Participation by design - Disability and Health Journal

OriginalArticle

Participationbydesign:Integratingasocialecologicalapproachwith universaldesigntoincreaseparticipationandaddvaluefor consumers

a JohnF.ButzerCenterforResearchandInnovation,MaryFreeBedRehabilitationHospital,235WealthyStSE,GrandRapids,MI,USA b DivisionofRehabilitation,MichiganStateUniversityCollegeofHumanMedicine,235WealthyStSE,GrandRapids,MI,USA

c DepartmentofEpidemiologyandBiostatistics,MichiganStateUniversityCollegeofHumanMedicine,235WealthyStSE,GrandRapids,MI,USA

d UniversalDesignConsulting,18114,MileRdNE,GrandRapids,MI,USA

articleinfo

Articlehistory:

Received31March2020

Receivedinrevisedform

10September2020

Accepted13September2020

PresentedinparttotheAmericanCongress ofRehabilitationMedicine,November2 4, 2016,Chicago,IL;theAmericanMedical RehabilitationProvidersAssociation, October23 25,2017,Chicago,IL;andEnvironmentsforAging,February28-March1, 2018,LasVegas,NV.

Keywords:

Facilityaccess

Socialecology

Peoplewithdisabilities

Costbenefit

Value-basedpurchasing

abstract

Background: Physicalactivityisanessentialcomponentofahealthylifestyle.Healthclubsencourage sustainedhealthylifestylesbutarestilllargelynotaccessibletopeoplewithdisabilities.Costisabarrier foraccessibilityenhancements.

Hypothesis: Wepostulatethat:(A)universaldesigncoupledwithasocialecologicalapproachimproves measuredaccessibilitycomparedwithexisting fitnessfacilitiesconstructedsincetheadoptionofthe ADA;(B)increasedaccessibilitycoupledwithanenvironmentfriendlytopeoplewithdisabilitiesattracts moreparticipantstoaYMCAthanpredictedbytraditionalindustrymarketresearchproducingarecoveryofthecostofincreasedaccessibility;and(C)attitudesoffacilitymemberstowardpeoplewith disabilitiesmayimproveifanaccessiblefacilityfacilitatesmorepersonalinteractionsbetweenpeople withandwithoutdisabilities.

Methods: AccessibilityismeasuredwiththeAccessibilityInstrumentsMeasuringFitnessandRecreation Environments(AIMFREE).Costrecoveryisdeterminedbycomparingexcessmembershiprevenuetothe costofuniversaldesignelementsbeyondregulatoryrequirements,andattitudestowardpeoplewith disabilitiesaremeasuredwiththeAttitudesTowardDisabledPersonsScale.

Results: AIMFREEscoresweresignificantlyhigherthancomparisonfacilitiesinallareasexceptfor equipment,parking,training,andprograms.Excessrevenueexceededtheextracostofaccessibility enhancementsandattitudestowardpeoplewithdisabilitiesdidnotchange.

Conclusions: Universaldesigncoupledwithasocialecologicalapproachimprovesaccessibilityin fitness facilitiesandresultsinareasonablepaybacktime.Attitudestowardpeoplewithdisabilitiesdidnot changeinaYMCAdesignedtoaccommodatepeoplewithdisabilities.

© 2020ElsevierInc.Allrightsreserved.

Introduction

Physicalactivityisanessentialcomponentofahealthylifestyle andisknowntoprotectagainstobesity,stroke,heartdisease,type2

* ThisresearchwassupportedinpartbyagrantfromProgressiveAE,Grand Rapids,MIUSA.

* Correspondingauthor.MaryFreeBedRehabilitationHospitalandMichigan StateUniversity,JohnF.ButzerCenterforResearchandInnovation,235WealthySt SE,GrandRapids,MI,USA.

E-mailaddress: john.butzer@maryfreebed.com (J.F.Butzer).

www.disabilityandhealthjnl.com https://doi.org/10.1016/j.dhjo.2020.101006 1936-6574/© 2020ElsevierInc.Allrightsreserved.

diabetesanddepression.1 Peopleareincreasinglyattending fitness facilitiesforexerciseandin2018heldover62milliongymmembershipsintheUnitedStates,up2.9%from2017.2Healthclubs encouragesustainedhealthylifestylesbypromotingphysicalactivity,providingtrainingandsupervision,andbyfosteringsocial relationships.However,peoplewithdisabilitieslivewithgreater riskforhealthconditions,3 andfacemorebarrierstoaccess fitness facilities.4,5 Regularphysicalactivity6 andage-friendlyenvironmentsaretwoessentialcomponentsofhealthyaging.7 Initiating andsustainingaprogramofregularphysicalactivityischallenging forallpeopleandparticularlychallengingforpeoplewith

Pleasecitethisarticleas:J.F.Butzer,R.Virva,A.J.Kozlowski etal.,Participationbydesign:Integratingasocialecologicalapproachwithuniversal designtoincreaseparticipationandaddvalueforconsumers,DisabilityandHealthJournal,https://doi.org/10.1016/j.dhjo.2020.101006

JohnF.Butzer a, b, *,RobertaVirva a, b,AllanJ.Kozlowski a, b, c,RebeccaCistaro a, b , MichaelL.Perry d

disabilitiesoragerelatedimpairmentsduetobarrierstoparticipation.8 Most fitnessfacilitiesarenotspecificallydesignedtobe accessibleforpeoplewithdisabilitiesoragerelatedimpairments.

ComplyingwiththebuiltenvironmentstandardsoftheAmericanswithDisabilityAct(ADA)iswidelyviewedassufficientto meettheneedsofpeoplelivingwithdisabilities.However, fitness facilitiescontinuetolackaccessibilityyearsafteradoptionofthe ADA.9 Someperceivethataccessibilityinitiativesbenefitonlya smallnumberofpersonswhousewheelchairsformobility.In addition,thecostofADAcomplianceisoftencitedasabarrierto makingrequiredoradditionalaccommodationforpeoplewith disabilities.10 Itispossiblethatafullyaccessiblefacilitymight attractmoremembers,ineffectpayingfortheaccessibilityenhancements;however,evidenceislacking.

Universaldesignistheintentionaldesignofthebuiltenvironmenttomakeitaccessibletothemostpeople.11 13 Initially,universaldesignfocusedonaccessibilityforpeoplewithpermanent disabilities,butmorerecentworkrecognizesacarefullyconstructedbuiltenvironmentprovidesaccesstothemostpeople includingthosewithtemporary,intermittentorage-relatedimpairments.However,universaldesigndoesnottypicallyaddressall thebarriersandfacilitatorsofthetotalenvironment.

Asocialecologicalapproachiscomplementarytouniversal designofthebuiltenvironmentandrecognizesthathuman behaviorisafunctionofthepersonandthetotalenvironmentin whichtheyexist.14 Therelationshipbetweenaccessibility,thebuilt environment,otherenvironmentalfactors,andparticipationis complex.14 16 Thetheoreticalbasisformeasuringenvironmental factorsbasedonsocialecological,lifespanandlifecoursemodelsis established14 andaconceptualframeworktoorganizeenvironmentalfactorsintoeightmajorcategorieshasbeenvalidatedwith peoplewithdisabilities.17 Thecategoriesarebuiltenvironment; naturalenvironment;transportation;systems,servicesandpolicies;economic;socialsupportsandsocietalattitudes;information andtechnologyaccess;andassistivetechnology(Fig.1).Whilethis qualitativeworkprovidesthegroundworkforobjectivemeasurementofenvironmentalfactors,wefeltitalsoprovidesthebasisfor

apracticalapproachtoaddressadditionalimportantenvironmentalfactorstoenhanceuniversaldesignofthebuiltenvironment,thecurrentbestpracticeforprovidingaccessibility.Weused apracticalexpertopinionapproachwithuserinputtoreduce barriersandenhancefacilitatorsintheenvironmentalcategories.

Inthecategoryofsocialsupportandsocietalattitudes,we addressedtraining,informationandpeersupportbutnotsocietal attitudesdirectly.Wefelttheimprovementintheotherenvironmentalfactorswouldimproveparticipationbutrecognizedthe importanceofsocietalattitudesandquestionedwhetherincreased personalinvolvementwouldimproveattitudes.Societalattitudes, inparticular,areanimportantdeterminantofinclusionand participationinsociety.18 Societalattitudescancreatebarriersto inclusionofpeoplewithdisabilities19 or,whenpositive,canfacilitateinclusion.20,21 Interactingpersonallywithpeoplewithdisabilitiesimprovesattitudestowardpeoplewithdisabilities.22 24 Specifically,asystematicreviewofpublishedstudiesexamining theattitudesofhealthcarestudentsandprofessionalstowardpatientswithphysicaldisabilityfoundthat “moreexperiencewith personswithphysicaldisabilities,bothprofessionallyandsocially, wasassociatedwithmorefavorableattitudes.“24 Nursingstudents withpriorworkexperiencewithpeoplewithdisabilitieshad significantlymorepositiveattitudestowardpeoplewithdisabilities.22 Incontrast,educationondisabilityhashadmixedresultsfor improvingattitudes.25 29 Itisnotknownwhetherincreased participationofpeoplewithdisabilitiesina fitnessfacilitywill changeattitudesofpeoplewithoutdisabilitiestowardpeoplewith disabilities.

Thisstudyreferstoanewlydesignedandbuiltfacility,theMary FreeBedYMCA(MFB-Y),whichemployedauniversaldesignfrom theplanningstageandreplacedanobsoleteolderYMCA(Old-Y). Informationwasgatheredfromfocusgroupsandbyvisitingstateof-the-artfacilitiesinArizonaandAlabama,whichledtocreative designfeaturesinthebuiltenvironmentandequipmentthat exceededtherequirementsoftheADA.Universaldesignspecificallyaddressedthe36-acresite;building,shower,toiletand equipmentaccessibility;parking;andcost.Subsequently,asocial

Fig.1. EnvironmentalBarriersandSupportstoParticipationReprinted fromtheArchivesofPhysicalMedicineandRehabilitation2015;96:578 88,17 HammelJ,MagasiS,HeinemannAetal.Environmentalbarriersandsupportstoeverydayparticipation:aqualitativeinsiderperspectivefrompeoplewithdisabilities,withpermissionfromElsevier.

ecologicalapproachwasinitiatedtoaddressthesevencategoriesof environmentalbarriersandsupportstoparticipationotherthan thebuiltenvironment.Specificsuggestionsforreducingbarriers andfacilitatingparticipationineachofthecategoriesweredevelopedbyateamofrehabilitationprofessionalswithuserinput.This effortfocusedmoreattentiontotransportation,ADAparatransit, stafftraining,programming,policies,governance,andeconomic accessibility.Fewfacilitieshavebeendesignedusingthisapproach, andconsequentlytheMFB-Yisthe firstcertifieduniversally designed fitnessfacilityintheUnitedStatesbytheGlobalUniversal DesignCommission.30 Operationsandprogramdevelopmentfor theMFB-Yalsofollowedsocialecologyprinciples.Personswith disabilitiesandcommunityadvocatesserveonthegoverningboard toensurecontinuedcommitmenttoinclusionandinnovative programming.Personaltrainershaveadditionaltrainingin disabilityawarenessand fitnesstraining.Consequently,allexercise classesareopentopersonsofanyability;adaptedspinning,yoga, andPilatesexerciseclassesareavailable;andtheMFB-Yishometo arobustwheelchairsportsprogram.Organizedwheelchairteam activitiesincludeon-sitebasketball,rugby,andsoftball.Some wheelchair-basedactivityispresentinthefacilitymostofthe availabletime.Thus,theMFB-Yservesasamodelenvironmentto studyvariousinnovativeprogramsforsustainedparticipation withoutsomeofthecommonconfoundingfactors.

However,sincetheYMCAfostersanopenparticipatoryenvironmentandencouragessocialinteraction,andsincethestudies citedsuggestthatpersonalinteractionisakeycomponentto improvingattitudes,wehypothesizethatincreasedparticipationof peoplewithdisabilitiesina fitnessfacilitymaychangeattitudesof peoplewithoutdisabilitiestowardpeoplewithdisabilities.The primaryobjectiveofthispaperistoreporttheresultsofamethod integratinguniversaldesignandasocialecologicalapproachto improvemeasuredaccessibilityinanew fitnessfacilityandto determineifincreasedaccessibilityattractedmorepayingmembers,effectivelyoffsettingthecostoftheaccessibilityenhancements.Asecondaryobjectivewastodeterminewhetherattitudes towardpeoplewithdisabilitieswerechangedbyparticipatingina fitnessfacilitydesignedforuniversalaccessandwheelchairsports participation.

Methods

Weutilizedavarietyofapproachesanddatasourcestodeterminewhetherourdesignapproachimprovedaccessibility,attractedmorepayingmembers,improved financialperformance,and changedattitudestowardindividualswithdisabilities.Thisstudy wasapprovedbytheMaryFreeBedHospitalInstitutionalReview Board.Participationwasvoluntary.Informedconsentwasreceived fromallparticipantsandalldatawasde-identified.

Facilityaccessibility

AccessibilitywasmeasuredwiththeAccessibilityInstruments MeasuringFitnessandRecreationEnvironments(AIMFREE).31

AIMFREEdatafromtheMFB-YwerecomparedwithrecentlypublishedmeanAIMFREEdatafromaconveniencesampleof227facilitiesacross10states.9 Wecomparedourscoreswiththemeanfor eachdomainforfacilitiesbuiltafterADAadoptiontoassess whetherauniversallydesignedfacilityintegratingasocial ecologicalapproachachievedhigherscoresthancurrentlyoperatingfacilitiesbuiltafterADAenactment.FouradditionalYMCA facilitiesconsideredtobeADAcompliantwerealsoassessedto determineifaccessibilitymeasurementwithAIMFREEforexisting facilitiescouldguidelow-costimprovementsinaccessibilityand aidinplanningforfuturemorecostlyimprovements.

TheAIMFREEProfessionalversionassessesthebuiltenvironmentandsixotherdomains:(1)equipment,(2)information,(3) programs,(4)policies,(5)professionalbehavior,and(6)professionalsupportandtraining.UseoftheAIMFREEissupportedby reportedcontentvalidityevidenceandinterrateragreement.31 A Raschscoringalgorithmtransformsrawscorestoastandardized andreproducibleinterval-levelmeasurementscale.32 AIMFREE scoringwasperformedinanon-sitesurveyaccordingtopublished methods9 byaresearchteammemberwhoisanexperienced licensedphysicaltherapist(RV)andadesignteammemberfamiliar withADArequirementsandUniversalDesignbestpractices. NeitherraterwasanemployeeoftheYMCAorapaidconsultant. Thedesignteammemberwasemployedbytheprojectarchitecture firmbutdidnotworkontheYproject.Measurementsofwidths andthresholdswereperformedwithastandardcommercialtape measure.Inclinesweremeasuredwithaninclinometerappona smartphone.Anarbitrarycutoffscoreof70hasbeenestablishedas aminimumtargetforaccessibility,butideallyallfacilitieswould continuetoaddressdeficienciesandstriveforascoreof100.9 A citeddisadvantageisthattheAIMFREEhasresponderburdenofup to2htocomplete.32

Costrecovery

Paybacktimewasreportedasthetimetakenforexcessrevenue toequalorexceedthecostoftheuniversaldesignelementsthat wereaddedaboveregulatoryrequirements.Paybacktimeisthe timetakentorecoveracapitalinvestmentandisonecommon approachusedincapitalbudgeting.33 Excessrevenuewascalculatedasuserfeerevenuemorethanmarketsurveypredicted maximum.Themaximumnumberofmembershipunitswas determinedbyanindependentprofessionalmarketresearch firm specializingin fitnessfacilitiesusingadatadrivenmarketresearch approach.Membershiprevenuewasrecordedmonthlyandreflects thenetofnewandlostmembers.Factorsincludedintheanalysis weredrivetimes,householdincome,familysize,levelonecompetitors,populationage,andmarketpenetrationfor fitnessfacilities.Thisdatatypicallyisusedtodetermineprojectfeasibilityand toestablishrealisticbudgets.Thisindependentlyderived maximummembershipestimateprovidesathresholdtomeasure whetherimprovingaccessibilityattractsmorepeopleofallabilities andwhetherthecostsofuniversaldesigncanberecoveredthrough increasedmembership.

Constructioncostsforbuildingcomponentsweredetermined fromseveralindustrystandardmethodsincludingtheRSMeans™ ConstructionCostDataBooks,aleadingcommercialconstruction costdatabase,reconciliationwithacostdatabasemaintainedby thearchitectural firmforthecurrentlocalmarket,andobtaining costestimatesfromlocaltradecontractors.Costforeachuniversal designelementbeyondthoserequiredbyregulatorybodieswas estimatedtothenearest$1000.Costisexpressedindollarsandasa percentageoftheconstructioncost.Theadditionalcostofuniversal designisreportedseparatelyfromconstructioncostsin Table2. Accordingtoindustrynorms,constructioncostincludesallsite work,buildingconstruction,constructionmanagersgeneralconditions,overhead,andfee.Itdoesnotincludeownersoftcosts, financing,designfees,landcostorownercontingencies.

Attitudestowardpeoplewithdisability

Attitudestowardspeoplewithdisabilitiesweremeasuredwith theAttitudesTowardDisabledPersonsScale(ATDP).21 TheATDPis themostwidelyusedandtestedinstrumentthathasevidencefor validusetomeasureattitudesofpersonsintheadultgeneral populationtowardpersonswithdisability.34 TheADTPhas

reportedevidenceforreliabilityandforcontentandconstruct validationwhenusedinthegeneralpopulation.21 TheADTPhas lowresponderburden;however,itscontentmaybedatedasitwas developedinthe1960s,anditmaybesubjecttoattitude-distorting influencesbecauseitasksrespondentsdirectlyabouttheirattitudes.WeusedtheATDPtomeasureattitudesoffacilitystaffandof membersfromtheOld-YandMFB-Y.34 Forcomparison,wealso measuredattitudesofrehabilitationclinicalprofessionalsfroma comprehensiverehabilitationfacilityservingpeoplewithdisabilities.Old-Ymembers(n ¼ 64)completedthesurveysbeforeoperationalopeningoftheMFB-Y.MFB-Ymembers(n ¼ 167)were surveyedduringthe firstyearofoperation.Old-YandMFB-Y respondingmemberswereapproximately2/3femalewithanage distributionslightlyskewedtowardage >40years.Bothsamples representedthesamepercentageofthetotalmembership.For comparison,employeesofarehabilitationhospitalweresurveyed withtheADTPatthesametimeasthesurveysfortheOld-Yand MFB-Yservingasacontrolgroupforthestudy(controlforOld-Y n ¼ 134,controlforMFB-Yn ¼ 112).ADTPsurveyswerecollected atdifferenttimesduringthedayandweektoachievearepresentativesampleofusergroups.ThenumberofMFB-Ymemberswith disabilitieswasmeasuredwiththeU.S.DepartmentofLabor VoluntarySelf-IdentificationofDisability35 form.

Statisticalanalysis

MFB-YAIMFREEstandardizedscoresacrossalldomainsthree yearspost-openingwerecomparedusingzteststoresultsofan averageof227facilitiesopenedpost-ADAreportedbyRimmer etal.9 AHolm’sStepDownprocedurewasappliedtoaccountfor themultiplecomparisonsandcontrolthefalsediscoveryrate.36,37

TheADTPscoresofmembersoftheOld-Ywerecomparedto membersoftheMFB-Ytodeterminewhetherexposuretoan increasednumberofpersonswithdisabilitiesandwheelchair sportsactivitieswouldimprovescores.TheOld-YandMFB-Ymean ATDPscoreswerecomparedbypaired t tests.Thetwocontrol groupswerealsocomparedwithpairedt-tests.Dataanalyseswere performedusingSASEnterpriseGuidesoftware(Version7.1;SAS InstituteInc.,Cary,NC,USA).

Results

Facilityaccessibilityanalysis

AIMFREEdomainscoresforMFB-Yrangedfrom57.6to100 (Table1).AlldomainsexceptSpasexceededorcloselyapproached thearbitrarycutoffscoreof70.9 ZscoredifferencesbetweenMFB-Y

dataandtheaveragescoresforthereportedsampleof227facilities openedpost-ADAweresignificantlyhigherfortheMFB-Yinall areasexceptforequipment,parking,trainingandprograms.

Costrecovery

Cost

Thecostofuniversaldesignelementsoverjurisdictional accessibilityrequirementswasapproximately1.70%ofthetotal project.Thespecificelementsandtheircosttothenearest$1000 areshownin Table2

Theprivatelockerroomswithamattable($15,000)andthe wheelchairsportsstoragearea($36,000)weresuggestedbyusers, ofrelativelylowcost,andtwoofthemorepopulardesignelements. Transferbenchesinthepools($6000)tofacilitateindependent poolentrywithoutuseoftheliftsandlockerroombencheswitha widerseatingsurface($1000)toincreasesittingstabilitywere examplesoflow-costelementswithhighvalue.

Membership

TheMFB-Yfacilitymembershipexceededmarketpotentialby 882unitsinthesecondyearandcontinuedtogrowbyanadditional 542unitsovermarketpotentialinyearthree.Withanaverage monthlyrevenueof$82permembershipunit,theadditionalcosts duetouniversaldesignwererecuperatedinapproximately1½ years(see Fig.2).

Attitudestowardpeoplewithadisability

Therewasnosignificantchangeinattitudesfor fitnessfacility membersasagroupafterexposuretothenewaccessiblefacility whichincludedmorememberswithdisabilitiesandwheelchair sportsactivities(Table3).Rehabilitationstaffweremeasuredasa controlgroupbecausehistoricalnormsdatefromthe1960’sand healthcareworkershavebeenreportedtohavehigherscores.All meanscoresforboththeOld-YandtheMFB-Ymemberswere higherthanhistoricalnorms.Ascalenormof75.1fortheATDPwas establishedfromasampleofuniversitystudents.21 Old-Ymembers butnotMFB-Ymembersscoredlowerthanrehabilitationstaff. Importantly,theinclusionofmorepeoplewithdisabilitiesand wheelchairsportsdidnotadverselyaffecttheattitudescores. EighteenpercentofbothOld-YandMFB-Ymembersself-identified asdisabled,whichiscomparabletothenationalaverage.However, thissamplewassmallrelativetothetotalnumberofmembers.

Table1

AIMFREEscorescomparedwithcommunitymeanscores.

Site

Parkingbeyondmunicipalrequirements0.13%$28,000

Sidewalkwidthbeyondrequirements0.06%$12,000

Playgroundsoftsurface & ramp0.26%$55,000

Viewingareasforsoccer fields0.02%$5000

Viewingarea & benchesforsoftball fields0.01%$3000

Raisedgardenbeds0.01%$3000

Building

Ramp(netaddafterdeductioncentralstair)0.35%$75,000

Privatelockerroomswithmattable0.07%$15,000

Automaticdoors0.13%$28,000

Increasedindoordoorwidths0.06%$13,000

Pooltransferstations(3)0.03%$6000

Wheelchairsportsstorageroom0.17%$36,000

Hearingloops0.03%$7500

Largerbenchesinlockerrooms0.00%$1000

Softenmillworkcornersinchildareas0.02%$5000

Equipment

Specialized fitnessequipment0.16%$35,000

Wheelchairscale0.02%$4000

Powerandmanualadjustabledesks0.11%$24,000

Other

Additionalstrategieswithoutextracostb 0.00%$0

Stafftrainingindisabilityknowledge0.05%$10,000 Additionalcost1.70%$365,500

a Constructioncost ¼ sitework,buildingcost,manager’sgeneralconditions,overheadandfee;notincludedareownersoftcosts, financing,design fees,landcostandownercontingencies.

b Colorpalate, flooringchoices,acousticaltreatments,eliminationofthresholdsandcurbs, flooringcolortransitions,lockerroomhardware,laminar air flowinpoolareas,poollaneand flagcolors,lighting,signage,wayfinding,publictransitstop,andentryshelter.

Discussion

Fitnessfacilities,byprovidingsocializationandsupervision/instruction,areanimportantvehicleforpromotinghealthyliving. Unfortunately,many fitnessfacilitiesremaininaccessibledespite theimprovementsgeneratedbytheADA.9 Pooraccessibilityprecludesparticipationbymanypeoplewithdisabilitiesorage-related impairments.Asocialecologicalapproachhasbeenproposedasa theoreticallysoundwaytoassessenvironmentfactorsimpacting

participationforpeoplewithdisabilities.Wedemonstratethat whencoupledwithuniversaldesign,asocialecologicalapproach canbeapracticalguidelineforimprovingaccessibilityin fitness facilities.Usingthisapproach,wesubstantiallyimprovedaccessibilityinanewfacilityoverindustryaveragesinsevenof11domains oftheAIMFREEinstrument.Follow-upintheMFB-Ythreeyears latershowedsustainedimprovementinthesevendomainsand additionalsubstantialimprovementinprogramming.Program developmentwasguidedbyuserinputandunderstandably

Table2

Costofuniversaldesignoverjurisdictionalaccessibilityrequirements.

Table2

%ofConstructionCosta Costin2014Dollars

Fig.2. Membershipunitscomparedwithmarketpotentialunits.

Table3

ATDPscoresbeforeandafteropeningnewfacility.

followedthefacilityopening.

TheAIMFREEwasalsousefulinidentifyingandbudgeting accessibilityimprovementsforexistingfacilities.Fouradditional YMCAfacilitiesconsideredtobeADAcompliantwerealsoassessed foraccessibility.Theassessmentresultedinsuggestedimprovementsinaccessibilitythatwerecategorizedaslow,medium,or highcost.Lowcostitemscouldbeimplementedimmediatelyand havesignificantimpact.Oneexampleillustratestheeducational andeconomicvalueoftheassessmentprocesswiththeAIMFREE. Anaccessibleshowerwasfrequentlydamagedbythehand-held showerbeingpulledfromthewallattachment.Staffattributed thistocarelessuseandrepeatedlyreplacedthehand-heldshowerhead.AfterbeinginvolvedwithAIMFREEassessmentand learningtoapproachtheproblemfromtheuserperspective,it becameapparentthatthelengthoftheconnectinghosewas insufficientforpracticalusebyaseatedperson.Arelativelyinexpensiveimprovementwasmaderesultinginareducedmaintenancecost.Otherexamplesoflow-costimmediateimpactchanges arisingfromtheAIMFREEassessmentarerearrangingequipment aislestoallowaccessbywalkerorwheelchairandmovinga magazinerackthatlimitedaccesstoadrinkingfountain.More majoraccessibilityimprovementswereaddedtothebudget process.

Costisoftencitedbysmallbusinessesasabarriertoenhancing accessibility.10 Costsareanessentialcomponentofdetermining valueinhealthcare(value ¼ outcomes/cost).However,costsare oftennotaddressedforspecifichealthcarerecommendationsor whenestablishingclinicalguidelines.39 Definingvalueinpostacutecare,whichincludesreturntohealthyliving,requiresa measurementofthecostorresourcesusedfortheoutcomeachieved.40 Weaskedwhetherincreasedaccessibilityandaddressing barriersandfacilitatorstoparticipationcouldattractmorememberstoa fitnessfacility,resultingintheaccessibilityimprovements essentiallypayingforthemselvesandaddingvalueforconsumers. MembershipattheMFB-Yexceededpredictedmarketpotentialin lessthantwoyearsandcontinuedtogrowinyearthree.This resultedinrecoveryofthecostofincreasedaccessibilityin approximately1½ years.Thesuccessofthisfacilityanditssustainedmembershipgrowthexceedingpredictedmarketpotential stronglysuggeststhatuniversaldesignandsystematically addressingbarriersandfacilitatorstoparticipationservesmore people,iscosteffective,andaddsvalueforconsumers.Wealsonote thatthesehighlydesirableenhancementstoaccessibilitywere achievedatasmallactualcost:1.7%oftotalprojectcost.

Wealsoaskedwhetherincreasingthenumberofparticipants wholivewithadisability,includingmanywhousewheelchairsfor mobility,wouldaffecttheattitudeofmemberstowardpeoplewith adisability.Inaddition,wecomparedtheattitudesof fitnessfacility memberswiththeattitudesoftheclinicalprofessionalstaffata majorrehabilitationfacility.Ithasbeenshownthatinteractingwith peoplewithdisabilitiescanimproveattitudes.However,wedidnot showasignificantchangeinattitudeamongall fitnessfacility membersasagroup.Allscoreswerehigherthanhistoricalmeasuresofthegeneralpopulationbutlower,asexpected,thanthose

ofclinicalrehabilitationprofessionals.Itmaybethatrelationships of fitnessfacilitymembersaremoreimpersonalcomparedtorelationshipswithcaregiversorclassmates,orthatmoredistant relationshipstakemoretimetodevelop.Also,theATDPisdated, andbecauseitasksrespondentsdirectlyabouttheirattitudes,may besubjecttoattitude-distortinginfluencessuchassocialresponse bias.

Conclusions

Universaldesigncoupledwithasocialecologicalapproachimprovesaccessibilityandmembershipgrowthof fitnessfacilities. TheAIMFREEinstrumentisausefulandpracticaltoolforguiding cost-effectiveimprovementsforexistingfacilities.Attitudestoward peoplewithadisabilitydidnotchangeina fitnessfacilitydesigned toaccommodatemanypeoplewithdisabilities;however,theinstrumentusedtomeasureattitudesmayneedupdatingtoprovide validscores.Andlastly,theextracostofimprovingaccessibilityand addressingbarriersandfacilitatorstoparticipationcanbeoffsetby increasedmembership.Demonstratingthevalueofaccessibility improvementsaddressesamajorbarriertoimprovingaccessibility.

Declarationofcompetinginterest

JohnF.Butzer,MDisavolunteermemberoftheBoardofDirectorsfortheYMCAofGreaterGrandRapids.

MichaelL.Perry,MArchwastheprincipalarchitectfortheMary FreeBedYMCA;isavolunteermemberoftheBranchBoardofthe MaryFreeBedYMCA;isamemberoftheBoardofDirectorsofthe GlobalUniversalDesignCommission;andisemployedbyUniversal DesignConsultingwhichisaffiliatedwithProgressiveAE.

RobertaVirvaMS,AllanJ.KozlowskiPhD,andRebeccaCistaro MSreportnoconflictsofinterest.

Acknowledgements

WethankAnnMarieJakubowski,MA,foreditorialassistance.

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