f 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 o f medications, comorbidities, and falls (over the past 12

months), highest level o f education completed, and use o f 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 o f walking aid; and 2) marital status. There were an

63
additional 10% o f participants using walking aids, and less than 10% were married

amongst those who did not complete the follow-up A S C Q .

A m o n g 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 o f 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 o f 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 o f 10 participants were excluded from the study for the following two reasons: 1)

Seven participants scored M M S E < 24 (indicating some level o f 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 o f the participant characteristics and measures.

Internal Consistency of the ASCQ

The resulting Cronbach's alpha was 0.95. Scaling using stepwise deletion o f each

item did not change the overall alpha with the exclusion o f any single item. See table 3.3

for the complete results.

Test retest Reliability of the ASCQ

64
 A m o n g 91 participants who completed their initial session, a total o f 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% o f total) with a mean age o f 77.3 ± 7.9 years completed the A S C Q on

two occasions. O f these, 28.4% o f 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 I C C =

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% C I 0.28,

0.73) for item u (walk a short distance without stopping) to 0.94 (95% C I 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 i n

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 o f the relationships that we expected. Although the magnitudes o f the

relationship between the A S C Q and the walk tests were slightly lower than expected.

Scatter plots o f 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 i n Figure 3.2.

3.5 Discussion

The importance o f 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 o f this relationship and

successful implementation o f 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 o f

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 i n 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 o f 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 o f this new self-confidence measurement tool, designed to assess an individual's

confidence o f their ambulation skill i n 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 o f the scale. Streiner and Norman (2003) also stated

that a minimum value o f 0.80 is expected to support internal consistency o f the scale. The

number o f items can increase the alpha and therefore there may be room to drop some o f

the A S C Q items. However, our analysis supports that there is no difference i n alpha i f

any single A S C Q item is deleted from the A S C Q . Additionally, the results o f our

previous study, which assessed the content validity o f the A S C questionnaire with 25

experts, support that all the A S C Q items are thought to provide useful information. H i g h

internal consistency may be explained by the item redundancy demonstrated by

similarities between some o f the items such as 'walk up' & 'walk down' or the number o f

items. It is possible that we have item similarity statistically; however, clinically there

can be important differences, such as the use o f 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 o f 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 ( I C C =

0.55). Looking at the particular item (the A S C Q item u, "walk a short distance without

stopping"), o f 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 o f time by these participants. The

unreported medical incidence or accident, presence o f other individuals such as family

members or friends or absence o f 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 o f the correlation analyses suggest there is support evidence to the

validity o f 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). W e speculated

that the walking distance (that an individual is able to walk for 6-minutes) would be a

better predictor o f an individual's ambulation confidence than the walking speed. The

results o f the A S C Q may be an indicator o f not only the distance that individuals can

68
walk, but also their comprehensive ambulation skill, 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 o f 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 o f

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, i n part, to

provide us with an idea o f the activity limitation o f 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 o f individuals with functional ability. Maybe a different method

should be used or maybe the construct o f 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% o f older adults aged 74-84 years and 70% o f

older adults over the age o f 84 are female. 56% o f the senior population aged 74 years

and over is married and approximately 60% never completed high school. Furthermore,

69
76% o f older adults take medication, and 83% still living at home reported at least one

chronic health condition (Health Canada, Government o f Canada 2001 & 2002). Our

sample reflected the population o f older Canadians based on sex, considering the average

number o f chronic conditions and their dependency on medication. However, the

majority o f 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 o f 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 i n 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 o f 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 o f the

A S C Q during time one, there was no way to control the influence o f 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 o f the multi-facetted

reasons for ambulation disability. Therefore future studies might assess how important

this construct is, and i f it influences participation i n the community and i n 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 o f

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 o f the psychometric characteristics o f

the A S C Q .

3.7 Acknowledgements

The authors thank all the participants, the West E n d Community Centre's Be-

W e l l Program (Ms. Lois Blair and M s . Bonnie M c K i n n o n ) , the L i o n ' 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 ( M s . Christine

Stardom and M s . Tanis Watson), the Geriatric Out-Patient Clinic at the St. Paul's

Hospital (Ms. Julie Cheng, M s . Karen Gilbert and Dr. Wendy Cook), the Geriatric Out

71
Patient Clinic at the Vancouver General Hospital's Monrone Clinic (Dr. Roger Wong),

the Kerrisdale Community Center's Osteoporosis Workshop ( M s 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 o f Respiratory and Critical Care Medicine, 166, 111-117.

Andersen, E . M . (2000). Criteria for assessing the tools o f disability outcomes research.
Archives o f Physical Medicine and Rehabilitation, 81(S2): S15-S20.

Bandura, A . (1977). Self-Efficacy: Toward a unifying theory o f 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 o f control. N e w Y o r k : Freeman.

Bandura, A . , & Adams, N . E . (1977). Analysis o f self-efficacy theory o f behavior change.

Cognitive Therapy and Research, 1(4), 287-310.

Bean, J.F., K i e l y , D . K . , Leveille, S.G., Herman, S., Huynh, C , Fielding, R., & Frontera,
W . (2002). The 6-Minute Walk Test in mobility-limited elders: What is being measured?
Journal o f Gerontology: Medical Sciences, 5 7 A (11), M 7 5 1 - M 7 5 6 .

Boyle, G . J . (1991). Does item homogeneity indicate internal consistency or item

redundancy in psychometric scales? Personality & Individual Differences, 12: 291-294.

Cromwell, D . , Eagar, K . , Poulos, R. (2002). Screening for cognitive impairment using

instrumental activities o f daily living in elderly community residents: a cross-sectional
study. Journal o f Clinical Epidemiology, 56(2): 131-7.

Dormer, A . , & Eliasziw, M . (1987). Sample size requirements for reliability studies.
Statistics in Medicine, 6, 441-448.

Folstein, M . F . , Folstein, S.E., M c H u g h , P.R. (1975). " M i n i - M e n t a l State" A practical

method for grading the cognitive state o f patients for the clinician. Journal o f Psychiatry
Research, 12: 189-98.

Fries, J.F. (1980). A g i n g , natural death, and the compression o f mobility. The N e w
England Journal o f Medicine, 303, 130-135

Gable, R . K . (1986). Instrument Development in the Affective Domain. M A : Kluwer

Academic Publishers.

Guccione, A . A . (Ed.). (2000). Geriatric Physical Therapy ( 2 nd

edition). St. Louis, M O :
Mosby-Year Book Inc.

73
Guralnik, J . M . , Ferrucci, L . , Simonsick, E . M . , Salive, M . E . , & Wallace, R . B . (1995).
Lower-extremity function in persons over the age 70 years as a predictor o f subsequent
disability. N e w England Journal o f Medicine, 332, 556-561.

Harada, N . D . , Chiu, V . , & Stewart, A . L . (1999). Mobility-related function i n older adults:

Assessment with a 6-Minute Walk Test. Archive o f Physical Medicine and
Rehabilitation, 80, 837-841.

Hirschberg, G . G . (1976). Ambulation and self-care are goals o f rehabilitation after stroke.
Geriatrics, 31 (5): 61-5.

Holman, H . R . , & Lorig, K . (1992). Perceived self-efficacy in self-management o f chronic

disease. In R. Schwarzer's (Ed.), Self-efficacy: Thought control o f action (pp.305-323).
Washington, D C : Hemisphere.

Hulley, S.B., & Cummings, S.R. (1988). Designing Clinical Research. M D : Williams &
Wilkins

Human Resources Development Canada (2003). A profile o f disability in Canada, 2001.

Ottawa, Ontario: Statistics Canada.

Kaplan, R . M . , Atkins, C . J . , Reinsch, S. (1984). Specific efficacy expectations mediate

exercise compliance in patients with C O P D . Health-Psychology, 3(3); 223-42.

Katz, S., Branch, L . G . , Branson, M . H . , Papsidero, J . A . , Beck, J.C., & Greer, D . S . (1983).
Active life expectancy. The N e w England Journal o f Medicine, 309, 1218-1224.

Kervio, G , Carre, F, & V i l l e , N . (2002, September). Reliability and intensity o f the Six-
Minute Walk Test in healthy elderly subjects. Medicine & Science in Sports & Exercise,
169-174.

Kreservic, D . M . , Mezey, M . (1997). Nurses are i n a position in all care settings to assess
elders functional status. Geriatric Nursing, 18: 216-22.

Lawton, M . P . , Broady, E . M . (1969). Assessment o f older people: self-maintaining and

instrumental activities o f daily living. Gerontologist, 9 (3): 179-86.

Lawton, M . P . , Winter, L . , Kleban, M . H . , Ruckdeschel, K . (1999). Affect and quality o f

life: objective and subjective. Journal o f A g i n g 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.

Lord, S.R., & M e n z , H . B . (2002). Physiologic, psychologic, and health predictors o f 6-

Minute Walk Performance in older people, 82, 907-911.

74
M c D o w e l l , I., & N e w e l l C . (1996). Measuring health: A guide to rating scales and
questionnaires, ed.2. Oxford, Oxford University Press.

McDonough, P . A . , Badley, E . M . , Tennant, A . (1995). Disability, resources, role demands

and mobility handicap. Disability and Rehabilitation, 17 (3-4): 159-68.

Pajanes, F. (2002). Emory University. Overview o f social cognitive theory and o f self-
efficacy. Accessed from: www.des.emory.edu/mff/eff.html.

Pal, J. (2004). University o f Otago. Postgraduate Theses and Dissertations: Validation o f

the Activities-specific Balance Confidence Scale ( A B C ) and the Falls Efficacy Scale
(FES) in People. Accessed from: http://physio.otago.ac.nz/research/thesis.asp

Patla, A . E . , Shumway-Cook, A . Dimensions o f Mobility: Defining the Complexity and

Difficulty Associated With Community Mobility. Journal o f A g i n g & Physical Activity,
7(1): 7-13.

Pferrer, R.I., Kurosaki, T.T., Harrah, Jr., C . H . , Chance, J . M . , Filos, S. (1982).

Measurement o f functional activities in older adults in the community. Journal o f
Gerontology, 37(3): 323-29.

Powell, L . E . , & Myers, A . M . (1995). The Activities-specific Balance Confidence ( A B C )

Scale. Journals o f Gerontology Series A - B i o l o g i c a l Sciences & Medical Sciences,
50A(l):M28-34.

Richardson, J., L a w , M . , Wishart, L . , Guyatt, G . (2000). The use o f a simulated

environment (easy street) to retrain independent living skills in elderly persons: a
randomized controlled trial. Journals o f Gerontology Series A - B i o l o g i c a l Sciences &
Medical Sciences. 55(10):M578-84.

R i k l i , R . E . , & Jones, C . J . (1997). Assessing physical performance in independent older

adults: Issues and Guidelines. Journal o f A g i n g and Physical Activity, 5, 244-261.

R i k l i , R., & Jones, J. (1998). The reliability and validity o f a 6-Minute Walk Test as a
measure o f physical endurance in older adults. Journal o f A g i n g and Physical Activity, 6,
363-375.

Statistics Canada (2001). A g i n g seniors: statistical snapshots o f Canada's seniors.

Accessed from: http://www.phac-aspc.gc.ca/seniors-aines/pubs/factoids/2001/intro e.htm

Shwarzer, R. & Renner, B . Freie Universitait Berlin. Health-specific self-efficacy scales.

Accessed from: www.ralfschwarzer.de/

Shumway-Cook, A . , C i o l , M . A . , Yorkston, K . M . , Hoffman, J . M . , Chan, L . (2003).

Mobility limitations in the medicare population: prevalence and sociodemographic and
clinical correlates. Journal o f the American Geriatrics Society, 51(3): 393-398.

75
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 i n 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 o f 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.

Spector, W . D . , Katz, S., Murphy, J.B., & Fulton, J.P. (1987). The hierarchical
relationship between Activities of Daily L i v i n g and Instrumental Activities of Daily
L i v i n g . Journal o f Chronic Disease, 40(6), 481-489.

Steffen, T . M . , Hacker, T . A . , & Mollinger, L . (2002). A g e - and gender-related test

performance i n community-dwelling elderly people: Six-Minute W a l k Test. Berg
Balance Scale, Timed U p & Go Test, and gait speed. Physical Therapy, 82 (2), 128-137.

Streiner, D . L . , & Norman G . R . (2003). Health Measurement Scales: A Practical Guide to

their Development and Use ( 3 edition). N Y : Oxford University Press Inc.
rd

Taylor, C . B . , Bandura, A . , Ewart, C . K . , Miller, N . H . , DeBusk, R . F . (1985). Exercise

testing to enhance wives' confidence in their husbands' cardiac capability soon after
clinically uncomplicated acute myocardial infraction. American Journal o f Cardiology,
55: 635-38.

Tombaugh, T . N . , & Mclntrye, N . J . (1992). The Mini-Mental State Examination: A

comprehensive review. Journal of the American Geriatrics Society, 40(9): 922-33.

Torrey, B . (2002). Clinical Briefs: A T S guidelines for the Six-Minute W a l k Test. Journal
of the American Academy of Family Practices, September: 904-906.

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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)

%Male 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

< H i g h school 17.6 19.4

H i g h 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

ASCQ 1 91 8.52 1.74 2.00- 10.00

ASCQ 2 67 8.69 1.61 3.45- -10.00

A B C (%) 88 83.7 18.9 13.13 - 100

IADL 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

ASCQ A l p h a i f the item ICC 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

ASCQ ABC IADL TUG 6MWT

ASCQ 1 .27* -.46** .36**

ABC 1 .36** . 48** .35**

IADL 1 -.42** .40**

TUG 1 -.82**

6MWT 1

* P<0.05 and **P<0.001, significant at 0.05 level (2-tailed)

The number o f 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 o f Daily L i v i n g scale

T U G - Timed " U p 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 3 participated were excluded
- A S C Q incompletion

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
Reminder Phone C a l 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 v s IADL ASCQ v s A B C

o
m
<

ASCQ

ASCQ v s 6MWT ASCQ vs TUG

P.

1 — 1
30.00^
a & ,"v
O
1-

ASCQ ASCQ

gure 3.2 - Scatter Plots o f the Relationships between the A S C Q and Other Measures

84
Chapter 4: General Discussion and Conclusion

4.1 Overview
The objectives o f this study were to assess the reliability, content and construct

validity o f the Ambulatory Self-Confidence Questionnaire ( A S C Q ) The results o f this

study provide support for the reliability and validity o f 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 o f 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 o f

rehabilitation science. To meet this goal o f 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 living 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 o f their activity

performance. For example, the results o f a study conducted by Hatch et al. (2003) show

that an individual's confidence in their activity specific balance skill is a strong indicator

85
under the hypothesis that assessing an individual's confidence with their ambulation w i l l

be a strong indicator o f their ambulation performance. A review o f 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 o f the most important steps o f creating a new scale is testing its

content (Gable, 1986, Beck & Gable, 2001). Chapter 2 introduced results o f our study

assessing the content validity o f the A S C Q . The A S C Q template was created by

professors at University o f British Columbia based on a review o f the literature and their

knowledge and experience related to the area o f 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 o f the items for the A S C Q . We asked the panel o f 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% o f the panel members

agreed the final revised A S C Q content was sufficient with regards to the appropriateness,

clarity, importance o f 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 o f a

study that examined the psychometric properties (internal consistency, two-week test

retest reliability; and construct validity) o f 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 ( I C C = 0.92). One might

argue that our alpha is too high, thus, it may indicate item redundancy (Streiner &

Norman, 2003) however, the results o f 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 o f the A S C Q . Assessment o f 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 o f the items and the

constructs overall. Moreover, it seems likely that the participants were unable to

differentiate between the questionnaire items. Alternatively, approximately 25% o f the

variation between the constructs remained unexplained. Therefore the correlation was

less than perfect and it seems likely that each o f the questionnaires taps different

information.

4.3 Limitations
There are several factors that influence the content validity, reliability, and

construct validity o f 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 o f our study limitations was related to sampling. Our sample was recruited

from particular a variety o f centers and clinics designed to ensure a mixture o f 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 o f the general older adult population.

87
Older Adults' Cognition: Self-Confidence and Insight
Cognitive impairment is one o f 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 E x a m (Folstein

et al., 1975) to screen for the presence o f 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 o f 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 o f whether an individual w i l l engage in an activity regardless o f their

insight. Therefore, insight should not interfere with the judgment o f confidence.

Measurement and Study Environment

Another limitation o f our study relates to data collection. The initial testing,

occurred in a variety o f different locations. Each testing location was unique, for

example, in some o f the centres we were provided with private space while in other

centres we used a common space to collect data under the observation o f 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 o f their ambulation confidence. For instance, the presence o f

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 o f 200 or more (Cronbach, 1951). In addition,

88
our entire sample was from the lower mainland. A lack o f 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 o f the A S C Q . The

ultimate goal o f the A S C Q is to be able to identify ambulation problems o f people living

in their environment, to discriminate between older adults with and without ambulation

problems, and to detect the effectiveness o f rehabilitation treatments and programs

prescribed to reduce older adults' ambulation disabilities. Hence, assessing discriminate,

predictive validity, and responsiveness o f the A S C Q and its application to disease

specific populations, are highly recommended to increase our knowledge o f the

psychometric characteristics o f 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 o f 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 o f I R T (1. the data are unidimentional and 2.

probability o f 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 o f trait) are

met (Embretson & Reise, 2000; Lord, 1980). The I R T 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 o f 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 o f 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 I R T and R M .

89
4.5 Final Thoughts
Ambulation and emotional wellness are crucial aspects to the health, level o f

independence and quality o f life o f community living 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 living

and further advance rehabilitation sciences.

90
4.6 References

Bandura, A . (1977). Self-Efficacy: Toward a unifying theory o f 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 o f control. N e w Y o r k : Freeman.

Bandura, A . , & Adams, N . E . (1977). Analysis o f self-efficacy theory o f behavior change.

Cognitive Therapy and Research, 1(4), 287-310.

Beck, C . T . , & Gable, R . K . (2001). Ensuring content validity: A n illustration o f the

process. Journal o f Nursing Measurement, 9 (2), 201-215.

Clark, C . (2003). Biomarks o f dementia and cognitive impairment. Chicago Workshop on

Biomarker Collection in Population-Based Household Surveys o f Older Adults.
Conference proceedings.

Cronbach, L . J. (1951). Coefficient alpha and the internal structure o f tests.

Psychometrika, 16, 297-333.

Fisher Jr., W . (1992). Progress i n 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 nd

edition). St. Louis, M O :
Mosby-Year Book Inc.

Lawton, M . P . , Winter, L . , Kleban, M . H . , Ruckdeschel, K . (1999). Affect and quality o f

life: objective and subjective. Journal o f A g i n g 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 Ed.) (2000). Foundations o f Clinical Research:

nd

Applications to Practice. N e w Jersey; Prentice-Hall, Inc.

91
Statistics Canada (2001). A g i n g seniors: statistical snapshots o f 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 o f 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 edition). N Y : Oxford University Press Inc.
rd

Trottier, L . (2003). The current state of insight research. Canadian Undergraduate Journal
of Cognitive Science, Fall: 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 o f stairs (4 steps or more) with a handrail?
4. walk down a flight o f 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 o f 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 - 1 0 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 o f 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 o f 40-45 participants are required for this
proposed study.

2. Construct Validity Sample

In order to examine the construct validity o f 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 o f 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 o f 10% o f the largest total sample size required for the
proposed study, a total o f 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 o f the walking path for 6 minutes.
• The walk should be carried out i n an area with minimal traffic that is 10-m i n
length.
• The length o f 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. D o not talk to anyone during the walk test. Use an even tone o f voice
when using the standard phrase o f 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 o f 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 o f tape on the floor.

9. Post-test: Record the distance that the subject walks i n 6 minutes w i l l be

recorded. (Duration o f time spent resting w i l l also be recorded.)

10. Congratulate the subject on good effort and offer a drink o f water.

98
Appendix V I : The Timed " U p & 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.

Standing & Sitting Turning

Protocol:

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.

• D o not talk to anyone during the walk test.

• D o 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.

99
Appendix V I I : A sample of the A B C Scale

For each of the following activities, please indicate your level o f 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

H o w 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 i n and out o f a car? %

J) walk across a parking lot? %

K) walk up and down a ramp? %

L) walk in a crowded mall?__ %

M) walk i n 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 o f 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 o f 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 v i a taxi, but does not otherwise use public transportation.
• Travels on public transport when accompanied by another.
• Travels limited to taxi or vehicle with assistance o f 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 o f 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 o f making financial decisions or handling money.

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Appendix I X : A sample o f 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 o f the person's orientation
to time and place, recall ability, short-term memory, and arithmetic ability providing
insight into cognitive loss.)

Y o u , 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- Whichfloorare we on? Score

Score (max 10)

Registration:
Y o u w i 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 o f letter in correct order, (i.e. i f subject
answered D L O R W , he or she gets 3 point).

Score (max 5)

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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 w i l l show the two simple objects (such as a pen or a wrist watch) to the subject, and
ask h i m 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 o f 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 w i l l give the subject a written instruction (sentence) then ask h i m 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 o f 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

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Copying:
Y o u w i l l give the subject a blank piece o f 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

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Appendix X : Socio-demographics and measurement outcomes categorized by the type o f
recruitment location

Characteristics Community Day Centre

Centre (n=45) & Clinic (n=46)
Mean age (S.D.) 74.1 (6.2) 81.0 (7.1)
%Male 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 o f 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

< H i g h school 13.3 21.7
H i g h 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 pO.Ol pO.Ol
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 Activity o f Daily L i v i n g Scale
T U G : The Timed " U p & G o " Test
6 M W T : The 6 Minute Walk Test

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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 o f 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

< H i g h school 16.7 20.0
H i g h 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 o f Daily L i v i n g Scale
T U G : The Timed " U p & G o " Test
6 M W T : The 6 Minute W a l k Test

106
Appendix X I I : 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 o f stairs .710 -.634 .060
Walk down a flight o f 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:

O n a scale from 1-10, how confident are you that you are able to .

1. step up to a standard height sidewalk curb? Item # Clarity Appropriateness

2. step down from a standard height sidewalk curb? 1
3. walk up a flight of stairs (12 steps)?
2
4. walk down a flight of stairs (12 steps)?
5. ride an escalator? 3
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)?
10
12. walk a short distance from a parking lot/
Bus stop to the closest store/bank/restaurant 11
(50 meters)? 12
13. walk through a supermarket or
13
shopping mall (300 meters)?
14. stop suddenly while walking? 14
15. carry a small item (<2.0kg) when walking? 15
16. walk on uneven or bumpy ground?
17. walk on slippery ground (icy or wet surfaces)? 16
18. walk independently 17
(without walking aide such as a cane or walker)?
18
19. enter and leave your home/apartment?
20. walk from one room to another in your home/at 19
your doctor's office? 20
21. walk in a crowd?
21
22. walk on flat/level ground?
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 Item r
clar]ty^~ Importance Distinguish
(4 steps or more) with a handrail? 1 | I
4. walk down a flight of stairs
(4 steps or more) with a handrail? 1 2 1
5. walk and talk at the same time? 1 3
6. walk up a ramp (mild incline)? [4 [ \
7. walk down a ramp (mild incline)?
i
8. cross a street without a timed
cross walk (walk signal)? 6 r
9. cross a street with 7 |
a timed cross walk (walk signal)? 1 8 I
10. use an escalator?
(9
11. walk on a moving sidewalk:
for example one at airport? 10
—
"
12. walk on a moving bus? 11
13. walk in the dark or at night? f 12
_14.walk a short distance without stopping:
for example from your home to a car? 1 1 3
I
_15.walk a long distance without stopping: 14 !
for example from your car at a parking 15
lot to a supermarket?
1 16 [
16. suddenly stop walking to avoid
an oncoming vehicle? [17 I 1 I
17. carry small items while walking:
for example a carton of milk? 19 I
18. walk on an uneven sidewalk?
19. walk on slippery ground: 20 1 •i
for example icy or wet surfaces? 21 [~ i
20. walk on grass? 22 [
21. walk through a crowded place:
for example a busy street?
22. walk from one room to another in your home?

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 M i l l e r , P h D , O T
Assistant Professor, D i v i s i o n o f Occupational Therapy, School o f Rehabilitation
Sciences, University o f British Columbia

Co-Investigator:
M i h o Asano, B S c ( C E P )
Master Student, D i v i s i o n o f Occupational Therapy, School o f Rehabilitation Sciences,
University o f British Columbia

Invitation to Participate:
Y o u are being invited to participate in this study because we wish to study the quality o f
a self-report questionnaire that assesses older adults' perceived confidence i n their
ambulation (walking) skill 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 i n 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 o f 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 o f M s . M i h o Asano. It is conducted
by Dr. B i l l M i l l e r and M s . M i h o Asano.

Background:
Older adults often demonstrate mobility (walking) problems as a result o f age-related
physical changes. Walking safely and independently is one o f the basic yet most
important parts o f daily living. Currently, there is no self-reported questionnaire that
focuses on assessing one's perceived confidence in their walking skill.

What is the Purpose of the Study?

The purpose o f the proposed study is to assess the quality (reliability and validity) o f a
new self-report questionnaire, the Ambulatory Self-Confidence Questionnaire ( A S C Q ) .
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 o f age
2. able to read, write, speak, and understand English
3. able to walk minimum o f 10 meters with or without walking aides
(examples: a walker or a cane) at home and in the community
4. living in their home

What Does the Study Involve?

Overview of the study:
If you agree to j o i n the study, we w i 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 E x a m followed by 3 brief questionnaires: the first
one looks at confidence in balance skill, the second one looks at your ability to perform
some activities o f daily living, and the third one looks at confidence in walking ability.
M i n i Mental State E x a m 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 i n 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 " U p & G o " Test and the 6 Minute Walk Test.

113
For the walk tests, you w i 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 " U p & 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 o f falls in the past 12 months, any major medical condition (i.e.
arthritis, heart condition) and use o f 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 o f 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 D a y 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 fill i n the questionnaire. The entire session w i l l take
approximately 10 to 15 minutes o f your time at your home.

What are the Possible Harms and Side Effects of Participating?

We do not anticipate any harm or side effect o f participating i n 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 o f the overall results after the entire study is finished.

What Happens if I Decide to Withdraw My Consent to Participate?

Your participation i n 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 w i l l be no penalty or loss o f 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 i n any way the quality o f care that I receive.

• I understand that I am not waiving any o f my legal rights as a result o f signing

this consent form.

• I have been told that I w i l l receive a dated and signed copy o f this form.

• I read this form and I freely consent to participate i n this study.

Printed name o f subject Signature Date

Printed name o f witness Signature Date

Name o f principal investigator/designated representative Signature Date

116