The impact of mobility scooter on occupational participation among older adults in Singapore: an exploratory study

Abstract Purpose With an ageing population, the use of mobility scooters by community-dwelling older adults with mobility limitations has been increasingly prevalent in Singapore. Their experiences in using mobility scooters remain unclear. This study aimed to explore the impact of mobility scooters on occupational performance and engagement among elderly Singaporeans. Materials and methods Mobility scooter users were recruited via purposive and snowballing sampling. Semi-structured interviews were conducted in English or Mandarin via phone call or face-to-face and audio-recorded with permission. Interviews were transcribed verbatim in their original language and translated to English (when applicable) for thematic analysis. Results Twelve eligible participants (mean age: 75 years) completed the interviews. They were predominantly female Chinese with 7 receiving training from occupational therapists (OT). Four main themes emerged from the interviews describing their experiences of using mobility scooters: factors of decision-making in getting a mobility scooter, enhanced occupational participation with the use of the mobility scooter, enablers for community participation and barriers to community participation. Despite having barriers, older adults with mobility limitations generally still had positive experiences to continue using mobility scooters to perform occupations in the community. Conclusions This study highlights the benefits of mobility scooters in supporting users’ occupational performance and engagement in the community. Continual efforts are required from all stakeholders to provide an accessible environment and improve societal attitudes to further support the mobility scooter users. IMPLICATIONS FOR REHABILITATION Mobility scooter users can be deterred from performing their preferred occupations if they had a prior negative encounter and they mainly rely on self-developed coping strategies to overcome possible barriers in the community. Occupational therapists should identify and address the potential barriers when prescribing mobility scooters to older adult users. Occupational therapists should work collaboratively with other key stakeholders, such as external vendors and government agencies, to co-create a universal guideline to support and safeguard mobility scooter users.


Introduction
The growing ageing population is a global phenomenon.According to the World Population Ageing 2019 report [1], the proportion of older persons aged 65 years and above in Singapore is expected to rise from 19.7% in 2017 to 40.1% in 2050.The prevalence of musculoskeletal disorders increases with age and is a common cause of significant limitations in physical functioning and mobility for older adults [2].Many studies have shown a significant association between reduced mobility and poorer quality of life as functional mobility is essential for participation in meaningful social, cultural, physical and productive activities in the community [3][4][5][6].
In consideration of the likelihood of comorbidities among the older adults, the International Classification of Functioning, Disability and Health (ICF) developed by the World Health Organisation (WHO) has shifted away from the focus on impairment, to adopting compensatory strategies to accommodate for physical limitations, with the intention to enable participation in daily activities [7].To facilitate this movement, the use of assistive technology as an intervention for older adults with mobility difficulties is recognized to promote independence and enhance social inclusion and participation [8].
Currently, there is a wide range of assistive technology being used and adopted by healthcare professionals to promote independent living in people with disabilities, such as assistive devices for self-care, powered mobility aids (PMA), and so on.Studies have shown that the use of PMA, such as mobility scooters is increasingly adopted as a mode of transport to enable older adults' participation in the community with a greater sense of independence and security [9][10][11][12][13][14].However, inaccessible built environments continue to pose barriers to the usage of mobility scooters and restrict community participation [9, 10,[12][13][14].In addition, societal attitude on the acceptability of mobility scooter users has the greatest influence on user experience [14].Similarly, inconsistencies in the provision of training threatens the safety and competence of mobility scooter users driving in the community [15].
With the increase in the use of mobility scooters in Singapore, the Active Mobility Advisory Panel was established as a group of individuals dedicated to guiding the rules and conduct of safe shared usage of active mobility devices in the community [16].Currently, there are available financial subsidies and physical infrastructures that support the use of mobility scooters in Singapore.For instance, the Seniors' Mobility and Enabling Fund managed by the Agency for Integrated Care (Government Agency) [17] provides eligible older adults up to 90% subsidies for mobility devices.The built environment has also been increasingly made accessible with Singapore's ongoing initiative to create an agefriendly and inclusive city through the continual effort to establish accessible walkways, lifts and transport systems in the physical environment [18].
Occupational therapists are concerned with the overall wellbeing of older adults with the focus to enable participation and engagement in meaningful activities to fulfil various roles that they have [19,20].In Singapore, they are also responsible for the prescription of a suitable assistive device to support individuals' occupational performance in daily occupations, including the prescription of a mobility scooter [21].With reference to the PMA Practice Guidelines for Occupational Therapists in Singapore developed by the Singapore Association of Occupational Therapists (SAOT) [21], occupational therapists act as gatekeepers to assess, prescribe and train users of PMA to use mobility devices safely and competently.However, with the surge of demand for PMA, such mobility devices are readily available in the commercial market and training is not mandatory.While many studies conducted outside Singapore have shown the benefits of using mobility scooters to promote active participation and healthy ageing [9-14], the evidence is lacking in Singapore given very few studies relating to PMA was conducted in Singapore.
With the increasing number of PMA users in Singapore and lack of standardization in the process of getting a PMA, this study aimed to explore the impact of the use of mobility scooters on occupational performance and engagement among older adults in Singapore from an occupational therapy perspective.It also aimed to facilitate a better understanding of the experience of training for mobility scooter users during purchase.The results from this study can be used as a guide for occupational therapists and relevant stakeholders to inform future practice guidelines in the prescription of mobility scooters to support older adults for independent living in the community.

Method
A qualitative study design was used in this study.Information from semi-structured interviews was analyzed with an inductive approach to elicit the lived experience of older adult users of mobility scooters [22].The consolidated criteria for reporting qualitative research was used as a reference [23].This study was approved by the Singapore Institute of Technology Institutional Review Board (Project Number: 2020079).

Participants
Using purposive sampling, participants were recruited via social media and word-of-mouth from July 2020 to December 2020.Older adults who met the following criteria were included: (1) aged 65 years and above; (2) current users of powered mobility scooters; (3) having at least 3 months of experience in driving a scooter; (4) ability to communicate using conversational English or Mandarin; and (5) ability to provide informed consent to participate in this study.Exclusion criteria included those who were not able to provide informed consent.In view of the Coronavirus Disease 2019 (COVID-19) pandemic, where social interaction was severely restricted, the snowball sampling method was utilized as a means to encourage referrals of suitable participants to ensure a sufficient sample size.When the early phases of Singapore's Circuit Breaker measures (stay-at-home order) ended and social interaction was allowed, face-to-face recruitment in the community was conducted.
Prior to the interviews, verbal informed consent from each participant participating in the phone interview was obtained and audio-recorded; written consent was obtained from those doing the face-to-face interviews.Participants were allowed to clarify with questions or withdraw from the study at any point in time.

Data collection
All semi-structured interviews were conducted either in English or Mandarin, according to participants' preferences.A list of guided interview questions (refer to the online Supplementary file 1) developed by the research team (occupational therapists) was used to find out the mobility scooter users' experiences in purchasing, training and driving the mobility scooters in the community.The questions were designed based on the understanding of the People-Environment-Occupation Model [24] where the interaction between People-Environment-Occupation affects people's occupational performance with the use of mobility scooters.The research team had piloted the interviews with family members to improve the standardization and quality of data collection.
All interviews were audio-recorded with a digital voice recorder with permission from the participants.During phone interviews, researchers worked in pairs, alternating after each consecutive scheduled phone interview where one was the main interviewer and the other took notes whenever relevant.For the face-to-face interview, only one researcher was present due to COVID-19 restrictions.

Analysis
All audio recordings were transcribed verbatim in the original language.The back-translation method was used if transcripts were required to be translated to English [25].Each transcript was cross-checked against the audio recording by another researcher for accuracy.All completed transcripts were reviewed repeatedly by the research team to minimize any errors.The NVivo 12 software was used to perform line-by-line coding.The first transcript was coded by the entire team of researchers to achieve standardization in the coding method.Subsequent transcripts were analyzed in pairs untill data saturation was reached as there were no new codes generated [26].To standardize the meaning of codes, a summary was written for each code for reference.Thematic analysis with an inductive approach was then used to identify broad themes from identified codes [27].Weekly research team meetings were carried out to review themes and interpretations before reaching a consensus [28].

Results
Initially, 18 participants were recruited.Prior to the interview, three withdrew due to personal reasons, two were uncontactable and one was declined during registration due to speech difficulties as a limitation of phone interviews requiring clarity in speech.A total of 10 phone interviews and 2 face-to-face interviews sessions were completed.On an average, phone interviews lasted approximately 40 min each while face-to-face interviews lasted approximately 25 min.
Data saturation was reached after 12 participants were interviewed.The characteristics of the participants are listed in Table 1.There was an equal number of participants who belonged to the young-old (65-74) and medium-old (75-84) age group.The majority of participants were female (75.0%),Chinese (91.7%) and living with their family (66.7%).All participants reported difficulties with mobility because of existing musculoskeletal disorder (33.3%) and other health conditions (58.3%) such as stroke, asthma and diabetes.The majority (83.3%) of participants had at least one condition affecting vision, with presbyopia being the most common condition.While all participants used a mobility scooter for community mobility, about half (58.3%) of them required a walking aid to ambulate independently at home and two participants (16.7%) furniture cruise at home.A greater proportion of participants had at least 1-year of experience in driving a mobility scooter with 41.7% having 1-2 years of experience and 41.7% having more than 2 years of experience.Amongst all the participants, more than half (58.3%) owned a car licence and experienced driving.All, except one participant, drove a fourwheeled mobility scooter.While most had some form of training prior to using a mobility scooter, seven (58.3%) had received formal training by a healthcare professional, three (25.0%)had received informal training by vendors who sold the mobility scooter and the remaining two (16.7%) did not have any training.In general, only a minority of participants (33.3%) reported a history of minor incidences while driving a mobility scooter.The detailed information on individual participants' demographics and experiences in the use of mobility scooters can be found in the online Supplementary file 2.
The main themes and sub-themes derived from the thematic analysis of completed interviews are presented in Figure 1.Results showed the interaction and influences of main themes and corresponding sub-themes on participants' use of mobility scooters for occupational participation (see Figure 1).Despite the existence of the potential barriers, multiple enablers had helped older adults make decisions in getting a mobility scooter to engage in meaningful activities in the community.

Decision-making factors in getting a mobility scooter
This study identified the decision-making factors in getting a mobility scooter in all participants.Two main factors were identified as sub-themes: Mobility scooter as an alternative "pair of legs" for users and perceived high competency of using a mobility scooter post-training.

Mobility scooter as an alternative "pair of legs"
Participants shared a consensus that the main intention to own a mobility scooter was for it to be used as a mode of transport to cope with physical limitations and difficulties in mobility.Participants appreciated the increase in mobility that a mobility scooter could provide.As shared by the participants:

[Arh] … I bought [a mobility scooter] because I cannot walk. (N4)
No, the mobility scooter, actually, is like you have a pair of good legs, you travel wherever you want to go.(N11)

Perceived high competency of using a mobility scooter posttraining
The decision to purchase a mobility scooter was further motivated by a high perceived competency of driving the mobility scooter following some forms of mobility scooter training.Participants also shared that they gained confidence in the ability to control and drive the mobility scooter with an easy and intuitive navigation system:

I was accustomed to it on my first try and hence my son bought it. (N1) Just as you think of it, turn left, it (mobility scooter) will go left. Then "forward" is to press this side, and "backward" is this side … Only four instructions only … (she added) It's very simple [la] … (N6)
The skillset required to drive a mobility scooter is easier and less complex compared to driving a car.
Hence, some participants felt that an informal trial before use was sufficient and formal training was not required as they were able to cope and emphasized learning by practice: When you buy, you can try and learn on the spot, it should be fine.(N1) The trial is enough, it depends on an individual.(N6) However, some participants valued the guidance provided to navigate through community spaces during formal training.They recognized the need for comprehensive training to better familiarize themselves with the use of mobility scooters, especially on public transport.As highlighted by the participants:

Enhanced occupational participation with the use of a mobility scooter
In this study, participants also shared the benefits of using a mobility scooter.All participants used the mobility scooter as an alternative mode of transportation to get around different community places to perform valued occupations unique to the individual.Increased community participation and the benefits of using a mobility scooter contributed to a general enhanced occupational participation among participants.

Increased community participation
As shown in Table 2, participants shared that the mobility scooter was solely used for various activities in the community.Activities included instrumental activities of daily living (IADLs), particularly grocery shopping (83.3%), visiting malls (66.7%) and purchasing of meals (58.3%).Other activities also included meeting friends and family (58.3%),visiting community centres for social activities (41.7%) and fulfilling medical appointments (41.7%).Often, they were performed within the vicinity of their neighbourhood:

I go to buy groceries, go to the market, go to the community centre. Sometimes I use it (mobility scooter) for appointments and ride it to the hospital. (N2) I will use it to visit the coffee shop or any other nearby places I need to go, or meet friends. (N7)
However, some participants also shared that the use of mobility scooters has enabled them to travel further places more easily compared to before.A participant shared:

Regaining independence using a mobility scooter
In addition, the ownership of a mobility scooter has provided greater convenience and an increased sense of independence for users in both self-care and community participation.This is validated as participants mentioned:

My husband did everything (last time). Now with a mobility scooter, I can do it myself. (N10)
The best thing is that it has enabled me to do what we need to do ourselves.(N5)

Enablers for community participation with the use of a mobility scooter
Participants attributed the use of mobility scooters in the community to the compatible features of mobility scooters for daily use.In addition, the accessibility of the built environment and the positive attitude of the public towards them provided a positive experience and facilitated their use of mobility scooters.A significant proportion of participants also credited their adaptability to challenges and self-developed coping strategies to prevent physical deterioration to their continued usage of mobility scooters in the community despite existing challenges.

Compatibility of the specifications of a mobility scooter for daily use
With an understanding of the impact of mobility scooters on community participation, various enablers of participants' continual participation in the community were highlighted.A notable factor was the compatibility of mobility scooter features for daily activities such as the presence of basket and mobility scooter's dimensions for ease of travel as mentioned by participants: There's only a basket in front, when we go and buy groceries we don't go daily.(N6) I chose this model of mobility scooter because it was not too big, and was not too long.Sometimes when I have to visit the doctor's and enter the lift, it is easier to manoeuvre with a smaller mobility scooter.(N2)

Accessibility of the built environment
The Singapore government has put in efforts to improve the community environment for better accessibility for people with disabilities.Some environmental improvements in the community, such as the availability of slopes, lift and adequate space along paths, as well as the ease of navigation within the physical spaces of public transport, have encouraged our participants to navigate around the community with the use of mobility scooters.Our participants expressed: But fortunately, Singapore is quite advanced now.Most of the new blocks have sufficient slopes.(N7)

The Mass Rapid Transit (MRT) is very easy! MRT is very easy, very wide inside. (N9)
The positive attitude of public towards a mobility scooter user Generally, participants shared that the public has been receptive, helpful and considerate when they used their mobility scooters for community mobility, assuring their use even in crowded places.They were also appreciative of people providing help readily when required: They understand that we are elderly, and most of us use the mobility scooter.Thus, regardless of walking or whatever, they will give way to us.(N2) The front wheel was stuck over the kerb … I had to wait for a passer-by to help me lift and get the mobility scooter down … (N4)

Adaptability to challenges of mobility scooter driving in the community
Beyond the scope of training, if received previously, participants attributed their use of mobility scooters to their ability to adapt to several unforeseen challenges in their naturalistic community over time.They cited the need to have awareness of potential risks and their personal limitations, good safety awareness and judgement to avoid risks and accommodate to challenging events when navigating through spaces for daily activities.Different adaptative strategies to overcome challenges in the use of mobility scooters were shared by the participants:

You must adjust yourself [what], you should know yourself, that's why … you … must have that ability to know … know what is right and wrong … (N6)
We also have to be safe.Because this mobility scooter doesn't cover you completely, it is like walking, so you must be careful.If you drive recklessly, it will be dangerous.(N8)

Self-developed coping strategy to prevent physical deterioration
Participants had awareness of the need to maintain an active lifestyle to prevent deterioration in physical health.Some participants cited continual effort to participate in physical exercise and against being over-dependent on the use of mobility scooters: When I am at home, I frequently walk without an aid, so I would not get frail.(N1)

Barriers to community participation with the use of a mobility scooter
Though the use of mobility scooters enhanced our participants' occupational participation, they also encountered some barriers while driving the mobility scooters in the community.They include limitations in the specification of a mobility scooter (e.g., battery), the existing inaccessible built environment and negative encounters with the public were highlighted by participants as barriers that deterred and discouraged them from using their mobility scooters in the community.

Limitations in the specification of a mobility scooter
Participants noted several barriers to the use of mobility scooters for community participation, which included safety considerations during wet weather and concerns against travelling far distance due to fear of the battery running out and the possible inconvenience.Two participants said:

Oh, raining [ah]. Raining, I won't dare to go out [lor]! (N3)
I will not ride (the mobility scooter) if it is too far.I am worried that the battery will not last if I travel too far, and there's not enough battery to make a return home (laughter).(N2)

Inaccessibility of built environment
Singapore has made most environment accessible for mobility scooter users.However, some participants have experienced inaccessible physical environment such as space constraints in the community and unfamiliarity with the environment still poses difficulties and discourage participants from visiting certain places.These were highlighted by some participants: Several participants have also experienced difficulties in accessing and manouvering within public transport such as buses due to inaccessibility of the built environment and space constraints.Therefore, these environmental barriers limit their use of motorized scooters while taking public transport:

I am unable to take the bus as sometimes the bus stops have steps, it is not accessible for mobility scooters, I will use a wheelchair instead. (N2)
More difficult to board the bus with a mobility scooter … it will require a lot of skills.(N5)

Negative encounters with the public
This study also revealed that negative encounters with the public may deter participants' participation and intentional avoidance of related activities.Participants commonly cited avoidance of crowded areas by limiting community participation to off-peak hours and avoiding the use of public transport due to negative experiences:

On the bus … After office (hours) … some of them [ah] show a black face … they are not happy that you want them to move away from the spot they are standing. (N9)
It was being scolded the second time I tried to board a bus with a mobility scooter.I was afraid of riding after being scolded.(N5) I was afraid of youths who were using electronic scooters in the past, but not now anymore.Those youths who use those scooters ride very quickly.

Discussion
This is the first study conducted in Singapore that provided an insight into local older adults' experience of using mobility scooters in the community.The main finding in this study is that the use of a mobility scooter had increased occupational performance and occupational engagement of older adults in valued community activities.Besides allowing older adults with mobility difficulties to continue participating in their valued activities within their community with greater ease and convenience, the use of mobility scooters has improved their sense of independence in performing these valued community activities.Albeit some challenges faced, participants continued to integrate the use of mobility scooters into their daily lives.This pattern is congruent with another study [29], validating the importance of using mobility scooters in improving users' quality of life.

Using mobility scooter to compensate for reduced mobility
In this study, local older adults either initiated the purchase or were prescribed mobility scooters due to reduced mobility.This is echoed in several similar studies that seek to understand the experience of mobility scooters [9- 14,30].It is expected as mobility is an important determinant for community mobility and the ability to participate in valued activities is crucial to maintain a person's health and well-being [3-6].In particular, the desire to use a mobility scooter by participants in this study was strengthened by their confidence in driving the mobility scooters as they perceived that mobility scooters were simple and intuitive to use.
Studies [13,31] have raised concerns about prolonged use of mobility scooters due to the risk of deterioration in physical functioning and increased risk for cardiovascular diseases following a reduction in the level of physical activity.On the contrary, participants in this study reported no subjective deterioration in physical health.They attributed the maintenance of health to a continual effort to keep an active lifestyle and a conscious effort against over-reliance on the use of a mobility scooter by limiting it for community mobility only.With a recognition of the importance of mobility and the convenience of using a mobility scooter to facilitate community mobility for participation in meaningful activities, further studies could be conducted to better understand if the benefit of usage outweighs the risks, especially if users are compliant with maintaining an active lifestyle to minimize possible deterioration in physical health after using a mobility scooter.In addition, educating users to reduce reliance on the mobility scooter to curb further physical deterioration may still be required during mobility scooter training [32].

Supporting participation in valued occupations
With a mobility scooter, common activities and places frequented by local older adults in this study included the market for grocery shopping, community centres for exercise or games, visiting family and friends and visiting healthcare facilities for medical appointments.This corresponds with international literature [10,12,33], but with less prevalence in leisure and meeting friends, possibly due to narrowing social circle of local older adults, with a culture of a family as precedence [34].
Similar to other studies [11,32], older adults in this study also showed that mobility scooters were used as means to maintain their current lifestyle rather than exploring new activities.This could be explained by the higher probability that the habits and routines of older adults have achieved congruence [35].Consistent with numerous studies [9- 13,30], participants in this study appreciated the increased convenience and sense of independence following the use of mobility scooters for community mobility.They visited amenities in the vicinity on a more frequent basis, which was also reported in another study examining older adults' life-space mobility using a mobility scooter in the community [36].This subjective experience following the use of mobility scooters for community participation represents a maintenance in occupational engagement for older adults, supporting the achievement of successful ageing in older adults for participation and well-being [37].Therefore, continual efforts should be in place to support older adults' use of mobility scooters for engagement in meaningful and valued occupations.

Influences of environmental factors on the use of mobility scooters
The environment is part of the PEO Model that has the influence to enable or pose as a barrier for the occupational performance of tasks and roles [24].Environmental factors that have been highlighted in this study include physical and social aspects.
Generally, participants in this study were satisfied with Singapore's built environment.This validates Singapore's governmental ongoing effort in building an age-friendly city to increase the availability of accessible walkways, lifts and transport systems.This is unlike the experience from users outside Singapore where deficiencies in infrastructures such as lack of ramps were daily occurrences for mobility scooter users, posing significant barriers and safety concerns for them [9, 10,13,14].While older adults in this study were spared from such challenging scenarios, they highlighted that in presence of inaccessibility, they would also face difficulties and would tend to avoid such environments, potentially limiting community participation in relevant activities.Therefore, there is a need for Singapore to continue building an inclusive, accessible and safe environment for all.
Older adults in this study shared that their experience with the public was mostly positive as most were considerate and would readily offer help to them if required, which is consistent with another study by Widehammar et al. [14].However, some participants who have had negative encounters (e.g., accidents) and intentionally avoided involved activity to prevent a possible repeat of the unfavourable experience.They would rather restrict their freedom than inconvenience others.The study [14] explained that societal attitude had the greatest influence on the use of mobility scooters and such issues reflected the insensitivity and lack of awareness of the public towards mobility scooter users in the community.Therefore, initiatives should be in place to increase knowledge and understanding of the needs of mobility scooter users among society and politicians.This is to maximize users' potential to fully participate in all valuable activities in their natural environment.

Inconsistencies in training
Mobility scooter users in Singapore have a mixture of training experiences.Contrary to only 25.0% of users receiving training found from an international survey [11], a majority of our participants (83.3%) had received training either from healthcare professionals or had informal trials with vendors who are commercial suppliers of mobility scooters.This is consistent with studies that revealed low prevalence and variability of training programmes for use of mobility scooters [10][11][12][13][14].The formal training by healthcare professionals seem to include the comprehensive experience of navigating through community spaces including public transport, yet informal training usually involved navigating through the immediate environment in the vicinity of the retail shop.Even though all participants reported initially perceived competence, some still reported difficulty navigating through narrow spaces efficiently such as within a bus, eventually avoiding the activity as a coping strategy.It was notable that all four participants who had a history of incidents in the use of mobility scooters owned a driving licence.This finding is similar to one study [38] where 66% of participants failed at least one test item when driving a mobility scooter although the majority held driving licences.Where having prior driving experiences may elicit confidence in driving a mobility scooter initially, it might not be a good measure of competency in the long run.Training programmes could have an increased focus on guiding participants to develop required skills to overcome possible difficult scenarios in their natural environment.

Implications for occupational therapy practice
From the perspective of occupational therapy, the increase in occupational performance and occupational engagement in community activities among older adult users of mobility scooters, advocates for its use as means of transport for those with mobility difficulties.As gatekeepers to assess, prescribe and train users of powered mobility aids, occupational therapists in Singapore should continue their efforts to promote the safe use of mobility scooters among the older adult population.
Occupational therapists could take the initiative to collaborate with other key stakeholders, including mobility scooter users, vendors, and governmental agencies to create a standardized assessment, training and follow-up programme for mobility scooter users.Currently, the Practice Guidelines for Prescribing Powered Mobility Aids by the SAOT [21] is the only guideline available in Singapore for the prescription of a PMA, including mobility scooter.It details clear requirements on the three stages of the assessment and training process, physiological characteristics required of a user and further service recommendations.However, these guidelines are targeted at occupational therapists and not enforced on commercial vendors who also provide sales of mobility scooters in Singapore.This could explain the inconsistencies in training and perceived competency as highlighted by participants in this study.A universal guideline that outlines the process for assessment, training and follow-up programme with consideration from all stakeholders would provide greater clarity and ensure safe use of mobility scooters for all.
Currently, studies show that no evidence-based training programme is available [15,39,40].However, only one study [41] showed that having a full-scale environmental simulation would be beneficial in the identification of usability barriers in the community.As new users of a mobility scooter, individuals may not be able to foresee potential challenges faced in the community.Besides basic manoeuvring skills, having full-scale simulated or naturalistic training within the community would hence be beneficial in acquiring skills necessary for safe, efficient and competent use in the community [42], as well as attaining their personal satisfaction [43].Presently, there is one simulated mobility park with a mock-up bus and a train cabin situated next to a community hospital that has enabled occupational therapists to carry out training for mobility scooter users on public transportation with ease.This initiative could therefore be expanded to hospitals for effective training programmes.However, notably, the increased frequency of training would mean that the organization may be required to reallocate resources to manage manpower [15].Hence, it is also important to consider that without comprehensive training, mobility scooter users may be underequipped to manage challenges in the community which may affect their community participation.
As healthcare professionals, occupational therapists need to advocate for users to maintain an active lifestyle even after adopting the use of a mobility scooter [32].In collaboration with vendors and other multidisciplinary professionals such as general practitioners and physiotherapists, occupational therapists could work together to review users' physical, cognitive, perceptual, sensory and psycho-affective health periodically.This is to ensure that all users have adequate capacity to drive the mobility scooter safely through their aged years.

Limitations
This study had several limitations.First, the selection of participants was not fully representable of existing and previous mobility scooter users in the community since those individuals that may have received one but are not using it were excluded.Hence, the findings in this study will be biased towards individuals who have found benefits in the use of a scooter.Second, as Singapore is a multicultural society, there was a lack of representation of men, people from other ethnic groups and different social classes that could affect the results as these characteristics may influence the choice of occupational performance and engagement.This could also be attributed to the limited language abilities of researchers, confining participants to only those who are conversant reducing representation of other ethnicities.Third, the accuracy of the data collected may have been limited with phone interviews subjected to poor connectivity incidents and limited observation of participants' behaviour and body language.Fourth, eliciting participants' experiences of the early phases of purchase, training and usage may have also been limited by potential recall bias.Fifth, some potential confounding factors such as family support and financial status were not included in this study, which may affect the overall result.Last, the credibility of the interview guide could be improved.Even though the interview guide based on the use of the PEO model to elicit the unique experiences of local users and identify the complex factors affecting users' experience of using a mobility scooter, there is no sample of reference to verify validity and credibility.Future studies can incorporate some standardized outcome measures, such as Life-Space Assessment [44], Short Form 36 Health Survey [45], to assess the level of community mobility and quality of life.A cross-sectional study can be considered to include all existing and previous mobility scooter users and determine the long term effects of the use of mobility scooters on users.Similarly, future research may also focus on comparing the change in occupational engagement for older adult users between pre-and post-mobility scooter use.

Conclusions
The findings show that the use of mobility scooters resolved physical limitations in mobility and increased occupational performance in existing occupations that older adults participate in.The use of mobility scooters provided increased convenience and a sense of independence among older adult users in their performance of community activities, thereby gaining occupational engagement in valued occupations in the community.Occupational therapists should continue to be the gatekeepers and work collaboratively with other stakeholders to promote active participation and ensure the safety of the mobility scooter users in the community.

Figure 1 .
Figure 1.Themes emerged from thematic analysis and the influencing factors on occupational participation in mobility scooter users.
a Age groups adapted from Singapore Department of Statistics (2020).b Family includes with spouse only, children only or both children and spouses.c Musculoskeletal disorder includes osteoporosis and osteoarthritis conditions.d Other health conditions include stroke, asthma, diabetes and spinal conditions.

Table 2 .
Occupation participation with the use of the mobility scooter.