Development of the Community Health Environment Checklist Holly Hollingsworth Susan Stark Kerri Morgan David Gray Partial Support for this report was provided by the Office on Disability and Health at the Centers for Disease Control and Prevention (R04/CCR714134) for a grant titled “Mobility, Disabilities, Participation and the Environment.”

Problem Statement ► Problem Statement  Community environments are not designed to meet the needs of people with disabilities.  Participation is impacted by how people are able to use their environments. ► Purpose  By identifying barriers and supports in the community environment, domains influencing social participation will be identified.

Research Question/Approach ► Research Question  What are the characteristics or features of an environment that make it more or less receptive to people with mobility impairments? ► Approach  We surrender our claim of objective expertise and respect the subjects expertise in their own situations (Gilgun 1998)  Cognitive mapping was used to identify a person’s perception of their environment.

Design and Procedure ► Design  Qualitative  In home interviews  Cognitive mapping exercise  Member check (focus groups) ► Analysis  Constant comparative method

Participants ► Inclusion Criteria  Presence of a mobility limitation  Resided in St. Louis metropolitan area  Left home 2-3x/ week ► Demographics  25 people with mobility limitations  Mean age= 46.9 yrs.  14 female/ 11 male  13 Caucasian/ 10 African American  stroke, SCI, CP, & post polio

Findings: 15 Key Destinations ► Government Buildings ► Major Tourist Destinations ► Performance Venues ► Large Stores ► Small Stores ► Self Care Service Providers ► Dining Establishments ► Transportation ► Health Care Providers ► Health Vendors ► Professional Service Providers ► Indoor Leisure ► Outdoor Leisure ► Religious Facilities ► Schools and Libraries

Findings: 22 Key Features ► ► Distances to Enter Building Accessible Parking ► ► Level Surfaces ► ► Curb Cuts ► ► Doors at Entrances ► ► Signage for Accessible Paths to Entrances ► ► Doors Inside the Building ► ► Loaner Scooters or Wheelchairs ► ► Signage for Accessible Elements ► ► Single Level ► ► Maneuverable Spaces ► Crowding ► Floor Surfaces ► Counters and Merchandise ► Accessible Places to Sit ► Adequate Lighting ► Accessible Restroom ► Drinking Fountain ► Accessible Phone ► Drive-through Window ► Usability ► Rescue Assistance

The CHEC ► Major sections:  Entering building  Using the building  Using restrooms  Amenities ► Features  22 Features  Captured the essence of the participant’s comments ► Items  Individual questions that capture the presence of the feature  Scored dichotomously (yes & N/A = 1 No = 0)

Flexibility of the CHEC ► Receptivity can be characterized at the Community Level  Total CHEC Scores on a sample of destinations  Receptivity of “ accessible restrooms” of entire community (features by destination) ► Receptivity can be characterized at the Destination Level  Total CHEC score of the destination or Area of a building (this building)  Receptivity of features (seating)

Review by consultants ► Consultants suggestions:  Scaling (to weight items)  Make the form “user friendly” and not technical  Make a “rule book” instead of a complicated scoring sheet

Rule Book and Glossary ► Available to provide assistance in determining score ► Resources on which rules are based:  Based on the important descriptions of the experts (people with mobility limitations)  Consultants (experts in architecture, universal design, occupational therapy)  Literature and standards

The RULE BOOK ► “ can you get in, do what you need to do and get out without much difficulty” ► Determine if “one” accessible feature is present and evaluate that feature (e.g. the accessible bathroom) (versus all features) ► Column 1 and 2 are the same as the CHEC ► The third column contains the rules for the corresponding item.

The GLOSSARY ► Items that are more difficult or involve measurements have a visual picture for clarification. ► Glossary items are numbered and arranged in alphabetical order. ► Links to the glossary can be found on the corresponding item in the CHEC

In the field ► Evaluations are completed during “busy time” ► Time  5 minutes small building  90 minutes large building ► 1-2 raters ► Using paper/pencil, PDA, or Tablet PC

Scaling and Scoring ► Scored dichotomously (yes & N/A = 1 No = 0) ► 22 Features weighted based on ranking of “importance” of items (based on ranking study) ► Weights were transformed monotonically to yield the range of a destination score to be from 0 to 100 ► Ranking Study  17 of the original subjects (78 different rankings by destination category)  Ranked each feature based on directions “imagine the most accessible place for you… “

Features & Weights Entrance9.62 Curb Cuts 8.65 Automatic Doors 8.65 Accessible Bathroom 8.65 Elevator/Single Level 6.73 Distance to Entrance 5.77 Accessibility features in order 5.77 Wide Spaces 5.77 Floor Surfaces 4.81 Lightweight Doors 4.81 Parking4.81 Spaces not Crowded 3.85 Accessible places to sit 3.85 Accessible path/entrance marked 2.88 Accessibility Signage 2.88 Accessible Counters 2.88 Lighting1.92 Accessible Phone 1.92 Accessible Drinking Fountains 1.92 Area of Rescue 1.92 Loaner Wheelchair/Scooter 0.96 Drive Through Window 0.96

Site: OT Building Section I YesNotesScore ENTER BUILDING Accessible parking Are there accessible parking spaces with adequate widths and aisles for a person with a mobility device to get in and out of their car? 0 Are the accessible spaces located closest (or most central) to the accessible entrance or accessible route with minimal traffic to cross in order to enter the building? 1 Does the facility have an enforcement procedure to ensure that accessible parking is used by only those who need it? 1 Subtotal = 2*4.81/3 2 of 3 Yes’s & Weight 4.81 EXAMPLE: CHEC Page 2 SECTION FEATURE

Scoring ► Scores are computed for each Feature within each Section. ► A Section score is the sum of the Feature scores. ► The total Destination score is the sum of the Section scores. ► The scoring has been scaled such that the highest Destination score is 100.

Sampling Strategy ► Identify the boundaries of a community  Political  Geographic  Identified by population of individuals with disabilities ► Identify all possible destinations within the community within each destination category ► Sample 10% of the destinations within each destination category ► If a “community” does not contain a destination within a category (e.g. hospital), use the closest destination of that type to the center of the community and rate that destination

University City, MO City Hall CHEC Sites Reported destinations visited by people with mlOverlap Jeff Cuthbert, OTR

Validation ► University City Missouri  Urban environment ► 63 destinations rated  1,500 sq ft – 20,000 sq ft (10-90 minutes) ► CHEC score 4.2 (poor)-97.2 (excellent) receptivity ► KR-20 =.95 ► Menomenee, Wisconsin  Rural environment ► 45 destinations rated  2000 sq ft – 20,000 sq ft ( minutes) ► CHEC score 21.2 (low) (excellent) receptivity ► KR20 =.92

Reliability ► Section I Entering the Building 0.72  Level Surface 0.80 ► Section II Using the Building 0.95 ► Section III Restrooms 0.87 ► Section IV Amenities 0.86

Rural v. Urban P=.08 P<.01 P=.12 P<.01

► Refine measure based on initial testing (CHEC 2.0) ► Validate instrument against gold standard (in process) ► Validate instrument against lived experience of individuals with mobility impairments ► Develop formal training program ► Develop web based data management and report generating software (identification of solutions as well as barriers) Next steps

Limitations in flexibility ► Difficult to translate to different cultures  Transportation differences ► Only developed for persons with mobility limitations – small sample size ► Value not in the final items but in the approach and method  Groups interested in vision/hearing may want a version  International partners may wish to develop a version

Why use this measure? ► Assesses the receptivity of the physical environment from the perspective of persons with mobility impairments ► Is brief, intuitive, and easy to administer ► Excellent internal consistency ► Internal validity ►