Encouraging Participation in Exercise for Individuals with

Mobility Impairments: Development of the CHEC-FIT

Danica Steinle, MSOT 08Washington University School of Medicine

Department of Occupational TherapyApril, 2008

Funding

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

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).

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

Background: Environment

• In 2002, 48% of the disabled population reported encountering barriers to access of local health facilities and 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)

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.

Aims of the Study

1.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

2. Test the CHEC-FIT for inter-rater reliability3.Examine the relationship between the CHEC-

FIT and AIMFREE scores

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

CHEC

Major Domains:• Entering building• Using the building• Using restrooms• Amenities

Features

• 22 Features captured from subjective data by individuals with mobility impairments

• Scored dichotomously (yes & N/A = 1 No = 0)

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.

CHEC-FIT Domains

1. Main Fitness Area Lighting, Staffing, etc.

2. Participation in ExerciseStrength & Aerobic Equipment, Swimming Pool, etc.

3. Locker RoomsLockers, Showers, etc.

4. MiscellaneousFees, Daycare, Transportation Route, etc.

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

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

1. Cannot afford membership2. Cannot afford special equipment 3. Fitness facilities are not accessible

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

1.Environmental Influences on Exercise Questionnaire (EIEQ)

2.Key Informant Interviews

Phase 2: Item Development Results

EIEQ

1. Affordable Membership2. Specialized Equipment 3. Respectable Staff4. Staff Support5. Temperature Inside the Building6. Wide Spaces7. Accessible Showers & Locker

Rooms8. Located near Public

Transportation Route

Key Informants1. General Accessibility

Features (wide doorways, etc.)

2. Caregiver or Support availability

3. Day Care

Phase 2: Item Development Results4 Domains

• Main Fitness Area• Participating in Exercise

– Staffing– Strength Equipment– Aerobic Equipment– Exercise Classroom– Swimming Pool

• Locker Room• Miscellaneous

54 Items→13 items→28 Items

→1 Item→7 Items→4 Items→5 Items→11 Items

→9 Items→4 Items

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?

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?

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

Domain: Locker Room

• Is an accessible bench or seating near by the accessible lockers?

Access Board, 1999

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?

Phases 3 & 4: Scoring and Testing

Scoring: completed by a focus group of nine individuals with mobility impairments

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.

Findings

According to Portney and Watkins, a score of .75 indicates good reliability.

CHEC-FIT Intraclass Correlation (ICC) .99

0 1.75 .90

SPSS 16.0

Findings

Pearson’s Correlation

Overall Scores .737*

Equipment Scores .628*

Swimming Pool Scores .866**

Locker Room Scores .686*

SPSS 16.0

*Significant at .05 level**Significant at .01 level

Accessing the Data

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

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

Implications for OTTherapists 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

With Much 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