Introduction

The Americans with Disabilities Act Accessibility Guidelines (ADAAG) were first developed in the 1990’s to enforce design requirements addressing accessibility issues. Several amendments have been made to the guidelines to improve transfer accessibility in the community. The most recent revision to the ADAAG occurred in 2002 to include guidelines for elements designed to aid transfers in certain recreational facilities, including swimming pools, boating areas, and amusement parks (United States Access Board, 2002). However, the guidelines established provide only a general level of accessibility for wheeled mobility device (WMD) users. Despite the standards set in place by the ADAAG, individuals with limited mobility still encounter accessibility barriers. Approximately 90% of WMD users in the United States report activity limitations, with only 14.7% reporting that they can effectively complete all activities of daily living (Harris, Sprigle, Sonenblum, Maurer, 2009). It has been found that WMD users make fewer trips outside the home and have less community involvement than individuals without mobility impairments (Harris, Sprigle, Sonenblum, Maurer, 2009).

Many barriers to transfer have been reported in regards to medical services. One study investigating health care barriers for spinal cord injury patients found that exam rooms were often too small to transfer and lacked adjustable tables and proper transfer aids, despite mandates set forth in the ADAAG (Stillman, Frost, Smalley, Bertocci, Williams, 2014). While most research to date has focused on barriers in health care accessibility, community transfer barriers exist in many other forms. The purpose of this study was 1) to identify areas of the community where transfers are not attainable due to accessibility issues and 2) to identify facilitators and barriers to transfer in the community. Findings from the study will indicate accessibility problems that WMD users currently face when transferring independently.

METHODS

Subjects

The study received approval from the University of Pittsburgh’s Institutional Review Board. Forty one subjects participated in the study and signed informed consent forms. Inclusion criteria were 1) own a wheeled mobility device 2) have been using the wheeled mobility device for at least one year prior to the study 3) 18 years or older and 4) could independently transfer with or without a transfer board.

Experimental Protocol

Subjects were asked to fill out a series of questionnaires regarding their transfer abilities. The survey format was based after the Facilitators and Barriers Survey of environmental influences on participation among people with lower limb Mobility impairments and limitations (FAMS/M) (Gray et. al). The survey was adapted to focus on understanding the facilitators/barriers to performing transfers in the built environment. Face and content validity for the modified survey was established by review of the literature and expert panel and consumer review and consensus (Boninger, Nadeau, Ganstrom, Butler-Forslund, Nawoczenski, Mulroy, Koontz, & Gagnon).

The first part of the survey aimed to investigate how environmental features such as a seat height higher than their WMD, space available to position the WMD, grab bars or handhelds, size of transfer surface, clearance for feet and legs, and storage space for the WMD impacted transfers and participation in community settings. The subject could respond ‘Yes’ if the factor affected transfer ability, ‘No’ if the factor did not affect transfer ability, and ‘NA’ if they did not encounter transfers where the factor was present. If the subject responded ‘Yes’ to the question, information was gathered about how much of an impact the factor had on participation. An example question can be seen in Figure 1, below.

In your community, do the following influency your particiaption in activities where transfers are involved?

3. Grab bars or handholds
Yes	→	How Much? Helps a lot Helps some Limits some Limits a lot How Often? Daily Weekly Monthly Less than monthly
No	→	Grab bars or handholds do not influence my participation
N/A	→	Do not have them in my community

The survey also aimed to investigate how the transfer accessibility of various locations influenced community participation. For each site, subjects were asked to what extent transfer accessibility effects their participation at the location. Subjects could respond ‘Helps some’ or ‘Helps a lot’ if the site was found to be accessible, ‘Limits some’ or ‘Limits a lot’ if the site was inaccessible for transfers to be performed when necessary or desired, and ‘has no affect’ if the site does not facilitate or hinder transfers. Subjects could also respond ‘Does not go’ if they did not go to a particular site or ‘Does not transfer’ if they did go to a site, but did not need or desire to transfer.  An example can be seen below in Figure 2.

1. How does the accessibility of transferring in a doctor's or dentist's office influence your participation in health care?

Helps a lot Helps some Has no effect Limits some Limits a lot
Go to the doctor but do not need or desire to transfer - Go to next question
Do not go to a doctor - Go to next question

A third and final part to the survey aimed to investigate transfer accessibility of seats in the community. including toilets in public restrooms, exam and imaging tables or chairs, seats in various modes of transportation, and seats at desks and tables. For each factor, subjects were asked how accessible transfers were at specific locations.  Subjects could respond ‘very  accessible’, ‘somewhat accessible’, ‘not accessible’, ‘don’t know’, or ‘not applicable’. Subjects answered ‘Don’t know’ when they had encountered the barrier, but couldn’t remember anything in regards to accessibility. Subjects answered ‘Not applicable’ if they had not encountered the barrier. An example question can be seen in Figure 3.

1. how accessible are transfers to TOILETS in the following places:	Very accessible	Somewhat accessible	Not accessible	Don't know	Not applicable
Doctors and dentist offices

Data Analysis

Percentages for the categories “helps a lot” and “helps some” were combined into one category (“helps”). The same process was repeated for the categories of “limits a lot”, and “limits some” (“limits”). Descriptive statistics in the form of percentages were performed using SPSS Version 21 (SPSS Inc, Chicago).

RESULTS

The 41 subjects who participated in the study consisted of 28 males and 13 females. They had an average age, weight, and height (± standard deviation) of 51.9 ± 12.2 years, 177.2 ±41.0 lbs, and 67.7 ±3.7 inches, respectively. The study population consisted of 27 manual wheelchair users, 10 power chair users, 3 manual-power-assist users, and 1 scooter user. Subjects reported having a wide range of disabilities including spinal cord injury, multiple sclerosis, traumatic brain injury and lower limb amputation.

A majority of subjects (≥ 58% of the sample) said that ample space next the transfer surface, presence of grab bars, surface size, clearance available for legs/feet and storage space for the WMD had an impact on their transfer ability and participation in the community (Table 1).

Table 1. Percentage of subjects reporting impact of environmental factors on transfers and their participation in the community (n=41)

Factor	Yes (%)	No (%)	Do not encounter (%)
Transfer surfaces higher than WMD	41.46	31.71	26.83
Space available next to the transfer surface to position WMD	58.54	41.46	---
Presence of grab bars	63.41	31.71	4.88
Soft surfaces	48.78	46.34	4.88
Surface Size	60.98	39.02	---
Clearance for legs/feet	68.29	31.71	---
Storage Space for WMD	58.54	41.46	---

Table 2 shows to what degree each transfer feature influenced a subject's participation in the community.   Only subjects who responded ‘Yes’ to the physical factors having an impact on participation in Table 1 were included in the analysis.

Table 2. Percentages of subjects reporting how much the environmental factors affected transfers and participation in the community.

Factor	Helps (%)	Limits (%)
Transferring higher than WMD (n=17)	11.76	88.24
Space next to surface to position WMD (n=24)	58.34	41.66
Presence of grab bars (n=25)	84.00	12.00
Soft surfaces (n=18)	66.67	33.33
Surface size (n=24)	83.33	16.67
Clearance for legs/feet (n=27)	62.96	37.04
Storage space for WMD (n=24)	66.66	33.34

Table 3 shows the percentage of subjects who transfer and do not transfer at each site listed on the survey. Subjects that reported that they did not go to a site were combined with subjects that did not transfer. The majority (> 50%) of subjects were found to perform transfers at all locations except at religious facilities, movies, sporting arenas, public parks, school, and work.

Table 3. Percentage of subjects who do and do not transfer at various locations in the community (n=41)

Site	Transfers (%)	Does not transfer (%)
Doctors or Dentist office	80.49	19.51
Medical or imaging table	85.36	14.64
Pool or hot tub	78.05	21.95
Religious facilities	45.00	55.00
Fast food restaurant	63.41	36.59
Non-fast food restaurant	63.41	36.59
Movies	46.34	53.66
Sporting arenas	48.78	51.22
Dressing room	60.98	39.02
Public parks	46.34	53.66
Recreation facility	61.54	38.46
Hotels	82.05	17.95
Airplane	74.36	25.64
Hair salon	58.97	41.03
Amusement park	56.10	43.90
School	12.19	87.81
Work	30.00	70.00
Boating area	51.22	48.78

Forty percent or more of subjects found that the accessibility of transfers in pools/hot tubs, boating areas, amusement parks, hotels, dressing rooms and hair salons/barber shops limits their participation (Table 4).

Table 4. Percentage of subjects reporting how transfer accessibility affects participation in the community (helps or limits).

Site	Helps (%)	Has no effect (%)	Limits (%)
Doctors or Dentist office (n=33)	24.20	45.50	30.30
Medical or imaging table (n=35)	17.14	65.72	17.14
Pool or hot tub (n=32)	31.25	21.87	46.88
Religious facilities (n=18)	16.67	50.00	33.33
Fast food restaurant (n=17)	23.53	52.94	23.53
Non-fast food restaurant (n=26)	19.23	42.31	38.46
Movies (n=19)	31.58	47.37	21.05
Sporting arenas (n=20)	20.00	45.00	35.00
Dressing room (n=25)	16.00	32.00	52.00
Public parks (n=19)	21.05	47.37	31.58
Recreation facility (n=24)	29.17	37.50	33.33
Hotels (n=32)	25.00	31.25	43.75
Airplane (n=29)	17.24	44.83	37.93
Salon/barber (n=23)	17.39	39.13	43.48
Amusement park (n=23)	8.70	39.13	52.17
School (n=10)	20.00	70.00	10.00
Work (n=12)	33.33	58.34	8.33
Boating area (n=21)	14.29	33.33	52.38

Toilets in hotels and airplanes were considered not accessible by up to 40% of subjects.   About 60% of subjects found imaging tables in MRI and X-ray rooms and doctor's offices to be somewhat or not at all accessible.  Seventy-two percent of subjects found tables in restaurants to be somewhat or not at all accessible (Tables 5 through 8 where VA= ‘very accessible’, SA=’somewhat accessible’, and NA= ‘not accessible’).

Table 5. Accessibility of toilets in the community.

	VA (%)	SA (%)	NA (%)
Doctor/Dentist office (n=39)	51.28	43.59	5.13
Fast food (n=31)	35.48	61.29	3.23
Non-fast food (n=36)	27.78	66.67	5.56
Hotels (n=34)	32.35	52.94	14.71
Airplanes (n=29)	13.79	48.28	37.93
School (n=17)	47.06	47.06	5.88
Work (n=16)	43.75	56.25	0.00

Table 6. Accessibility of exam and imaging tables in the community

	VA (%)	SA (%)	NA (%)
Doctors office (n=39)	41.03	56.41	2.56
Dentist office (n=36)	44.44	44.44	11.12
Hospitals (n=40)	50.00	42.50	7.50
PT/OT clinics (n=39)	66.67	33.33	0.00
MRI rooms (n=39)	38.46	51.28	10.26
X-ray rooms (n=41)	36.59	51.22	12.20

Table 7. Accessibility of seating in public transportation (n=41).

	VA (%)	SA (%)	NA (%)
Own van/ car (n=34)	58.82	38.24	2.94
Another person’s car/van (n=38)	21.95	58.54	12.20
Airplanes (n=33)	18.18	69.60	12.12
Paratransit (n=24)	58.33	41.67	0.00

Table 8. Accessibility of community tables (n=41).

	VA (%)	SA (%)	NA (%)
School (n=14)	35.71	50.00	14.29
Work (n=16)	37.50	56.25	6.25
Doctors office (n=37)	43.24	45.95	10.81
Hospitals (n=37)	40.54	54.05	5.41
Restaurants (n=37)	27.03	70.27	2.70
Hotels (n=32)	31.25	56.25	12.50

DISCUSSION

The purpose of this study was to look at transfer issues and their effects on participation in the community. A variety of public locations were examined, including medical facilities, restaurants, work, school, and transportation and travel locations.

Medical facilities

Findings for accessibility to transfer within medical facilities were consistent with prior research reporting that accessibility limitations are common in medical facilities (Stillman, Frost, Smalley, Bertocci, Williams, 2014). Over 30% of participants reported participation limitations in doctors and dentists offices and 19.5% of subjects reported not going to a doctor or dentist office at all.

Public toilets in health care facilities were found to be accessible to the majority of the population, with 51.28% of participants classifying them as very accessible and only 5.13% reporting them as not accessible. Tables were also found to be fairly accessible, with 43.24% and 40.54% reporting tables as very accessible in doctor’s offices and hospitals, respectively. The transfer accessibility of medical and imaging tables was specifically examined. Tables at physical therapy clinics and occupational therapy clinics were given the best ratings by subjects, with 66.67% reporting that the tables were very accessible. However, less than 50% of the subjects reported that the tables at doctors offices, dentists offices, MRI rooms, and X-ray rooms were very accessible. The research suggests that WMD users may be limited in receiving certain forms of healthcare technology due to transfer limitations, especially imaging services like MRIs and X-rays. By making imaging tables more accessible to transfer, certain treatments that are available to the general population may become more available to WMD users.  

Restaurants

A large percentage of the study sample reported not going to either fast food restaurants or non-fast food restaurants (36.59%). Toilets in fast food restaurants were found to be more accessible than toilets in non-fast food restaurants (35.48% versus 27.78% rated as very accessible), with the majority of subjects classifying them as only somewhat accessible. Tables in restaurants were largely considered somewhat or not at all accessible which may explain in part why some people choose not to eat out or find that the accessibility of restaurants limits their participation.   

Work and School

The majority of subjects reported that they didn’t perform transfers at either work or school (70.00% and 87.81% respectively).  For those that do transfer, accessibility had little impact on their participation which may be due to the types of the jobs or activities that are performed or other accommodations that may be available in these environments (e.g. personal assistance and/or jobsite modifications that enable for performing tasks while remaining seated in a wheelchair).

Transportation and Travel Locations

Personal transportation vehicles had the best ratings for transfer accessibility, with 58.82% of subjects rating their own vehicle as very accessible. Other vehicles were rated lower, with 23.68% providing ratings of very accessible and 13.16% rating them not accessible. Additionally, paratransit, which specializes in providing accessible transportation to individuals with disabilities, had similar accessibility ratings to personal vehicles, where 58.33% of subjects gave it a very accessible rating and no subjects reported paratransit services to be inaccessible.

Airplanes were given very low accessibility ratings.  About 38% of subjects reported being limited in airplane transfers. Only 13.79% of subjects reported airplane toilets as very accessible to transfer to, while 37.93% considered them not at all accessible. Additionally, only 18.18% of subjects reported seating on airplanes to be very accessible. The results also suggested that hotels posed transfer accessibility problems for WMD users, with 43.75% of subjects being limited. Although hotel bathrooms are designed to be accessible, 67.7% of participants reported that they were somewhat or not at all accessible. About 68% of subjects found tables in hotel rooms to be somewhat or not at all accessible.  Transfer limitations for airplanes and hotels may discourage WMD users from traveling long distances.

Transfer Accessibility Improvements

The results provide insight on how barriers to transfer in the community can be improved. The transferability of a large portion of the subjects was hindered by the height of the transfer surface being higher than their WMD. Providing height-adjustable surfaces in certain sites, including medical facilities and hotels, may increase healthcare access and travel opportunities.

Several environmental factors were found to facilitate independent transfers. Grab bars were found to be advantageous to most WMD users, and placing them in public areas where transfers would normally occur may be helpful. Subjects also reported that having ample space and clearance for legs and feet is important for transfers. Increasing the size of transfer seats and surfaces may also aid transfers. Finally, providing WMD users with an area to stow their mobility device within proximity of where the new seat, activity, or task is taking place may encourage more participation in the community.    

Limitations and Future Work

The surveys used in the study were not validated for reliability; however, they were closely based on a reliable survey examining community accessibility for WMD users (Gray, Hollingsworth, Stark, Morgan, 2008). This study only considered the impact of accessibility on transfers with regard to participation.  More extensive research is needed to investigate other benefits that may follow if environments were made more accessible such as a reduced rate of wheelchair-related falls and associated costs of injury, reduced caregiver burden and support, and improved access to health care services. 

CONCLUSION

 Study findings suggest that transfer accessibility in medical facilities, restaurants, school, work, modes of transportation, and travel facilities could be improved. Specifically, reducing the amount of transfers higher than WMDs, adding grab bars to the environment, providing enough space, leg clearance, and seat area, and providing storage space for wheelchairs may improve transferability in the community. Accessibility improvements made to medical facilities, restaurants, vehicles, airplanes, and hotels, may help to increase community participation by WMD users.