Danica Steinle , MSOT 08 Washington University School of Medicine

1. Encouraging Participation in Exercise for Individuals with Mobility Impairments: Development of the CHEC-FIT DanicaSteinle, MSOT 08 Washington University School of Medicine Department of Occupational Therapy April, 2008

2. Funding This project was funded by a grant from the Missouri Foundation For Health

3. Background: Wellness • In 2003, 53% of adults with disabilities lacked physical activity or lead a sedentary lifestyle compared to 34% of adults without disabilities (CDC, 2006). • Improve physical characteristics (Guttman, 1976; Shepard, 1991; Wahman, Gabriele & Richard, 2006). • Improved psychological benefits such as higher acceptance of disability, higher self-esteem/efficacy, and sense of life control (Guttman, 1976; Rejeski, Focht, 2002; Wahman, Gabriele, Richard, 2006).

4. Quotes on the Benefits of Exercise • “I can go up and down stairs to the basement without any problem (increase endurance), can go outside and get mail (when weather is good) without problem.” • “I have better endurance; I don't suffer from fatigue as easily” • “I feel that my balance and leg strength are better and I do notice a difference in everything I do especially with cooking and cleaning around the house. My endurance is somewhat better” • “It has become easier to transfer myself.” Chang, 2006

5. Background: Environment • In 2002, 48% of the disabled population reported encountering barriers to access of local health facilitiesand wellness programs (CDC, 2006). • Environmental factors play an important role in determining individuals with mobility impairments rate of participation (Rimmer, Riley, Wang, Rauworth, & Jurkowski, 2004; Kirchner, Gerber, & Smith, 2007)

6. Purpose of the Study To develop a measurement tool for assessing the environmental receptivity specific to inside fitness facilities to help acknowledge supports/barriers that play a role in exercise participation by individuals with mobility impairments.

7. Aims of the Study • Develop an instrument that can be used by allied health professionals, community health planners, and exercise participants to assess the environmental barriers that affect participation in exercise within fitness facilities • Test the CHEC-FIT for inter-rater reliability • Examine the relationship between the CHEC-FIT and AIMFREE scores

8. Measurement Tools Although a few valid and reliable environmental measures exist each has there own limitations when assessing accessibility of fitness facilities: • ADA Accessibility Guidelines for Buildings and Facilities (ADAAG) • Accessibility Instruments measuring Fitness and Recreation Environments (AIMFREE) by Rimmer • Community Health Environment Checklist (CHEC) by Stark

9. CHEC Major Domains: Features 22 Features captured from subjective data by individuals with mobility impairments Scored dichotomously (yes & N/A = 1 No = 0) • Entering building • Using the building • Using restrooms • Amenities

10. CHEC-FIT The Community Health Environment Checklist – Fitness Facilities (CHEC-FIT), is a user friendly measurement tool that can be used to objectively assess the aspects of the physical environment within fitness facilities that are important to persons with mobility impairments.

11. CHEC-FIT Domains • Main Fitness Area Lighting, Staffing, etc. • Participation in Exercise Strength & Aerobic Equipment, Swimming Pool, etc. • Locker Rooms Lockers, Showers, etc. • Miscellaneous Fees, Daycare, Transportation Route, etc.

12. Methods The CHEC-FIT was developed using a multi-step method divided into four phases. • Phase 1: Retrospective quantitative study • Phase 2: Item development • Phase 3: Scoring • Phase 4: Psychometric testing

13. Phase 1: Retrospective Study The Missouri Foundation For Health (MFH) sponsored study entitled “Exercise Programs and Health Promotion for Unserved and Underserved People with Mobility Impairments” was used to gather retrospective data on why individuals with mobility impairments do not exercise as much as they want to exercise • Cannot afford membership • Cannot afford special equipment • Fitness facilities are not accessible

14. Phase 2: Item Development Using a two-step approach both objective and subjective data was gathered to identify environmental features of interest for the measure • Environmental Influences on Exercise Questionnaire (EIEQ) • Key Informant Interviews

15. Phase 2: Item Development Results EIEQ Key Informants General Accessibility Features (wide doorways, etc.) Caregiver or Support availability Day Care • Affordable Membership • Specialized Equipment • Respectable Staff • Staff Support • Temperature Inside the Building • Wide Spaces • Accessible Showers & Locker Rooms • Located near Public Transportation Route

16. Phase 2: Item Development Results 4 Domains 54 Items 13 items 28 Items 1 Item 7 Items 4 Items 5 Items 11 Items 9 Items 4 Items • Main Fitness Area • Participating in Exercise • Staffing • Strength Equipment • Aerobic Equipment • Exercise Classroom • Swimming Pool • Locker Room • Miscellaneous

17. Domain: Main Fitness Area • Are all entrances to the fitness area accessible? • Is the floor surface smooth and easy to walk or roll over? • Is the floor surface free from clutter and debris?

18. Domain: Participation in Exercise • Can an individual in a wheelchair use some of the strength equipment (aerobic equipment) from the wheelchair without transferring? • Are gloves, wraps, hooks available to use for griping handle bars on both weight and aerobic equipment for individuals whom do not have grip strength?

19. Domain: Participation in Exercise • Does at least one of each type of strength equipment (aerobic equipment) or machine have clear floor space and served by an accessible route? Access Board, 1999

20. Domain: Locker Room • Is an accessible bench or seating near by the accessible lockers? Access Board, 1999

21. Domain: Miscellaneous • Is the fitness facility located near a public transportation route? • Does a sliding fee, discount or scholarship program exist to help with membership fees for individuals with disabilities?

22. Phases 3 & 4: Scoring and Testing Scoring: completed by a focus group of nine individuals with mobility impairments

23. Phases 4: Testing Testing: a team of three raters individually assessed 10 fitness facilities using the CHEC-FIT to establish inter-rater reliability. Each CHEC-FIT took approximately 20 minutes to complete.

24. Findings According to Portney and Watkins, a score of .75 indicates good reliability. CHEC-FIT Intraclass Correlation (ICC) .99 .75 .90 1 0 SPSS 16.0

25. Findings *Significant at .05 level **Significant at .01 level SPSS 16.0

26. Accessing the Data

28. Limitations • Scoring system only reflects true receptivity and not amenities • Raters were all OT students, whom have been educated about accessibility features and were familiar with the original CHEC • Small sample size used to correlate CHEC-FIT and AIMFREE scores • Instrument is specific for individuals with mobility limitations

29. Future Research • Further psychometric testing comparing the CHEC-FIT to AIMFREE scores • Placing individuals with mobility limitations in the specific sites and further compare direct subjective data to objective data gathered by the CHEC-FIT

30. Implications for OT Therapists need to play an important role in promoting physical activity among individuals with mobility impairments and to promote exercising within fitness facilities • Measuring fitness facilities for accessibility • Educate clients • Educate fitness professionals • Reassess fitness facilities

31. WithMuch Appreciation • Gray Lab: Dr. David Gray, Kerri Morgan, Dr. Holly Hollingsworth • Dr. Susan Stark and Emily Somerville • EMC Staff: Sue, Jess and Melissa • CHEC-ers: Hillarie and Erin • Parents • Focus Group Participants