Built environment instruments for walkability, bikeability, and recreation: Disability and universal design relevant?

Disability and Health Journal 5 (2012) 87e101 www.disabilityandhealthjnl.com

Built environment instruments for walkability, bikeability, and recreation: Disability and universal design relevant? Jennifer A. Gray, Ph.D., M.P.P.a,*, Jennifer L. Zimmerman, Ph.D.b, and James H. Rimmer, Ph.D.c a

School of Nursing and Health Studies, Northern Illinois University, Dekalb, IL 60115-2854, USA b Department of Psychology, DePaul University, Chicago, IL 60604, USA c Lakeshore Foundation/University of Alabama-Birmingham Research Collaborative at Birmingham, Birmingham, AL 35204-3361, USA

Abstract Background: Despite a plethora of instruments that measure the built environment with respect to its effect on potential physical activity, little is known about how relevant these instruments are for people with disabilities (PWDs). Objective: This review comprises an in-depth review of instruments related to the built environment and physical activity, as well as an examination of such instruments to determine their applicability for PWDs. Methods: In this paper, the term ‘‘built environment’’ refers to human-made structures (e.g., urban and rural design characteristics, recreational structures) that may facilitate or impede an individual’s ability to be physically active. A content analysis was conducted on 95 instruments measuring walkability, bikeability, and recreation with respect to disability and universal design (UD) relevance. Instruments were also cataloged according to other dimensions, including psychometric properties, data collection modalities, and impact or use. Results: Roughly one third of all instruments include some disability-specific items, and only a few UD principles are consistently demonstrated across all instruments. Psychometric information is available for approximately one half of the instruments. Most instruments use objective/audit methods of data collection, with less using subjective/perceived and Geographic Information System (GIS) methods. With respect to instrument impact/use, just over one half of the instruments have articles cited in the peer-reviewed literature. Conclusions: Recommendations for new and revised built environment instruments include more focus on specific disability populations, incorporation of all UD principles, as well as attention to psychometric quality and measurement specificity. Ó 2012 Elsevier Inc. All rights reserved. Keywords: Disability; Universal design; Built environment; Measurement; Instrument; Physical activity; Recreation

Though physical inactivity has been shown to be a leading cause of mortality and morbidity [1-3], less than 50% of the adult U.S. population engages in the recommended levels of physical activity [4]. These statistics are even more problematic for people with disabilities (PWDs), The authors have no conflicts of interest or financial disclosures to declare. The research was supported by a supplement to the National Center on Physical Activity and Disability (NCPAD) by the Centers for Disease Control and Prevention (CDC), National Center on Birth Defects and Developmental Disabilities, Disability and Health Branch (Grant no. 5U59DD000437). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Centers for Disease Control. We are grateful for the support and assistance of our colleagues from the Center on Health Promotion for People with Disabilities and assistance with earlier drafts of the manuscript from Yochai Eisenberg and Benjamin Graham. * Corresponding author: School of Nursing and Health Studies, Northern Illinois University, Dekalb, IL 60115-2854. E-mail address: [email protected] (J.A. Gray). 1936-6574/$ - see front matter Ó 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.dhjo.2011.12.002

estimated to be 54 million Americans, or almost 1 in every 4 to 5 individuals [5], who are more inactive than the general population [6,7]. Researchers continue to search for answers as to why the majority of Americans are not engaging in regular physical activity [8]. In addition to biologic, psychologic, and behavioral explanations [9-12], there has been a proliferation of research examining the impact of the built environment on physical activity [13,14]. In this paper, the term ‘‘built environment’’ refers to human-made structures, such as urban and rural design characteristics, recreational structures, and walking and biking paths, which may facilitate or impede an individual’s ability to be physically active [15-19]. Healthy communities provide supportive physical and social environments that contribute to a higher quality of life [20]. These environments are based on urban and rural design features that provide residents with healthy, safe, and accessible activity choices. Built environment features

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conducive to community physical activity, for example, have been shown to include the presence of sidewalks and parks, aesthetically pleasing environments, adequate street lighting, and environmental safety [8,15]. Crosswalk signage/signals, crosswalks, and other design measures can help protect physically active pedestrians and bicyclists from motorists [21]. The impact of the environment on health and well-being has contributed to an abundance of instruments measuring the effects of the built environment on physical activity participation [18,19,22]. Such information is collected through a combination of subjective/perceived community surveys, audits, and geographic information system (GIS) methods, with a focus on the streetscape and community infrastructure, recreational features, and land use, among other topics. Several studies have provided reviews of built environment instruments with respect to community physical activity [18,23], and have highlighted current research challenges such as applicability for a variety of populations [18,24-26]. However, to our knowledge, there are no published comprehensive reviews examining the potential relevance of existing built environment instruments for PWDs [27-30]. Considering that there are only a limited number of built environment instruments designed specifically for PWDs [31,32,40,43,50,81,103], it is important to determine whether existing instruments designed for the general community are applicable to PWDs, as well as other populations, or can be modified using universal design (UD) principles. The application of UD represents such environmental inclusivity as ‘‘the design of products and environments to be usable by all people, to the greatest extent possible, without the need for adaptation or specialized design’’ [124]. UD principles can guide the development or alteration of specific environmental features [125] to be accessible for users with a range of needs, with particular application to PWDs. In this paper, we review published built environment instruments specific to walking, bicycling, and recreation to determine their disability and UD relevance. We provide additional information on instrument detail, instrument impact in the field to inform instrument development or revision.

Method The search strategy for built environment instruments comprised an identification of citations and instruments published through literature searches, review articles, reference lists from identified articles, and professional contacts. Databases included Medline, Ovid Social Sciences, Web of Science, Health and Psychosocial Instruments, and Google Scholar. Key words were measurement, instrument, assessment, tool, environment, environmental determinant, physical environment, built environment, physical activity, exercise, health promotion, walkability, bikeability, and

recreation. Instruments were excluded if they focused entirely on behavioral or physiological measurements related to physical activity in a geographical space (e.g., time spent exercising or measuring heart rate during exercise) or had limited instrument development information. Using these exclusion criteria, we narrowed the instrument sample from 183 to 95 instruments published between 1985 and 2009. The final sample included environmental audits and perceived environmental measures of walkability, bikeability, and recreation structures and spaces, which encompass built structures and spaces in which individuals are physically active. GIS, environmental assessments of urban and rural design qualities, and instruments specific to transportation also were included. Each of the instruments was reviewed according to the following dimensions: (1) impact/use, referring to whether the instrument and related articles were cited by others; (2) professional field of origin, indicating whether an instrument’s authors come from health (i.e., public health or medicine), planning (i.e., urban or city planning), or transportation fields; (3) subject focus of walkability, bikeability, and/or recreation; (4) instrument data collection methods (i.e., subjective, audit/objective, or GIS); (5) whether the instrument contains multiple domains (i.e., 5 or more domains); (6) whether there are multiple items per domain (i.e., 10 or more items within a domain), and whether it has high specificity, requiring exact measurements (e.g., sidewalk width or slope grade) or very specific ordinal response categories; (7) psychometric properties; (8) whether disability issues are considered; and (9) what UD principles are represented. To assess the impact or use of a particular instrument, the Web of Science Cited Reference Search as well as Google Scholar was used to indicate whether instrumentspecific articles were cited by others. Although this provides some gauge of impact or use, many instruments have no related peer-reviewed articles, which limit the extent to which they can be tracked. Under psychometric properties, it is noted whether the instrument has an acceptable reliability score using 1 of 3 methods: internal consistency (i.e., Cronbach’s alpha of 0.70 or higher [18,126]), test-retest reliability (i.e., intraclass correlation of 0.60 or higher [127,128]), and/or interrater reliability (i.e., Kappa of 0.60 or higher [127,128]). Instrument validity information is provided for convergent (i.e., correlation of 0.50 or higher) or discriminant validity (i.e., correlation of 0.50 or lower) [126]. We indicate whether instruments include disabilityspecific items. The Americans with Disabilities Act (ADA) definition of disability, ‘‘a physical or mental impairment that substantially limits an individual in 1 or more major life activities’’ is used [129]. Instruments including items relevant to user impairments and limitations are noted, such as curb cut dimensions for wheelchair users, bathroom accessibility for people with various disabilities, and the presence of accessible signage [130].

J.A. Gray et al. / Disability and Health Journal 5 (2012) 87e101

UD is defined and identified for each instrument according to its 7 standard principles (Table 1) [125]. We indicate which of the UD principles are present in each instrument: equitable use, equally available and useful structures and products for people of different abilities (e.g., a website including text-to-speech software), flexibility in use, providing users of different abilities with options for accessing a built environment structure or product (e.g., options for use of ramps, stairs, escalators, elevators, lifts), simple and intuitive use, easy-to-understand designs that accommodate people of all abilities (e.g., lever handles or push buttons), perceptible information, enable users of all sensory abilities to readily access information, and use the structure or design for its intended purpose (e.g., meaningful icons and large text), tolerance for error, built-in features that minimize hazards caused by accidents or unintended actions (e.g., flashing lights and audible crosswalk signals guarding against inappropriate crossing), low physical effort, a structure or product that minimizes user fatigue (e.g., flat terrain and easy grip appliances), and size and space for approach and use, which enables users of all abilities to approach and use the built environment structure or product (e.g., large bathroom stalls and wide hallways and doorways).

Results The instrument review covers the 10 review dimensions defined in the Methods section (Table 2). Examination of instrument impact or use revealed that 58 (61%) instruments have related articles that are cited in the peerreviewed literature. Regarding professional field of origin, 66 (69%) instruments come from health, 20 (21%) from transportation, 15 (16%) from planning-related fields, and 5 (5%) with backgrounds from more than 1 professional field. Eighty-two (86%) of the instruments focus on walkability, 46 (48%) on bikeability, 58 (61%) on recreation, and 61 (64%) on 2 or more of these subjects. For data collection methods, 56 (59%) of the instruments use audit/objective, 39 (41%) subjective, and 15 (16%) GIS methods of data collection, with 13 (14%) using a combination of methods. Though the least amount of instruments include GIS data collection methods, 7 (7%) instruments use it in conjunction with other data collection methods. Nineteen (20%) instruments exhibit a high level of specificity, meaning that some items pertain to exact measurements (e.g., sidewalk width or slope grade) or use very specific ordinal response categories. Thirty-four instruments (36%) have multiple domains, indicating that they incorporate 5 or more domains, and 24 (25%) have multiple items, meaning that there are 10 or more items for at least 1 domain. Furthermore, the following number of instruments include items about surfaces and structures-related content: (1) 31 (33%) on materials used (e.g., asphalt, gravel), (2) 58 (61%) on dimensions (e.g., width, slope), (3) 56 (59%) on

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condition and maintenance (e.g., sidewalk maintenance, ramps clear of water accumulation), (4) 40 (42%) on permanent and temporary obstructions (e.g., lampposts, steps, tree branches), (5) 44 (46%) on crosswalk signage and signals (e.g., traffic signals for pedestrians/bicyclists, ADA standards for audible pedestrian signals), and (6) 18 (19%) on general signage and signals (e.g., tactile and visual aids in signage). With respect to psychometric properties, approximately half or 50 (53%) of the reviewed instruments has some information on reliability and validity that is available for users to evaluate the potential quality and usefulness of the instruments. Although comparison across instruments is difficult because of the breadth of psychometric tools used, of the instruments that reported this information, 26 (52%) instruments meet the acceptable criteria for reliability, and 2 (4%) for validity. Of the instruments reviewed, we coded 26 (27%) as having some relevance to PWDs. A subset of 10 (11%) instruments were identified as being developed specifically for PWDs or older adult populations, whereas the remaining 16 (17%) instruments included a few items pertaining to disability but were not designed specifically for this population. In most instances, disability-specific items were related to accessibility in the streetscape (e.g., streets, curb cuts, parking). Only in isolated cases with 7 (7%) instruments were ADA guidelines specifically indicated, which were usually related to curb ramp and crosswalk specifications. Other disability-specific content areas included items about accessible bathrooms, drinking fountains, and signage offered in alternate formats. List 1 provides information on topics from disabilityrelevant instruments, including ADA compliance and perceptions of environmental accessibility. Item content includes that of pedestrian accessibility, public transportation, parking, recreation accessibility, signage and signal accessibility, and public amenities accessibility (e.g., accessible bathrooms or drinking fountains), among other topics. In total, 77 (81%) of instruments were coded as having some UD relevance. The UD principles of tolerance for error, equitable use, and low physical effort are most often present in the reviewed instruments, whereas the principles of perceptible information, size and space for approach and use, flexibility in use, and simple and intuitive use are present less frequently. Across all instruments, the UD principle of tolerance for error is most widely present in the reviewed instruments, regarding minimizing hazards and accidents (present in 62 [65%] instruments). For example, the Bicycle/Pedestrian Feasibility Study (Old Durham-Chapel Hill Road) [35] includes items regarding high visibility crosswalks, raised and flashing crosswalks, crosswalk warning signs, pedestrian countdown signals, and painted stripes. The principle of equitable use, where a space is equally available and useful for people of different abilities, and the principle of low physical effort to minimize user fatigue, are each present in 37 (39%) instruments. The BRAT Direct

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Table 1 Instrument Review Instrument name

1 Imp 2 Fld 3 Subj Foc 4 Data Coll 5 Mult Dom 6 Mult Itm 7 Psy

8 Dis 9 Univ Des

Kihl et al. (2005)31

NA

P

W/B/R

O

Y

Y

NA

Y

E/P/T

Rimmer et al. (2004)32

Y

H

R

O

Y

N

R: ICC 5 0.70-0.90 M ICR 50.00-0.89

Y

E/F/SI/P/T/L/SS

Kissee et al. (2007)33

NA

H

W/B/R

O

Y

Y

NA

Y

E/SS

City of Arlington34 Durham-Chapel Hill-Carrboro Metropolitan Planning Organization (2006)35 Bedimo-Rung et al. (2006)36

NA NA

P P

W/B W

S S, G

N N

Y N

NA NA

N N

E E/L/T

NA

H

W/R

O, G

Y

Y

NA

N

E/T/L

Safedmonton Working Group (2006)37 Horner-Johnson (2002)38 National Center for Bicycling and Walking (2002)39 Stark et al. (2007)40

NA

P

W

O

Y

Y

NA

Y

NA

NA NA

H T

R W/B/R

S O

N Y

N Y

Y Y

NA E

Y

H

W

O

Y

N

NA R: Ca 5 .95 M V: content NA

Y

E/L/SS

Abley et al. (2010)41 Spruijt-Metz et al. (2005)42

Y NA

T H

W/R R

S S

N N

N N

Craig Hospital Inventory of Environmental Factors (CHIEF) Department of Transportation Bicycle Compatibility Index (DOT-BCI) (RWJF Bikeability Checklist) Effect of Environment on Physical Activity Environmental Assessment of Public Recreation Spaces (EAPRS) Toola Environmental Design and Pedestrian Travel Behavior Environmental Supports for Physical Activity Questionnaire Environmental, Social, and Personal Correlates of Cycling

Whiteneck et al. (2004)43

Y

H

W

S

N

Harkey et al. (1998)44

NA

T

B

S

Craig et al. (2002)45

Y

H

W/B/R

Saelens et al. (2006)46

Y

H

Shriver (1997)47

Y

Kirtland et al. (2003)48

Facilitators and Barriers Survey/ Mobility (FABS/M)

AARP Livable Communities Guide and Quiz Accessibility Instruments Measuring Fitness and Recreation Environmentsa Active Community Environments (ACE) Checklist Arlington Bike Survey Bicycle/Pedestrian Feasibility Study-Old Durham/Chapel Hill Roada BRAT Direct Observation (BRAT-DO) City of Edmonton CPTED Safety Audit Community Access Survey Community Assessment Tool Community Health Environment Checklist (CHEC) Community Street Review Core Measures of Trail Use

N

NA N R: ICC 5 0.93 M N Ca 5 .76-.93 M V: content and discriminant NA Y

E/P/T/L NA

E

N

N

R: r 5 0.90-1.0

N

L/T

O

N

N

N

E/P

W/B/R

O

Y

Y

R: 65.6% of items had agreement over 60% NA

N

E/T/L

P

W/B/R

O, S

Y

N

N

NA

Y

H

W/B/R

G, S

Y

N

N

NA

Titze et al. (2007)49

Y

H

W/B

S

Y

N

N

L

Gray et al. (2008)50

Y

H

W/R

S

Y

Y

R: k 5 0.07-0.37 P 5 0.28-0.74 R: ICC 5 0.37-0.72 Ca 5 .39-.66 R: Ca 5 .35-.94 r 5 0.52-0.81 V: content and discriminant R: ICC 5 0.85-0.94 M Ca 5 .83 M V: face/content

Y

E/T/L

J.A. Gray et al. / Disability and Health Journal 5 (2012) 87e101

Authors

Y

H

W

S

N

N

NA

N

E/T

U.S. Department of Transportation52 Dixon (1996)53

NA

T

W

O

N

N

NA

Y

E/L/P

Y

T

W/B/R

O

N

Y

R: NA V: face

N

E/T

Leslie et al. (2007)54

Y

H

W

G

N

N

NA

N

NA

Farhang et al. (2007)55

NA

H

W/B/R

O

Y

Y

NA

N

E/T

US Environmental Protection Agency (2007)56 Keysor et al. (2005)57

Y

H

W/B/R

O

Y

Y

Y

T

Y

H

W/R

S

N

N

R: k 5 0.20-1.0 V: construct NA

Y

T

Sallis et al. (2009)58

Y

H

W/B/R

S

N

N

R: 68% of items had agreement over 70%

N

T

Day et al. (2006)59 Design for Active Communities Task Force60 League of American Bicyclists61

Y NA

P P

W/B/R W/B R

O O

Y N

Y Y

NA NA

N Y

T/L E

NA

P

B

O

Y

Y

NA

N

T

Wilcox et al. (2000)62

Y

H

W/B/R

O

N

N

N

L

Measure of the Quality of the Environment (MQE)

Boschen et al. (1998)63

Y

H

W/R

S

N

N

Y

E/T/L

Measurement Instrument for Urban Quantities Related to Walkabilitya Measurement Properties of Neighborhood Scales National Association of County and City Health Officials (NACCHO) Public Health in Land Use Planning and Community Design National Center for Safe Routes to School (NCSRTS) Parents Survey Neighborhood Accessibility Indexa

Ewing et al. (2006)64

Y

P, T

R

O

Y

N

R: 85% of items had agreement above 60% V: content R: ICC 5 0.34-0.58 Ca 5 .88-.95 M V: content R: Ca 5 .73-.83 M r 5 0.60-0.88 M

N

NA

Mujahid et al. (2007)65

Y

H

W/R

S

Y

N

NA

N

NA

Roof and Maclennan (2008)66

Y

H, P

W/B/R

O

Y

N

NA

Y

E/P/T

National Center for Safe Routes to School (2009)67

NA

H

W/B

S

N

N

V: content

N

T

Krizek (2003)68

Y

P, T

W/B

O, G

N

N

R: Ca 5 .77-.87 M V: r 5 0.71 M

N

L

J.A. Gray et al. / Disability and Health Journal 5 (2012) 87e101

Suminski et al. (2005)51

Features of the Neighborhood Environment and Walking Federal Transit Administration’s ADA Assessment Sheetsa Gainesville Bicycle and Pedestrian Level of Service Performance Measuresa GIS Walkability Index or PLACE (Physical Activity in Localities and Community Environments)a Healthy Development Measurement Tool (HDMT) Healthy School Environments Assessment Tool (HealthySEAT) Home and Community Environment Instrument (HACE) International Physical Activity Prevalence Study Environmental Module (IPS) or Physical Activity Neighborhood Environment Survey (PANES) Irvine Minnesota Inventory King County Active Community Checklist League of American Bicyclists Bicycle Friendly Communities Campaign Leisure Time Physical Activity

(Continued) 91

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Table 1 Continued Instrument name

Objective and Perceived Measures of the Built Environment Objective Built Environment Index Using GISa Participation Survey/Mobility (PARTS/M) Path Environmental Audit Tool (PEAT)a Pedestrian and Bicyclista Intersection Safety Indices Bicycle Items Pedestrian and Bicyclist Intersection Safety Indices Pedestrian Itemsa Pedestrian and Bicycle Crash Analysis Tool (PBCAT) Bicyclist Audita Pedestrian and Bicycle Crash Analysis Tool (PBCAT) Pedestrian Audita Pedestrian and Bicycle Environment Factor (PBEF)a

1 Imp 2 Fld 3 Subj Foc 4 Data Coll 5 Mult Dom 6 Mult Itm 7 Psy

8 Dis 9 Univ Des

69

Gauvin et al. (2005)

Y

H

W/B

O

N

N

R: Ca 5 .93-.96 M

N

T

Caughy et al. (2001)70

Y

H

R

O

Y

N

Y

NA

Barnes-McGuire (1997)71

Y

H

W

S

N

N

R: Ca 5 .77-.85 M V: r 5 0.20-0.47 R: ICC 5 0.62-0.88 M

N

NA

Saelens et al. (2003)72

Y

H

W/B/R

S

N

N

NA

N

T/L

van Lenthe et al. (2005)73

Y

H

R

S

N

N

R: k 5 0.01-0.94

N

NA

Zenk et al. (2007)74

Y

H

W/R

O

Y

Y

N

NA

Giles-Corti et al. (2006)75

Y

H

W/B

S

N

N

R: k 5 0.66-0.85 M ICC 5 0.55-0.96 R: Ca 5 .79 M

N

NA

Steptoe and Feldman (2001)76 Timperio et al. (2004)77

Y Y

H H

W W/R

S S

N N

N N

R: ICC 5 0.51-0.97 NA

N N

NA T

Northwest Americans with Disabilities Act and Information Technology Center, CDRC/ Oregon Health and Science University (2005)78 Michael et al. (2006)79

NA

T

W

O

N

N

R: k 5

Y

E/T/L

Y

H

W/R

G, O, S

N

N

R: ICC 5 0.95 M

N

T

Parks and Schofer (2006)80

Y

T

W

G

N

N

N

E

Gray et al. (2006)81

Y

H

R

S

Y

N

Y

E

Troped et al. (2006)82

Y

H

W/B/R

O

Y

N

R: Ca 5 .71-.92 M r 5 0.77-0.91 M V: content R: k 5 0.03-1.0 ICC 5 0.04-0.84 NA

Y

E/T/L/SS

Carter et al. (2006)83

NA

T

B

O

N

N

NA

N

T

Carter et al. (2006)83

NA

T

W/B

O

N

N

NA

N

T

Harkey et al. (2006)84

NA

T

W/B

O

Y

Y

NA

N

T

Harkey et al. (2006)84

NA

T

W

O

Y

Y

NA

N

T

US Department of Transportation, Federal Highway Administration85

NA

T

W/B

G

N

N

R: k 5 0.09-1.0

N

N

0.07-0.20

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Neighborhood Active Living Potential (NALP) Neighborhood Brief Observation Measure Neighborhood Characteristics Questionnaire Neighborhood Environment Walkability Survey (NEWS) Neighborhood Inequalities in Physical Activity Neighborhood Observational Checklist Neighborhood Physical Activity Questionnaire (NPAQ) Neighborhood Problems Scale Neighborhood Walking and Cycling among Children NW Americans with Disabilities Act and Info Tech Center: Accessible Parking Inventorya

Authors

Pedestrian Environment Data Scan (PEDS) Tool Pedestrian Environment Quality Index (PEQI) Pedestrian Environmental Factor (PEF)a Pedestrian Infrastructure Prioritization (PIP) Decision Systema Pedestrian Location Identification (PLI) e Tools 1 and 2a Perceived Environment Attributes

NA

P

W/B/R

O

N

N

NA

N

T/L

San Francisco Department of Public Health (2008)87 Parsons Brinckerhoff Quade and Douglas, Inc., et al. (1993)88 Moudon (2001)89

NA

H

W

O

N

N

R: ICC 5 0.95 M

N

E/T/L

NA

T

W

G

N

N

NA

N

T/L

NA

T

W

O

N

N

NA

Y

T

Moudon (2001)90

NA

T

W

G

N

N

NA

N

E/T/L

Duncan and Mummery (2005)91

Y

H

W/B/R

S, G

N

N

N

T/L

Humpel et al. (2004)92

Y

H

W/R

S

N

N

R: ICC 5 0.73-0.91 M Ca 5 .73-.88 M R: ICC 5 0.68-0.89 M

N

T/L

Sallis et al. (1997)93

Y

H

W/R

S,O

N

N

NA

N

L

Vest and Valadez (2005)94

NA

H

W/R

S

N

N

R: Ca 5 .44-.91

N

NA

Burton et al. (2007)95 California Department of Public Health (2008)96 Eyler et al. (2003)97

Y NA

H H

W/R W/B/R

S O

N N

N N

NA NA

N N

T E/T

Y

H

W/B/R

S

N

N

R: rs O0 .70 M

N

T/L

Lee et al. (2005)98

Y

H

W/B/R

O

N

N

N

T

Evenson and McGinn (2005)99

Y

H

W/B/R

S

N

N

N

T/L

Erwin (2008)100

Y

H

W/R

O

N

N

R: ICC 5 0.40-0.80 Ca 5 .81 M R: k 5 0.25-1.0 ICC 5 0.63-0.95 M R: k 5 0.04-1.0

N

L

Kealey (2005)101

Y

H

W/B/R

O

Y

Y

NA

Y

E/T/L

Bassett (2008)102

Y

P

W/B/R

O

Y

Y

R: k 5 0.80 M

Y

E/T

Rimmer et al. (2009)103

NA

H

W

O

Y

Y

NA

Y

E/F/T/L/SS

NA NA

H H

W/R W/B

O O

Y N

N N

NA NA

Y N

E/T E/T/L

NA

P, T

W

O

Y

N

Y

E/T/L

Y

H

W/B

O

N

N

R: 67% of items had agreement over 60% R: k 5 0.61 M

Y

E/T/L

Cavnar et al. (2004)104 America Walks and Physical Activity Policy Research Network (CDC) (2006)105 Safety Audit Checklist for Dual-Use Main Roads, Western Australia Paths (1997)106 Senior Walking Environmental Cunningham et al. (2005)107 Assessment Tool (SWEAT)

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Perceived Environment Attributes, Residential Location, and Walking Perceived Environmental Variables d Physical Activity Perceptions of Neighborhood Characteristics and Leisure Time Physical Activity Physical Activity and Health Physical Activity Community Assessment Physical Activity in Communities Questionnaire Physical Activity Resource Assessment (PARA) Instrument Physical Environment Questionnaire Preadolescent Environmental Access to Physical Activity Questionnaire Prevention Research Center Healthy Aging Research Network (PRCHAN) Environmental Audit Tool Promoting Active Communities Assessment Q-PAT (Quick Pathways Accessibility Tool)a Recreation Facility Evaluation Tool Safe Routes Startup Checklist

Clifton et al. (2007)86

(Continued) 93

94

Table 1 Continued Authors

1 Imp 2 Fld 3 Subj Foc 4 Data Coll 5 Mult Dom 6 Mult Itm 7 Psy

Slips Assessment Tool (SAT)

Mason and Health, Safety and Engineering Consultants, Ltd. (2003)108 Giles-Corti and Donovan (2002)109

NA

H

W

O

N

N

R: Ca 5 .65-.83 M

Y

E/T

NA

H

W/R

S,G

N

N

R: ICC 5 0.19-0.92

N

T

Brownson et al. (2004a)110

Y

H

W/B/R

S

Y

Y

N

T/L

Brownson et al. (2004b)111

Y

H

W/B/R

O

Y

Y

R: k 5 0.07-0.69 ICC 5 0.19-0.77 NA

N

T

Giles-Corti and Donovan (2002)112

NA

H

W/B/R

S

Y

Y

R: ICC 5 0.76-0.98 M A 5 88-97%

N

T

McKenzie et al. (2000)113

Y

H

R

O

N

N

R: ICC 5 0.76-0.98 M A 5 88-97%

N

T

McKenzie et al. (2006)114

Y

H

R

O

N

N

N

T

Pikora et al. (2002)115

Y

H

W/B

O,G

N

N

R: 31% of k values were greater than 0.75 98.5% of items had agreement over 75% R: k 5 0.61

N

T/L

Williams et al. (2005)116

Y

H

W

O,G

N

N

NA

N

T/L

Ogilvie et al. (2008)117

Y

H

W/B/R

S

N

N

R: r 5 0.42-0.91

N

T

Forsyth et al. (2009)118 NSW Health Department (2002)119 The Robert Wood Johnson Foundation and Pedestrian and Bicycle Information Center120 Emery et al. (2003)121

Y NA NA

H, P H T

W/B/R R W

G, S O, S O

Y N N

Y N N

NA NA R: ICC 5 0.79-0.90 M V: r 5 0.58, r 5 0.62 M

N N N

T/L NA 70

Y

H

W/B

O

N

N

NA

N

E/T

Brownson et al. (2004)122

Y

H

W/R

S

N

N

N

T/L

Dannenberg et al. (2005)123

Y

H

W/R

O

N

N

R: k 5 0.23-0.67 W 5 0.50-0.87 NA

Y

E/T

Socioeconomic Status Differences and Perceived Access to Supportive Physical Environment St. Louis Environment and Physical Activity Instrument Street-Scale Analytic and Checklist Audit Tool Study on Environmental and Individual Determinants of Physical Activity System for Observing Play and Leisure Activity in Youth (SOPLAY) System for Observing Play and Recreation in Communities (SOPARC)a Systematic Pedestrian and Cycling Environmental Scan (SPACES) Tool to Assess Sidewalk Maintenance (University of South Carolina Prevention Research Center) Traffic and Health in Glasgow Questionnaire Twin Cities Walking Survey Walk It Active Local Parks Walkability Worksheet

Walking and Biking Suitability Assessment (WABSA)a Walking Activities in Rural Communities Worksite Walkability Audit Tool

8 Dis 9 Univ Des

Note: (1) Imp, impact/use: indicates whether an instrument-specific article was cited in peer-reviewed literature: Y 5 yes, NA 5 not available, (2) Fld, field: H 5 health, P 5 planning, T 5 transportation, (3) Subj Foc, subject focus: W 5 walkability, B 5 bikeability, R 5 recreation, (4) Data Coll, method of data collection: S 5 subjective/perceived, O 5 objective/audit, G 5 GIS, (5) Mult Dom, multiple domains: Y 5 yes, N 5 no, (6) Mult Itm, multiple items: Y 5 yes, N 5 no, and a a next to the instrument name indicates high measurement specificity (i.e., asked for specific measurements in feet, inches), (7) Psy, psychometrics: R 5 reliability, V 5 validity, M 5 meets criteria, r 5 Pearson’s correlation, k 5 kappa, ICC 5 intraclass correlation, ICR 5 internal consistency using Rasch analysis, r 5 Spearman’s rho, Ca 5 Cronbach’s alpha, W 5 Kendall’s coefficient of concordance, A 5 (interrater) agreement, NA 5 not available, (8) Dis, considers disability issues: Y 5 yes, N 5 no, (9) Univ Des, universal design: E 5 equitable use, F 5 flexibility in use, SI 5 simple and intuitive use, P 5 perceptible information, T 5 tolerance for error, L 5 low physical effort, SS 5 size and space for approach and use.

J.A. Gray et al. / Disability and Health Journal 5 (2012) 87e101

Instrument name

J.A. Gray et al. / Disability and Health Journal 5 (2012) 87e101

95

Table 2 Universal Design Principle Definitions, Examples, and Use in the Reviewed Instruments124,125 UD principles Definitions Examples

Use

1. Tolerance for error

62 (65%)

2. Equitable use 3. Low physical effort 4. Perceptible information

5. Size and space for approach and use

6. Flexibility in use

7. Simple and intuitive use

Built-in features that minimize hazards caused by accidents or unintended actions Equally available and useful structures and products for people of different abilities A structure or product that minimizes user fatigue Enable users of all sensory abilities to readily access information and use the structure or design for its intended purpose Enables users of all abilities to approach and use the built environment structure or product Provides users of different abilities with options for accessing a built environment structure or product Easy to understand designs that accommodate people of all abilities

Observation (BRAT-DO) [36] includes items to measure the predominant width of the path or path segment, as an example of equitable use. The Community Street Review [41] provides an example of low physical use, as it contains items on whether a path has even surface quality and is safe from falls and slips due to cracked pavement. The remaining principles are present less frequently. The principle of perceptible information, which allows those of all sensory abilities to use the built environment structure, is demonstrated in 6 (6%) instruments. For example, the AARP Livable Communities Guide and

List 1. Disability-related instrument topics  Outdoor structures comply with ADA guidelines (e.g., curb ramps, curb cuts, crosswalks, transit stops)  Wheelchair accessibility (e.g., width of corridors, ramps, doors)  Availability of accommodations for PWDs (e.g., transportation, parking spaces)  Information and signage available in various formats (e.g., Braille, large print, pictograms, audio)  Accessible amenities (e.g., outside: water fountains; inside: bathrooms, locker rooms, and showers)  Short distances between building structures and natural environment  Impact of natural/built environment on physical activity and participation in community for PWDs  Park accessibility for PWDs  Accessible equipment for PWDs (e.g., exercise machines)  Adapted sports programs for seniors and PWDs  Negative attitudes, prejudice and/or discrimination toward PWDs  Social support for PWDs from family, friends, colleagues, and neighbors  Policies/rules related to disability accessibility  Lack of or obstacles to programs/services with respect to PWDs  PWDs involved in planning process and needs assessment

Flashing lights and audible crosswalk signals guarding against inappropriate crossing Website including text-to-speech software

37 (39%)

Flat terrain, easy grip appliances

37 (39%)

Meaningful icons, large text, and Braille on signage

6 (6%)

Large bathroom stalls, wide hallways and doorways

5 (5%)

Options for use of ramps, stairs, escalators, elevators, lifts

2 (2%)

Lever handles, push buttons

1 (1%)

Quiz [31] includes items about whether curb cuts are textured. The Community Street Review [41] contains items about visual or tactile aids, and the National Association of County and City Health Officials (NACCHO) Public Health in Land Use Planning and Community Design instrument [66] includes items about the presence of voice/audio or visual clues at crosswalks and transit stops. The principle of size and space for approach and use, indicating ample space for users of all abilities to approach and use a built environment structure, is present in 5 (5%) instruments. For example, the Path Environmental Audit Tool (PEAT) [82] includes items on whether restrooms are accessible to wheelchair users. The Quick Pathways Accessibility Tool (Q-PAT) [103] includes items on whether there is a minimum 60  60 inches clear landing area in front of all doors. Such information can indicate whether a specific structure is large enough to accommodate different user groups (e.g., pedestrians, bicyclists, wheelchair, and stroller users). The principle of flexibility, providing users of different abilities with options for accessing a built environment structure, is present in 2 (2%) instruments. For example, the Accessibility Instruments Measuring Fitness and Recreation Environments (AIMFREE) [32] includes items on whether there are marked alternate routes with a ramp when steps are present, and whether there are alternate accessible means of entering/exiting a pool, such as a pool lift, zero depth entry, and a wet/dry ramp. The Quick Pathways Accessibility Tool Q-PAT [103] contains items on whether there is a sign indicating an accessible route when 2 routes are present (i.e., 1 accessible and 1 inaccessible). The principle of simple and intuitive use, being easy to understand for users of all abilities, is present in 1 (1%) instrument. For example, the AIMFREE [32] contains items on whether buttons and displays are present on

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exercise equipment, such as treadmills, stair steppers, or exercise bicycles, which can make it more likely for users to understand operations.

Discussion The focus of this paper was to examine a sample of built environment instruments specific to walking, biking, and recreation for their disability relevance and UD applicability. Other relevant details also were noted. Such information can be useful for locating, designing, and modifying built environment instruments that provide information on environmental accessibility for PWDs, as well as other populations. Regarding instrument impact or use, we indicate what instruments have articles cited in the peer-reviewed literature. Although this provides some indication of use, it does not capture other instruments which likely are used regularly, but to our knowledge have no related peerreviewed literature (e.g., the Department of Transportation Bicycle Compatibility Index e RWJF [44], or Federal Transit Administration’s ADA Assessment Sheets [52]). Such instruments, however, may be disseminated through a variety of other means, such as website presence. The fact that the majority of instruments originate in a health-related field suggests that development of instruments from other professional fields may yield new perspectives on what types of data should be gathered and used. Future instruments may be developed from a combination of professional fields to help broaden the type and use of information collected. Although approximately one-fifth of instruments demonstrate high levels of specificity (i.e., requiring exact measurements), which are helpful in determining whether built environments are ADA compliant and encourage physical activity for multiple populations, this alone does not determine an instrument’s use or value. In some cases, instruments providing a subjective perspective are warranted. Some instruments with high specificity and multiple domains and items may be paired with instruments using subjective data collection methods. For example, the Environmental Assessment of Public Recreation Spaces (EAPRS) Tool [46] includes very specific response categories for the topics of trails, facilities (e.g., restrooms), play sets (e.g., playgrounds), athletic fields, and other recreation structures. Instruments with lower specificity and subjective data collection methods (e.g., Participation Survey/Mobility [PARTS/M] [81] or Craig Hospital Inventory of Environmental Factors [CHIEF] [43]) can provide a valuable subjective perspective about the built environment from the viewpoint of PWDs. Respondents with disabilities who have experienced challenges or facilitators in the built environment can influence the inclusion of items in objective instruments as well as the design of new ADA regulations. Though instruments with multiple domains, multiple items, and high specificity can provide a wealth of valuable

information about the effect of a built environment on a specific population’s potential for activity, shorter, less detailed instruments may be easier to administer and facilitate a better response rate. In some cases, it may be useful to use more than 1 instrument with varying levels of detail and focus. For example, the PEAT [82] provides multiple domains related to walkability, bikeability, and streets/ traffic/intersections (e.g., road curb cuts, pedestrian signals, crosswalks, trail dimensions, and amenities). This may be paired with a shorter instrument focusing on walkability (e.g., Walkability Worksheet RWJF [120]) or bikeability (e.g., Department of Transportation Bicycle Compatibility Index [44]). Psychometric information can inform users about the reliability and validity of specific instruments. Considering that over one-half of the instruments have psychometric information and that only one-half of these instruments meet acceptable reliability criteria suggests the need for more rigorous testing of many built environment instruments. As expected, we found a handful of built environment instruments designed specifically about PWDs, with others having some disability relevance. The instruments typically focus on topics such as street accessibility (e.g., curb cut accessibility), accessible amenities (e.g., bathrooms and drinking fountains), signage, and information about specific ADA requirements. In some cases, a user may pair a disability-specific instrument with a mainstream built environment instrument to obtain an accurate assessment of community suitability for PWDs. For example, instruments measuring subjective consumer assessments of community accessibility for PWDs (e.g., FAB/S [50]) can be used with an instrument measuring objective features of an environmental structure (e.g., path width or slope) (e.g., EAPRS Tool [46]). In addition to disability relevance, instruments were examined for UD applicability. While the UD principles of tolerance for error, equitable use, and low physical effort are present in one-fifth to one-third of the instruments, the remainder of UD principles - size and space for approach and use, perceptible information, flexibility, and simple and intuitive use e are only present in a few instruments. Our review suggests a need for all UD principles, and particularly the latter four principles, to be included in new and/or adapted instruments. Through application of such UD principles, items addressing the needs of PWDs can be incorporated into the future design or revision of generic built environment instruments to obtain information necessary for building an accessible community. Several instruments focus on the built environment and PWDs. The AIMFREE [32] includes both professional and consumer instrument versions with objective/audit items on the accessibility of surfaces and structures in fitness centers and swimming pools for people with various disabilities. The Q-PAT [103] includes detailed objective/audit items with respect to pathways and other outdoor characteristics problems for people with physical disabilities. It can be used

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to collect specific measurements on paths/sidewalks and curb cuts, for example. Similarly, the Prevention Research Center Healthy Aging Research Network (PRC-HAN) Environmental Audit Tool [101] includes detailed information on land use, walkways, trails, streetscape, and social and aesthetic factors specific to the needs of older adults. Detailed instructions, as well as pictures and diagrams are provided for auditors. The PEAT [82] also provides objective/audit information on physical features of community paths and trails. Extensive instructions, as well as pictures and diagrams are available for auditors. Some items are relevant for PWDs (e.g., intersection curbs being wheelchair accessible). Two other instruments, the Community Health Environment Checklist (CHEC) [40] and the Facilitators and Barriers Survey/Mobility (FABS/M) [50], focus on ways the built environment affects PWDs’ activity levels. For example, the CHEC [40] includes items on how the environment (e.g., surfaces, curb cuts) affects the activity level of people with mobility impairments. Similarly, the Facilitators and Barriers Survey/Mobility (FABS/M) [50] includes items on environmental facilitators and barriers from the perspective of respondents with disabilities. Respondents must indicate why they find specific environmental features to be a facilitator or barrier to their activity and mobility. Some instruments can provide comprehensive reviews of specific topics. For example, the EAPRS Tool [46] is a very comprehensive and detailed audit tool regarding the state of recreation settings, including trails, parks, water areas, and other related topics. Alternatively, the Gainesville Bicycle and Pedestrian Level of Service Performance Measures [53] are unique and concise measures of level of service for bicycle and pedestrian use in a transportation corridor, using GIS data collection methods. Other instruments can assist with planning for active communities. The King County Active Community Checklist [60] focuses on planning active communities with respect to transit, urban area land use, as well as other factors. It includes items regarding the inclusion of various disadvantaged populations (e.g., older adults, PWDs) in the planning process. The Promoting Active Communities Assessment 102 provides great examples of examining communities’ policies and planning related to the built environment and physical activity. The League of American Bicyclists Bicycle Friendly Communities Campaign [61] application covers topics such as engineering, education, enforcement, evaluation and planning, and feedback to help gauge the infrastructure, and safety-related issues for community members engaging in bicycling. To complete this review, we provide a few final recommendations for new or revised instruments (List 2). Overall, few instruments focus on topics such as recreation, planning, and policy for active communities, and school-related physical activity (both at and in transit to school, as well as specific populations, such as PWDs). More information is needed on topics pertinent to specific populations, although few

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List 2. Recommendations for new or revised instruments  Address infrequently-addressed subject areas (e.g., recreation, planning and policy for active communities, school-related physical activity [both at and in-transit to school]), and certain populations (e.g., generally PWDs and individuals with specific types of disabilities).  Include items that address issues important to specific populations (e.g., people with mobility impairments).  Incorporate more UD principles, especially those rarely included in current instruments (e.g., perceptible information, size and space for approach and use, flexibility, and simple and intuitive).  Incorporate higher specificity by including items that assess actual measurements (e.g., sidewalk width or curb ramp slope).  Operationally define the term ‘‘accessible’’.

instruments focus on PWDs, even less focus on specific types of disabilities, such as individuals with visual or hearing impairments. The term ‘‘accessibility’’ is frequently but inconsistently used across the reviewed instruments. Specific operationalization of the term can clarify whether information is being collected for the general or specific populations. Furthermore, incorporation of higher levels of instrument specificity through items assessing actual measurements (e.g., sidewalk width, curb ramp slope) can provide more detailed information relevant to such populations. The use of UD principles, particularly those rarely used in current instrumentation (e.g., perceptible information, size and space for approach and use, flexibility, and simple and intuitive) can provide additional detailed information about such populations. Information on such features can indicate accessibility for multiple user groups. For example, tactile boundaries (e.g., textured, truncated dome surfacing) between the sidewalk and street can be helpful for individuals with visual impairments, and audible and vibrotactile signals can service individuals with auditory disabilities (perceptible information). Ample sidewalk landing areas at curbs can ensure that the space is useful for multiple users (space and size for approach and use). Two paths made of different materials (e.g., gravel and rubberized outdoor surfacing) provide options for users’ needs (flexibility). Easy-to-understand signage and instructions for recreational area use allow for users of different abilities to follow (simple and intuitive). Signal cues can prevent individuals from crossing at inappropriate times or in dangerous situations. Information on crosswalk timing is useful, as some user groups (e.g., individuals with mobility and/or cognitive impairments) may cross at a slower speed than the 4 feet per second industry crossing standard [131,132]. A path that has even surface quality and is safe from falls and slips due to cracked pavement, as well as inadequate maintenance to surfaces exhibiting cracks, bumps, holes, and other surface imperfections, can be a potential tripping hazard for an individual with a foot drop or mobility device (tolerance for error). Whether a sidewalk/path meets ADAAG guidelines (i.e., be at least 5 feet, 10 inches for a pedestrian zone sidewalk corridor [133]),

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indicates whether it is accessible to multiple users, such as wheelchair, stroller, and/or delivery cart users is (equitable use). Conclusion Our analysis of 95 instruments provides information on the gaps in disability, UD principles, and other issues in current built environment instrumentation related to walkability, bikeability, and recreation. More focus on various populations and topics, such as disability issues, as well as UD principle incorporation, psychometric analysis, and measurement specificity is needed. Such instruments will yield more detailed information on environmental accessibility for people with a variety of disabilities [25], and can help build communities that allow for PWDs and the population-at-large to lead healthy, active lives. References [1] McGinnis J, Foege WH. Actual causes of death in the United States. JAMA. 1993;270:2207-2212. [2] Blair SN, Brodney S. Effects of physical inactivity and obesity on morbidity and mortality: current evidence and research issues. Med Sci Sports Exerc. 1999;31:S646-S662. [3] Martinson BC, O’Connor PJ, Pronk NP. Physical inactivity and short-term all-cause mortality in adults with chronic disease. Arch Intern Med. 2001;161:1173-1180. [4] CDC. Physical activity among adults with a disabilitydUnited States, 2005. MMWR. 2007;56:1021-1024. [5] Brault M. Americans with disabilities: 2005. Curr Popul Rep. 2008;70-117. [6] Rimmer JH, Shenoy SS. Impact of exercise on targeted secondary conditions. In: Field MJ, Jette AM, Martin L, eds. Workshop on disability in America: a new look. Washington, DC: The National Academies Press, 2006; p. 205-221. [7] Rimmer JH, Rubin SS, Braddock D, Hedman G. Physical activity patterns of African American women with physical disabilities. Med Sci Sports Exerc. 1999;31:613-618. [8] King AC, Castro C, Wilcox S, Eyler AA, Sallis JF, Brownson RC. Personal and environmental factors associated with physical inactivity among different racial-ethnic groups of U.S. middle-aged and older-aged women. Health Psychol. 2000;19:354-364. [9] Trost SG, Owen N, Bauman AE, Sallis JF, Brown W. Correlates of adults participation in physical activity: review and update. Med Sci Sports Exerc. 2002;34:1996-2001. [10] Dishman RK, Sallis JF. Determinants and interventions for physical activity and exercise. In: Bouchard C, Shephard RJ, Stephens T, eds. Physical activity, fitness, and health: international proceedings and consensus statement. Champaign, IL: Human Kinetics, 1994; p. 214-238. [11] Sallis JF, Owen N. Physical activity and behavioral medicine. Thousand Oaks, CA: Sage Publications, Inc.; 1999. [12] Humpel N, Owen N, Leslie E. Environmental factors associated with adults’ participation in physical activity: a review. Am J Prev Med. 2002;22:188-199. [13] Brownson RC, Haire-Joshu D, Luke DA. Shaping the context of health: a review of environmental and policy approaches in the prevention of chronic diseases. Ann Rev Public Health. 2006;27: 341-370. [14] Institute of Medicine, Transportation Research Board. Does the built environment Influence physical activity? Examining the evidence. Washington, DC: The National Academies; 2005.

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