See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/325356164

The accessibility of fitness centers for people with disabilities: A systematic

review

Article  in  Disability and Health Journal · May 2018

DOI: 10.1016/j.dhjo.2018.04.002

CITATION READS

1 104

3 authors, including:

Gisela Sole Hilda Mulligan

University of Otago University of Otago
93 PUBLICATIONS   807 CITATIONS    56 PUBLICATIONS   324 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

The Canterbury Fatigue Project - Minimise Fatigue, Maximise Life: Creating Balance with multiple sclerosis View project

Outcomes of anterior cruciate ligament ruptures and reconstruction View project

All content following this page was uploaded by Gisela Sole on 25 September 2018.

The user has requested enhancement of the downloaded file.

 Disability and Health Journal xxx (2018) 1e12

Contents lists available at ScienceDirect

Disability and Health Journal

journal homepage: www.disabilityandhealthjnl.com

The accessibility of fitness centers for people with disabilities: A

systematic review
Allyson Calder a, *, Gisela Sole b, Hilda Mulligan a
a
Centre for Health, Activity and Rehabilitation Research (CHARR), School of Physiotherapy Christchurch, University of Otago, PO Box 4345, Christchurch
Mail Centre 8140, New Zealand
b
Centre for Health, Activity and Rehabilitation Research (CHARR), School of Physiotherapy, University of Otago, PO Box 56, Dunedin, New Zealand

a r t i c l e i n f o a b s t r a c t

Article history: Background: Fitness centers could be ideal places for people with disabilities to engage in the recom-
Received 15 November 2017 mended levels of physical activity for healthy well-being. However, one of the primary barriers to
Received in revised form participation at fitness centers is an inaccessible built environment.
9 March 2018
Objective: This review study aimed to evaluate the accessibility of public indoor fitness centers for people
Accepted 28 April 2018
with disabilities.
Methods: We searched electronic databases and web based search engines using keywords and syno-
Keywords:
nyms for fitness centers, people with disability and accessibility. Observational studies that used stan-
Fitness centers
Disabled persons
dardized measures to evaluate fitness centers were included and critically appraised using a modified
Architectural accessibility version of the checklist for randomized and non-randomized studies developed by Downs and Black. We
Legislation analyzed the data descriptively. This systematic review protocol is registered in PROSPERO
Attitude (ID:CRD42016043945).
Results: A total of 533 fitness centers were evaluated for accessibility across 14 studies. Ten (85%) of the
14 studies were undertaken in the United States of America. Instruments (n ¼ 2) used to evaluate fitness
centers were based on the Americans with Disabilities Act compliance legislation and measured domains
of physical access (e.g., bathrooms, equipment, parking) and system access (e.g., policies, programs,
professional behavior). We calculated weighted percentage mean scores per accessibility domain. The
least accessible domain was “hot tubs/whirlpools/saunas/steam rooms” at 33%, with “programs” being
the most accessible domain at 68%.
Conclusions: Fitness center accessibility for people with disabilities remains poor. Adopting the princi-
ples of universal design in legislation would achieve equitable access for all, thereby allowing people
with disabilities to participate actively in their communities with dignity and autonomy.
© 2018 Elsevier Inc. All rights reserved.

Introduction
Participation in physical activity for people with disabilities has
substantial benefits to reduce secondary conditions1,2 and posi-
tively influence healthy well-being.3 Many people with disabilities,
however, demonstrate very low levels of physical activity.4 Indoor
fitness centers could be an ideal environment for individuals with
disability to participate in physical activity, and to include cardio-
vascular fitness and strength training into their exercise programs.
These types of exercise are recommended aspects of physical
* Corresponding author.
E-mail addresses: ally.calder@otago.ac.nz (A. Calder), gisela.sole@otago.ac.nz
(G. Sole), hilda.mulligan@otago.ac.nz (H. Mulligan).
activity for this population group.5 Fitness centers could also pro-
vide opportunity for social engagement6 and an atmosphere where
individuals with disabilities could feel safe, supported, valued and
accepted.7 However, very few people with disabilities participate in
physical activity at fitness centers due to social (attitudinal) and
environmental barriers.8e10
A lack of knowledge and understanding of disability issues (e.g.,
by family members, friends, able-bodied members of society,
fitness center staff, building professionals and health professionals)
can create social barriers to access and participation at fitness
centers.11 In addition, people with disabilities report feeling un-
supported by the attitudes of health professionals, fitness center
staff and, at times, family members and friends8,11 which can create
further disincentives for them to participate in physical activity.12

https://doi.org/10.1016/j.dhjo.2018.04.002
1936-6574/© 2018 Elsevier Inc. All rights reserved.

Please cite this article in press as: Calder A, et al., The accessibility of fitness centers for people with disabilities: A systematic review, Disability
and Health Journal (2018), https://doi.org/10.1016/j.dhjo.2018.04.002
2 A. Calder et al. / Disability and Health Journal xxx (2018) 1e12
Attitudes of fitness center staff (particularly management) can lead
to barriers in system access. System access refers to organizational
factors13 such as fitness center policies, programs being offered,
membership costs and staff training.14 Indeed, studies have shown
that fitness center staff have insufficient training and knowledge
about disability specific conditions.8,11,15e17
The built environment can also present barriers to participation
in physical activity.8,18 People with disabilities consider poorly built
environmental accessibility as the primary barrier to engagement
in physical activity at fitness centers.1,19,20 Inaccessibility of the
building (i.e. physical access13) such as inaccessible access routes
and bathroom facilities are common obstacles that people with
disabilities encounter. Inaccessible equipment is another hurdle,
where most fitness centers lack adaptable equipment to meet the
needs of people with disabilities.21 There is often a lack of space
around the equipment20 which can create safety issues or can
prevent transfer to and use of equipment.8,21
It is a basic human right for people with disabilities to experi-
ence equitable access and participate in their environment without
restrictions or discrimination.22,23 Many countries have introduced
legislation to prevent discrimination against people with disabil-
ities where the United States of America (USA) has led the world
through the inception of the Americans with Disabilities Act (ADA)
in 1991. Two decades after the ADA, the World Health Organiza-
tion's (WHO) report on disability encouraged researchers to focus
on ways to measure environmental influences on disability in a
variety of contexts24 (eg., evaluation of physical barriers to partic-
ipation such as fitness facility accessibility).
There is a growing body of international research (predomi-
nately from the USA) that has evaluated physical and system access
of fitness facilities against the ADA compliance legislation. Green,25
Hiss and Rauworth26 and Ramot, Lahav and Bendel27 have
emphasized the importance of synthesizing accessibility audit data
from research studies to determine where the barriers are and why
they might exist. Understanding accessibility barriers may allow
development of recommendations for more inclusive and equitable
access to fitness centers so that people with disabilities can
participate in physical activity with independence, dignity and
autonomy. Therefore, the purpose of this study was to systemati-
cally review and synthesize the research studies that have evalu-
ated fitness center accessibility.
Methods
Protocol and registration
A protocol for this systematic review was registered a priori in
PROSPERO28 (ID: CRD42016043945). We chose prospective regis-
tration for our systematic review to avoid unintended duplication,
enhance transparency and credibility, and minimize reporting bias
of the study outcomes.29,30
Search strategy
In March 2017, we systematically searched electronic databases
(AMED 1985 to March 2017, CINAHL, Embase 1947 to March 2017),
Ovid MEDLINE (R) 1946 to March 2017, ProQuest Dissertations &
Theses, Scopus, SPORTDiscus, TRIP, and Web of Science Core
Collection), web based search engines (Google Scholar) along with
hand searching reference lists of relevant studies. The search was
limited to studies published in the English language and their full
text availability. We searched all of these resources using key search
terms and associated synonyms for fitness centers, people with
disability and accessibility (appendix 1).
Please cite this article in press as: Calder A, et al., The accessibility of fitness centers for people with disabilities: A systematic review, Disability
and Health Journal (2018), https://doi.org/10.1016/j.dhjo.2018.04.002
Data collection procedures
We sought observational cross-sectional (analytical or descrip-
tive) published studies and postgraduate theses/dissertations
which used standardized measures to evaluate the accessibility of
indoor fitness centers open to the public. Studies or theses that
specifically evaluated therapeutic facilities (e.g., fitness centers at
rehabilitation hospitals) were excluded because it has been sug-
gested that these facilities report a much higher degree of acces-
sibility17 and they are often not open to the public without specific
health care referral. Public buildings not related to pursuing rec-
reational, sporting or exercising activities (e.g., banks, restaurants,
cinemas) and studies and theses that explored the subjective per-
ceptions or views of people with disabilities about accessibility of
fitness centers were also excluded.
Two researchers independently screened titles and abstracts
against the predetermined eligibility criteria. Then full texts of
potentially relevant studies and theses were obtained and screened
against the eligibility criteria. If we found multiple reports of the
same studies (i.e. thesis/dissertation and associated peer-reviewed
published journal article), both were included for review. The two
researchers then independently determined which studies would
be included. Any discrepancies were discussed together until
consensus was reached.
Data extraction procedures
One researcher independently extracted the data. Extracted
data pertained to country and location of where the study was
undertaken, sample size, fitness center description, facility con-
struction or renovation dates, evaluation instruments and facility
evaluators. Data from multiple reports of the same study were
extracted separately from each publication source and then com-
bined. A second researcher independently verified the data
extraction for ten percent of the included studies. We also con-
tacted authors of studies with missing data.
Methodological quality
To date there are no gold standard critical appraisal tools to
assess the methodological quality for observational analytical or
descriptive cross-sectional studies.31 Therefore, we chose the
checklist developed by Downs and Black32 for randomized and
non-randomized studies for two reasons. First, the original Downs
and Black checklist has undergone psychometric analysis for items
of reliability (test-retest reliability (r ¼ 0.88), inter-rater reliability
(r ¼ 0.75) and internal consistency (KR-20 ¼ 0.89)), external val-
idity (KR-20: 0.54) and criterion validity (0.89 correlation).32 Sec-
ond, it includes items that evaluate selection bias and confounding
bias which are the main limitations of cross-sectional studies.33
We modified the Downs and Black32 critical appraisal checklist
for this systematic review. To do this, we selected items 1e3, 6, 7,
10e12, 18, 20e22, and 25 directly from the original version of the
checklist, judging that they best represented the limitations likely
attributed to observational cross-sectional studies. Confounders
were established a priori and included i) studies where fitness
center staff self-evaluated their own facility or ii) if individuals with
diverse disabilities evaluated the fitness centers because of the
potential for differing personal perspectives and experiences of
disability. We also included and modified item 13 to suit the
external validity of the studies under review.
Two independent researchers appraised each study and/or
thesis. The researchers then met to discuss and resolve any dis-
crepancies until consensus was reached. Following discussion
within the research team, a pragmatic decision was made to
 A. Calder et al. / Disability and Health Journal xxx (2018) 1e12
include studies and theses that had reached a pre-determined
threshold for methodological quality of 75% which we felt
would enhance confidence in the results. We calculated the inter-
rater agreement using the Cohen's Kappa statistic with a 95%
confidence interval.
Data analysis
We analyzed the data using descriptive statistics. We then
calculated the weighted mean percentage per domain of accessi-
bility (e.g., access routes and entrance areas, equipment, bath-
rooms) to accommodate varying sample sizes across the studies/
theses.
Results
Eighteen studies were included for review (11 published stud-
ies12,34e43 and seven theses44e50) (Fig. 1). We combined the data of
two published studies34,43 that had accompanying theses. There-
fore, a sample of 16 studies and/or theses (now to be referred to as
‘studies’) underwent critical appraisal for methodological quality.
Methodological quality
The methodological quality of included studies ranged from 62
to 100% (Table 1). Over half of the studies (n ¼ 10) had missing data.
We could only contact four of the 10 studies with missing data
because the remaining six studies did not provide author contact
Fig. 1. PRISMA flow diagram of the study selection process.
Please cite this article in press as: Calder A, et al., The accessibility of fitness centers for people with disabilities: A systematic review, Disability
and Health Journal (2018), https://doi.org/10.1016/j.dhjo.2018.04.002
3
information. Two of the four authors replied offering further
information.
Deficiencies were noted across all three aspects of the Downs
and Black32 checklist (reporting, external validity and internal
validity); however, threats to methodological quality primarily
occurred within the external validity category. Several studies did
not specifically state i) whether fitness centers were representative
of the entire population from which they were recruited (n ¼ 6) or
ii) the proportion of fitness centers the authors asked and who
agreed to participate (n ¼ 7). Selection bias was present in three
studies due to purposive sampling strategies. Threats to internal
validity occurred to a lesser extent. Five studies failed to report the
period of time over which the fitness centers were recruited or
underwent evaluation. Confounding bias occurred in two studies
where one study did not report who evaluated the fitness centers,
and in the other study, people with disabilities carried out the
evaluations. In the reporting category, six studies did not provide
estimates of the random variability of the data (i.e., interquartile
ranges, standard error, standard deviations or confidence intervals).
We calculated the inter-rater agreement between the two in-
dependent appraisers. The percentage agreement was ‘almost
perfect’ at 90%; however, the level of agreement that may have
occurred by chance was moderate (k ¼ 0.67; 0.54e0.81 95% CI). The
majority of disagreement occurred in items 11, 12, and 25 of the
Downs and Black32 critical appraisal tool. This was due to the ap-
praisers interpreting the scoring instructions slightly differently.
For example, for item 25, one appraiser answered ‘no’ if the fitness
centers were evaluated by a person with disability because they
4 A. Calder et al. / Disability and Health Journal xxx (2018) 1e12

Table 1
Methodological quality of the studies.

Study Modified Downs and Black items and score Total %

1 2 3 6 7 10 11 12 13 18 20 21 22 25

Aldimkhi44 Y Y Y Y Y NA N UTD Y Y Y Y UTD Y 10/13 77

Aldimkhi45 Y Y Y Y Y Y Y Y Y Y Y Y Y UTD 13/14 93
Arbour-Nicitopoulous & Martin-Ginis34 Y Y Y Y Y Y Y Y Y Y Y Y Y Y 14/14 100
Cardinal & Spaziani35 Y Y Y Y N NA UTD UTD Y Y Y Y Y Y 10/13 77
Dolbow & Figoni36 Y Y Y Y N NA Y Y Y Y Y Y UTD Y 11/13 85
Figoni et al.37 Y Y Y Y N NA Y Y Y Y Y Y Y UTD 11/13 85
Gross et al.38 Y Y N Y Y NA UTD UTD Y Y Y UTD UTD Y 8/13 62
Johnson et al.39 Y Y Y Y N NA Y Y Y Y Y Y Y Y 12/13 92
Koh47 Y Y Y Y Y NA N N Y Y Y Y Y Y 11/13 85
Laiser48 Y Y Y N Y Y UTD UTD Y Y Y Y Y Y 11/14 79
Langley49 Y Y Y Y Y Y UTD UTD Y Y Y Y UTD Y 11/14 79
Nary et al.40 Y Y Y Y N NA Y Y Y Y Y Y Y Y 12/13 92
Pike et al.41 Y Y Y Y Y Y Y Y Y Y Y Y Y Y 14/14 100
Rimmer et al.12 Y Y Y Y N NA N UTD Y Y Y UTD Y Y 9/13 69
Rimmer et al.42 Y Y Y Y Y Y UTD N Y Y Y Y Y Y 12/14 86
Stoelzle & Sames43 Y Y Y Y N NA Y UTD Y Y Y Y Y Y 11/13 85

Key: Y (yes); N (no); UTD (unable to determine).

were likely to answer the subjective questions differently
depending on their disability. However, the second appraiser
answered ‘yes’ as they felt if the evaluators of the fitness centers
had undergone clearly described training, then it was not a
confounder.
Two studies (Gross, Kroll and Morris38 and Rimmer et al.12) did
not attain the pre-determined 75% threshold so were excluded
from the review.
Demographics of included studies
A total of 533 fitness centers were evaluated for accessibility
across the 14 remaining studies. The number of fitness centers
evaluated per study ranged from 3 to 227 (median ¼ 20). The de-
mographics of included studies are shown in Table 2.
Fitness facility instruments and evaluators
Two instruments were used to evaluate the fitness centers. Six
studies used modified versions of the ADA Accessibility Guidelines
(ADAAG) Checklist for Buildings and Facilities instrument. This
checklist surveys minimum standards of accessibility compliance
against the legislative Titles II and III of the ADA.51 The ADAAG
instrument includes the accessibility domains of parking, ramps,
entrances and exits, building lobbies and corridors, elevators,
rooms and spaces, toilet rooms and bathrooms, showers, signage,
telephones and drinking fountains. Items are scored as either ‘met’
or ‘not met’ against the accessibility compliance legislation. To the
best of our knowledge, the ADAAG has not undergone psycho-
metric analysis.52 Figoni et al.37 (the oldest study in our review)
adapted the ADAAG instrument to evaluate accessibility of fitness
centers. The other five studies took Figoni et al.'s37 modified ADAAG
checklist and modified it further to suit their study objectives.
Recreation and leisure studies graduate students (n ¼ 1) or the
study researchers (n ¼ 5) evaluated the fitness centers in these six
studies.
The remaining eight studies used the Accessibility Instruments
Measuring Fitness and Recreation Environments (AIMFREE) sur-
vey.53 Developed by Rimmer and colleagues,17 the AIMFREE survey
instrument evaluates public fitness centers for people with
mobility and visual impairments. The AIMFREE consists of fifteen
accessibility domains which evaluate physical access and systems
access. Physical accessibility domains include access routes and
entrance areas, equipment, information and signage, locker rooms
and showers, hot tubs/whirlpools/saunas/steam rooms, elevators,
bathrooms, swimming pools, parking, telephones and water
fountains. The systems access domains include professional
behavior, professional training and support, policies, and programs.
There is a professional version and consumer version of the AIM-
FREE instrument. The professional version objectively evaluates
fitness facilities against accessibility compliance standards.54 The
consumer version was developed to be used by individuals with
disability to determine if a fitness center is suitable to meet their
personal accessibility needs.54 Six studies in this review used the
AIMFREE professional version where the researchers (n ¼ 5) or
health professional students trained by the researchers (n ¼ 1)
carried out the fitness center evaluations. The consumer version of
the AIMFREE was used in two studies where people with disabil-
ities evaluated the fitness centers. The AIMFREE instrument uses a
weighted scoring algorithm to determine an accessibility rating for
each domain. Psychometric analysis of the AIMFREE instrument
found that, although the instrument demonstrated good internal
consistency, fair structural validity and excellent content validity,
the reliability was rated poor, thereby potentially introducing a
high degree of error with repeated measurements.52 Further psy-
chometric analysis of the AIMFREE instrument is recommended. In
the first instance, authors should ensure they evaluate an adequate
sample size of fitness centers and provide an in-depth account of
their methods.55
Country, legislation and fitness center construction/renovation
The majority of studies were undertaken in the USA (n ¼ 10)
which represented 85.2% of the fitness centers evaluated, followed
by Kuwait (n ¼ 2), Canada (n ¼ 1) and Singapore (n ¼ 1). These
countries possess different policies and legislation regarding
building accessibility. While the USA led the adoption of the ADA
legislation, setting minimal standards for accessibility to public
facilities,56 Canada57 and Singapore58 also have mandatory building
code compliance legislation for barrier-free accessibility of public
buildings. Kuwait, however does not have an official legally binding
building code to enforce accessibility compliance of newly con-
structed public buildings, and instead uses international accessi-
bility guidelines for people with disability.44,45
Eight of the studies included in this review recorded fitness
center construction dates. However, only two of these studies (Pike,
Walker, Collins, and Hodges41 and Rimmer, Padalabalanarayanan,
Malone, and Mehta42) examined accessibility before and after the

Please cite this article in press as: Calder A, et al., The accessibility of fitness centers for people with disabilities: A systematic review, Disability
and Health Journal (2018), https://doi.org/10.1016/j.dhjo.2018.04.002
 Table 2
and Health Journal (2018), https://doi.org/10.1016/j.dhjo.2018.04.002
Please cite this article in press as: Calder A, et al., The accessibility of fitness centers for people with disabilities: A systematic review, Disability
Demographics of included studies.
Author/s Date Region/s, Country Legislation
Aldimkhi44 Kuwait
Kuwaiti Law No.49 article 12
(1996)
Aldimkhi45 Al-Ahmadi, Al-Asimah, Al-
Farwaniyah, Hawalli
Governorates; Kuwait
Kuwaiti Law No. 8 (2010)
Arbour46 and Hamilton-Wentworth area,
Arbour-Nictipoulos & Ontario; Canada
Martin-Ginis34 The Accessibility for Ontarians
with Disabilities Act (AODA)
(2005)
Cardinal & Spaziani35 Western Oregon; USA
American Disabilities Act Titles
II & III (1991)
Dolbow & Figoni36 Hattiesburg Metropolitan area,
Mississippi; USA
American Disabilities Act Titles
II & III (1991)
Figoni et al.37 Kansas City Metropolitan Area;
USA
American Disabilities Act Titles
II & III (1991)
Johnson et al.39 Rural Western Wisconsin; USA
American Disabilities Act Titles
II & III (1991)
Sample size Facility description (inclusion/exclusion
criteria)
12  Fitness centers and health clubs Not stated
 Categorized based on membership cost:
expensive (n ¼ 11); moderate (n ¼ 13);
inexpensive (n ¼ 36)
20  Type: Men only (n ¼ 10); women only
(n ¼ 1); mixed gender (n ¼ 6)
 Membership: 150e2000 (n ¼ 10); 2001
e10,000 (n ¼ 10)
 Membership fee per annum (USD): $500
e1500 (n ¼ 12); $1501e5000 (n ¼ 8)
 Number of floors: 1e2 (n ¼ 11); 3e5
(n ¼ 9)
44  Fitness centers, recreation centers and
community swimming pool facilities
Types Private for-profit
- Fitness centers (74%)
- Recreation centers (0%)
- Swimming pools (0%)
 Public non-profit
- Fitness centers (26%)
- Recreation centers (100%)
- Swimming pools (100%)
50  Physical activity facilities that are open
to men and women
 Type: franchise/chain, hospital, non-
profit, private, worksite
 Membership: 100->10,000 individuals
10  Included: fitness facilities
 Excluded: physiotherapy centers,
facilities specializing in dance, weight
loss, martial arts, and massage
34  Included: public fitness centers
 Excluded: facilities with a primary focus
on martial arts, dance, massage,
chiropractic, physical therapy, athletic
training, personal training, education,
hospital wellness, rehabilitation, private
corporate fitness, beauty, and weight
loss
16 Private for-profit or public non-profit
facilities open to both genders while
offering cardiovascular and resistance
training equipment, personal training,
aquatic areas and/or fitness classes
Construction and/or renovation
dates of facilities
Facility construction dates
 2000-2006 (n ¼ 10)
 2007-2014 (n ¼ 10)
 8 facilities opened between 2010 equipment, information/signage, elevators, bathrooms,
and 2014
Facility construction dates
 1999: recreational (n ¼ 22);
fitness (n ¼ 8)
 2000: recreational (n ¼ 3);
fitness (n ¼ 7)
Accessibility renovation changes
 Yes: recreational (n ¼ 17);
fitness (n ¼ 9)
 No: recreational (n ¼ 8); fitness
(n ¼ 9)
Facility construction dates
 Mean year 1975 (95% CI 1968
e1981)
Renovation
 42 facilities renovated more than
once between 1983 and 2001
 Mean year of renovation 1995
(95% CI 1993e1997)
Not stated
Not stated
Facility construction dates
 Mean year 2001 (95% CI 1994
e2008)
Renovation dates
 Four facilities renovated
between 1999 and 2009
Instrument, domains evaluated and fitness facility
evaluators
AIMFREE professional version
Domains: Access routes and entrance areas, equipment,
locker rooms/showers, hot tubs/whirlpools/saunas/steam
rooms, elevators, bathrooms, swimming pools, water
fountains
Evaluator: Study author
AIMFREE consumer version
Domains: access routes and entrance areas, locker rooms/
showers, hot tubs/whirlpools/saunas/steam rooms,
programs, professional behavior, swimming pool, parking
Evaluators: Consumers with disability (eight wheelchair
users, two used walking stick)
AIMFREE professional version
A. Calder et al. / Disability and Health Journal xxx (2018) 1e12
Domains: parking, access routes and entrance areas,
bathrooms, elevators, locker rooms/showers, equipment,
policies, programs, professional training/support,
swimming pools
Evaluators: Principal investigator and three researchers
trained by principal investigator
76 item checklist adapted from McClain et al. (1990, 1993)
and Figoni et al. (1998).
Domains: customer service desk, access to and around
equipment, drinking fountains, telephones, rest rooms/
locker rooms, elevators, path of travel, exterior entrances/
doors, ramps, parking
Evaluator: 2nd author with expertise in ADA guidelines and
work experience in the fitness/wellness industry
74 item checklist adapted from McClain et al. (1990, 1993)
and Figoni et al. (1998).
Domains: parking, ramps, exterior doors, path of travel,
elevators, rest rooms/locker rooms, drinking fountains,
access to and around equipment, customer service desk,
specialized adaptive equipment, specialized staff training
Evaluator: Study authors
74 item checklist adapted from McClain et al. (1990, 1993).
Domains: parking, ramps, exterior doors, path of travel,
elevators, rest rooms/locker rooms, telephones, drinking
fountains, access to and around equipment, customer
service desk
Evaluators: Three female investigators (assume study
authors but not stated)
74 item checklist adapted from McClain et al. (1990, 1993)
and Figoni et al. (1998).
Domains: parking, ramps, exterior doors, path of travel,
elevators, rest rooms/locker rooms, bathrooms, telephones,
drinking fountains, access to and around equipment,
customer service desk, aquatic pool options, building
accessories (braille, steps, handrails), exercise equipment
Evaluators: Study authors
5
(continued on next page)
 Table 2 (continued )
and Health Journal (2018), https://doi.org/10.1016/j.dhjo.2018.04.002
Please cite this article in press as: Calder A, et al., The accessibility of fitness centers for people with disabilities: A systematic review, Disability
Author/s Date Region/s, Country Legislation
Koh47 Singapore
Code on accessibility in the built
environment (1991)
Laiser48 City of Chicago and surrounding 15
areas; USA
American Disabilities Act Titles
II & III (1991)
Langley49 City of Chicago; USA
American Disabilities Act Titles
II & III (1991)
Nary et al.40 Topeka, Kansas; USA
American Disabilities Act Titles
II & III (1991)
Pike et al.41 North Texas; USA
American Disabilities Act Titles
II & III (1991)
Rimmer et al.42 10 states across the USA
American Disabilities Act Titles
II & III (1991)
Stoelzle,50 Stoelzle & Minneapolis-St. Paul
Sames43 Metropolitan area, Minnesota;
USA
American Disabilities Act Titles
II & III (1991)
Abbreviations: Accessibility Instruments Measuring Fitness and Recreation Environments (AIMFREE); American Disabilities Act (ADA); United States of America (USA); Young Men's Christian Association (YMCA).
Sample size Facility description (inclusion/exclusion
criteria)
3 Low cost community sports and recreations
facilities that include a gymnasium,
swimming pool and a sports hall which are
located in typical housing estates
 Independent privately owned facilities Not stated
(n ¼ 5)
 Franchise/chain facilities (n ¼ 5)
 YMCA facilities (n ¼ 5)
22  Privately owned facilities (n ¼ 11)
 Franchise/chain facilities (n ¼ 11)
8  Included: private for-profit facilities and Not stated
private non-profit facilities open to the
public
 Excluded: school district and municipal
recreational facilities, facilities without
a primary focus on fitness such as martial
arts, rehabilitation, weight loss, athletic
training facilities
52  Included municipal or semi-private
aquatic facilities open to the public for
a nominal daily fee and located in urban/
suburban areas
 All aquatic facilities ranged from 200 to
300 person capacity
 Typical daily user rates: 75e175 users
per day
227 Included
 Privately owned for-profit (n ¼ 19) and
non-profit (n ¼ 208)
 227 fitness facilities included:
- fitness facilities/health clubs (100)
- hospital/rehabilitation facilities11
- University/college facilities (87)
- Park district/community center29
20 Included
 Fitness facilities open to the public
where membership included both
males and females.
 Facilities needed to offer at least one
piece of cardiovascular and resistance
type equipment
Excluded
 Fitness facilities based in hospitals,
hotels, work places and universities
Construction and/or renovation
dates of facilities
Facility construction dates
 Facility 1 2003e2006
 Facility 2 1998e2001
 Facility 3 1970e1973
Renovation dates
 Facility 3 1996e1998
Not stated
Facility construction dates
 Pre-ADA (n ¼ 25)
 Post-ADA (n ¼ 27)
109 facilities were constructed pre-
ADA: for-profit,6 non-profit (103)
109 facilities were constructed
post-ADA: for-profit,9 non-profit
(100)
9 facilities provided no construction
dates
One third of the facilities
constructed in the early 1970s.
Four facilities renovated after the
ADA.
6
Instrument, domains evaluated and fitness facility
evaluators
AIMFREE consumer version
Domains: access routes and entrance areas, information/
signage, elevators, locker rooms/showers, bathrooms,
swimming pool, equipment, parking, telephones, water
fountains
Evaluators: Two individuals with disability (one crutch user
and one wheelchair user)
AIMFREE professional version
Domains: access routes and entrance areas, equipment,
information/signage, locker rooms/showers, hot tubs/
whirlpools/saunas/steam rooms, elevators, bathrooms,
swimming pool, parking, telephones, water fountains,
professional behavior, professional training/support,
policies, programs
Evaluator: Study author
AIMFREE professional version
Domains: access routes and entrance areas, equipment,
A. Calder et al. / Disability and Health Journal xxx (2018) 1e12
information/signage, locker rooms and showers, elevators,
bathrooms, water fountains
Evaluator: Study author
83 item checklist adapted from McClain et al. (1990, 1993)
and Figoni et al. (1998).
Domains: parking, ramps, exterior doors, path of travel,
elevators, rest rooms/locker rooms, telephones, drinking
fountains, access to and around equipment, pool access,
adaptive equipment, staff training, adaptive programming,
pro-rating of membership fees, visits at no charge for
individuals to assess accessibility
Evaluators: Study authors where one was a wheelchair user
with experience in evaluating accessibility of public
buildings
74 item checklist adapted from McClain et al. (1990, 1993)
and Figoni et al. (1998).
Domains: parking, ticket counter, gate/entry, men's and
women's restrooms, dressing area, drinking fountains, path
of travel, pool entry method
Evaluators: Recreation and leisure studies graduate students
AIMFREE professional version
Domains: access routes and entrance areas, equipment,
information/signage, locker rooms/showers, hot tubs/
whirlpools/saunas/steam rooms, elevators, bathrooms,
swimming pool, parking, telephones, water fountains,
professional behavior, professional training/support,
policies, programs
Evaluators: Physical therapy, occupational therapy and
exercise science students and staff
AIMFREE professional version
Domains: Access routes and entrance areas, equipment,
information/signage, locker rooms/showers, hot tubs/
whirlpools/saunas/steam rooms, elevators, bathrooms,
professional support/training, swimming pool, parking,
telephones, water fountains
Evaluator: Study author
and Health Journal (2018), https://doi.org/10.1016/j.dhjo.2018.04.002
Please cite this article in press as: Calder A, et al., The accessibility of fitness centers for people with disabilities: A systematic review, Disability

Table 3
mean data and weighted percentage mean data with associated sample sizes (n) per accessibility domain.

Accessibility domains Study percentage mean data (%) with associated sample sizes (n) Weighed mean
44 45 37 39 47 49 40 41 42 data (%) (n)
Aldimkhi Aldimkhi Arbour-Nicitopoulos Cardinal & Dolbow & Figoni et al. Johnson et al. Koh Langley Nary et al. Pike et al. Rimmer et al. Stoelzle &
& Martin-Ginis34 Spaziani35 Figoni36 Sames43

Access routes & entrance 47.60 (12) 50.22 51.05 67.00 57.50 42.25 56.25 72.83 53.75 71.00 83.97 50.62 39.8 55.42
areas* (20) (44) (50) (10) (34) (16) (3) (22) (8) (52) (227) (20) (518)
Equipment*

A. Calder et al. / Disability and Health Journal xxx (2018) 1e12

55.61 67.56 47.69 8.00 10.00 16.00 42.00 44.6 54.82 69.99 e 53.16 40.36 44.20
(12) (20) (44) (50) (10) (34) (16) (3) (22) (8) (227) (20) (466)
Information/signage* e 33.81 e e e e e 29.93 32.42 e e 47.04 32.17 43.83
(20) (3) (22) (226) (20) (291)
*
Locker rooms/showers 50.72 57.35 41.89 e e e 32.00 43.21 46.65 e e 53.03 49.57 50.29
(12) (20) (44) (16) (3) (19) (227) (20) (361)
Hot tubs, whirlpools, 50.81 52.97 e e e e e e e e e 28.53 56.37 33.26
saunas, steam rooms* (12) (20) (227) (20) (279)
Elevators* 26.25 81.14 49.02 83.00 100.00 48.00 5.00 74.45 27.69 e e e 71.88 58.52
(12) (20) (44) (50) (10) (34) (16) (2) (12) (20) (220)
*
Bathrooms 29.98 46.48 31.07 44.00 20.00 0.00 47.00 63.77 37.23 67.00 63.90 44.55 73.44 42.94
(12) (20) (44) (50) (10) (34) (16) (3) (22) (8) (52) (218) (20) (509)
y
Professional behavior e 62.70 e e e e e e e e e e e 62.70
(20) (20)
Professional training & e e 47.93 e 0.00 e e e e e e 62.68 51.90 53.64
supporty (44) (10) (91) (20) (181)
Policiesy e e 47.07 e e e e e e e e 49.71 e 49.06
(44) (135) (179)
y
Programs e 52.48 63.15 e e e e e e e e 71.66 e 67.58
(20) (44) (122) (186)
Swimming pool* 27.07 39.15 36.96 e e e 9.00 42.40 e e 48.3 47.43 67.57 44.22
(12) (20) (44) (16) (3) (52) (161) (20) (328)
Parking* 29.92 e 54.81 56.00 80.00 24.00 50.00 e e 69.00 78.20 66.94 56.92 61.01
(12) (44) (50) (10) (34) (16) (8) (52) (213) (20) (459)
*
Telephones 30.51 e e 88.00 e 74.00 6.00 e e 67.00 e 35.00 23.33 54.23
(12) (50) (34) (16) (8) (41) (20) (181)
*
Water fountains 73.11 (12) e e 55.00 e 15.00 58.00 e e 60.00 70.20 82.26 77.78 65.62
(50) (34) (16) (8) (52) (111) (20) (303)

Key: domains of physical access *; domains of systems access y; domain not evaluated -.

7
8 A. Calder et al. / Disability and Health Journal xxx (2018) 1e12
inception of the legislation. Pike et al.41 found that fitness centers
constructed following the passing of ADA legislation were signifi-
cantly more accessible in the domains of parking, ticket counter,
drinking fountains, dressing areas, restrooms and pool entry re-
quirements. These findings were similar to Rimmer et al.'s42 study
where access routes and entrance areas, equipment, information
and signage, locker rooms and showers, bathrooms and swimming
pools were significantly more accessible after implementation of
the ADA legislation.
Descriptive analysis of included studies
To analyze the data of all included studies we first grouped
similar accessibility domains from the two instruments (ADAAG
and AIMFREE) that were used to evaluate the fitness centers. We
found the AIMFREE instrument included all of the accessibility
domains from the six studies that modified Figoni et al.'s37 in-
strument. We have therefore presented the results using the
accessibility domains from the AIMFREE instrument.53
The majority of the included studies analyzed their data
descriptively, reporting percentage mean scores for each accessi-
bility domain. Laiser48 was the only included study that did not
report percentage mean data. These authors did not use the scoring
system accompanying the AIMFREE instrument, so we have not
been able to include their findings in the descriptive analysis. We
captured the mean percentage scores and calculated overall
weighted mean percentage scores per accessibility domain for each
study (Table 3). Weighted mean scores consider the influence of
sample size of the studies, so those with larger sample sizes attri-
bute more ‘weight’ to the score. We calculated the weighted mean
percentage scores if two or more studies evaluated an accessibility
Fig. 2. Weighted percentage mean (%) data per accessibility domain across all of the included studies.
Please cite this article in press as: Calder A, et al., The accessibility of fitness centers for people with disabilities: A systematic review, Disability
and Health Journal (2018), https://doi.org/10.1016/j.dhjo.2018.04.002
domain. None of the studies reported on all 15 accessibility do-
mains. The weighted mean percentage accessibility scores ranged
from 33.26% (hot tubs) to 67.58% (programs) (Fig. 2 and
supplementary material). Table 4 provides a narrative summary
explaining common barriers found across the studies (although not
all studies reported flaws from the fitness centers they evaluated).
Discussion
This study aimed to systematically review cross-sectional
observational studies that evaluated the accessibility of fitness
centers for people with disabilities. The weighted percentage mean
data illustrate that no domain had a high level of accessibility.
Instead, and disappointingly, all domains fell within a range of
33e68% accessibility. In this review, the lowest ranked accessibility
domain was hot tubs, whirlpools, saunas and steam rooms. It may
not be too surprising that this domain scored very poorly, as it is
outside the scope of the ADA compliance legislation17 and was only
evaluated in four studies. The system access domains (policies,
programs, professional behavior, and professional support and
training) are also beyond the built environment legislative stan-
dards of compliance (in the USA), although interestingly, programs
and professional behavior ranked in the top three accessibility
domains in our study. However, these findings should be inter-
preted with caution because very few studies evaluated these
accessibility domains. Indeed, none of the studies evaluated all four
of the system access domains. Of the two instruments used to
evaluate accessibility in the studies, the AIMFREE is the only in-
strument (with psychometric analysis) to incorporate system ac-
cess in addition to physical access domains. However, system access
domains are very important aspects for people with disabilities
 A. Calder et al. / Disability and Health Journal xxx (2018) 1e12 9

Table 4
Narrative summary of common accessibility barriers.

Accessibility domain Common accessibility issues

Access routes and entranceways* Doors

 Manual door openings requiring grasping or twisting of handle36,39,40,43,49,50
 Lack of push button opening doors43,44,49,50
 Lack of power assisted doors49
 Heavy doors requiring >5 lbs of force40
Path of travel
 No detectable warning textures for curb cuts44
 Step access only37,44
 Only stair access to upper floors36,40,44
 Not all emergency exits accessible to wheelchair users47
 Narrow passageways36,40
 Carpets not fastened to the floor43,50
 Obstructed pathways40
 No adjustable lighting43,50
Ramps
 Ramps not meeting safe incline of 1:1236,37,40
 Lack of landing space at the top and bottom of ramps36,37
 Lack of handrails for ramps longer than 72 inches37,40
 Ramps placed in an indirect and/or longer route to access the facility47
Service desks
 Customer service desk or juice bar counter without a portion <3 feet high or less with a clear width of 3 feet36,37,40,44,48
Equipment*  Access to and around equipment blocked by obstacles37,47,48
 Equipment too close together36,37,43,47,48,50
 Lack of space to transfer on/off equipment47
 None or limited adaptive equipment provided e.g., arm ergometers, straps for bike pedals, transfer boards, standing
frames36,40,43,47,50
 Lack of small weight increments on exercise machines (i.e < 5 lbs)39,43,50
 Lack of swing away seats on exercise equipment39
 Difficult to read displays and lack of audio/braille on the equipment buttons43,47,50
Information/Signage*  Lack of signage for accessible access route to enter facility or around the facility39,49
 Lack of provision for alternative means of accessible information on notice boards or print material47,49
 Lack of braille, large print or audio for brochures47
 Lack of images of people with disabilities on print material43,50
 Tactile cues about location not available49
Locker rooms/showers* Lockers
 Lockers mounted too high40,43,44,50
 Locker handles difficult to open44
Showers
 Shower stalls too narrow40,47
 Poor size or incorrectly mounted seating40,43,47,48,50
 gInaccessible shower controls40
 Curbs in shower stalls40
 No grab bars or mounted in an inaccessible place44,47,48
 Non-detachable shower units47
 Disability shower often used for storing equipment47
Elevators*  Poor signage - lacked tactile, visual and audio accessibility features44,47
 No grab bars47
 Door width insufficient for people using mobility aids44
Bathrooms*  Inadequate toilet stall dimensions36,37,40,43,44,47,50
 Toilet stall doors too narrow37,39,48
 Toilet stall doors that swing inwards40
 Lack of automatic, power assist or push buttons to open doors43,44,48e50
 Toilets too low to transfer on/off safely40
 Toilet paper dispenser mounted out of reach49
 Mirror placement too high for wheelchair users36,40,47
 Sink without adequate leg clearance for wheelchair users36,40,49
 Sinks mounted too high for wheelchair users40,47
 Towel dispensers mounted too high40
 No covering of abrasive surfaces and hot water pipes underneath sinks39,40
 No wall mounted grab bars or positioned incorrectly36,40,44
 Dressing area benches incorrect size for safe transfers41,44
 No scales available43,44,50
 Slippery floors44
Professional training and supporty  Lack of staff with specialized training in disability issues36
 Lack of staff with qualifications in exercise or therapeutic exercise36
 Staff either not trained or very few are trained in wheelchair transfers39,43,50
 Lack of employees attending conferences about accessibility43,50
 Small numbers of staff receive information about basic prescription medications and their effect on exercise43,50
Policiesy  Lack of information provided regarding accessibility of the facility48
Programsy  Half of the facilities reported adaptive programming was available (but they did not report further details)40
Swimming pools*  Stairs in path of travel to swimming pool40
 Lacking ramp or lift for pool entry40,44,47
 Lacking a ledge to hold when entering water47
(continued on next page)

Please cite this article in press as: Calder A, et al., The accessibility of fitness centers for people with disabilities: A systematic review, Disability
and Health Journal (2018), https://doi.org/10.1016/j.dhjo.2018.04.002
10 A. Calder et al. / Disability and Health Journal xxx (2018) 1e12

Table 4 (continued )

Accessibility domain Common accessibility issues

 Lack of floatation devices for people with disabilities47

 No power assist doors to access the steam room43,50
 Lack of space to store assistive equipment43,50
Parking*  Insufficient width of parking space for people using mobility aids37
 Lack of adjacent aisles or aisles too narrow37,40,44,48
 Lack of disability parking or insufficient number of designated spaces40,43,44,48,50
 Parking a long way from facility entrance43,47,50
Telephones*  Mounted too high40,43,50
 Telephone cords too short for used by a seated person40
 Lack of amplifying devices for people with hearing impairments43,50
Water fountains*  Lack of knee clearance space for wheelchair users to get close enough36,40,43,50
 Spout too high for seated person40
 Water machines requiring the person to grasp or flip a lever43,50

Key: Domains of physical access *; domains of system access y.

because these domains can create significant barriers to partici-
pation in physical activity at fitness centers.17,25 For example,
studies have shown that fitness center staff lack training in
disability issues and the provision of suitable programs for people
with disabilities.6,21,59 However, evaluating system access domains
in fitness centers is problematic. They create a potential for high
risk of bias because evaluation requires an interview with a fitness
center staff member who could be highly likely to provide the most
socially acceptable answer.
All of the studies in our review used instruments developed
according to the USA ADA compliance legislation. It is particularly
discouraging therefore to observe that decades after the inception
of this legislation, people with disabilities still cannot enjoy
participation in physical activity with dignity and autonomy in an
equitable environment.8,20,59,60 Although the primary idea of leg-
islative standards was to ensure inclusive access,10,61 this review
study has illustrated this is not yet the case. Although fitness cen-
ters built after the inception of the mandatory legislation show
higher levels of accessibility,41,42 people with disabilities continue
to face many accessibility barriers at fitness centers.
One of the leading causes of an inaccessible built environment
likely sits with the individuals who create the compliance legisla-
tion and their lack of understanding of the barriers people with
disabilities encounter.62 This may be because policy and legislation
developers would be predominately able-bodied, leading them to
focus their attention towards the population majority, which is
viewed as an ablest society.22,63 Little thought appears to be given
to how the built environment can provide equitable access for
people with disabilities,64 perhaps because people with disabilities
are perceived to make up a very small part of the population.62
Green25 and Bromley et al.22 also suggest that those individuals
who produce the building legislation continue to work in a medical
model mind set, believing disability is the result of a medical
condition rather than a problem imposed on people via the built
environment and society. Indeed, disabled end-users are rarely
sought to collaborate with legislation makers about inclusive access
in the built environment,62,65 likely resulting in the formation of
sub-standard building legislation regarding accessibility for all of
the population. Rimmer et al.42 and Riley et al.10 support this
notion, observing that the building regulations in the USA are
minimal standards for accessibility compliance. Although people
with disabilities have the right to litigate cases of inaccessibility in a
court of law (thereby forcing a fitness facility to make structural
changes to enable its use), very few choose to do so. People with
disabilities appear to accept that they must adapt to an inaccessible
built environment rather than challenge governmental authorities
and/or legislation.22
Along with sub-standard accessibility legislation, other issues
with building regulations have been identified which have a
cumulative effect and further restrict individuals with disabilities
from participating within the built environment. It has been re-
ported that building legislation is difficult to enforce59 because it is
confusing and ambiguous. Indeed, ambiguity allows building reg-
ulators to interpret the legislative standards in different
ways.25,62,63 Loopholes have also been identified in the compliance
legislation concerning building renovation or reconstruction.66
Adaptation of existing infrastructure is very expensive, and fund-
ing such renovations to ensure inclusive access can be extremely
challenging for building owners.9 Riley et al.10 and Imrie and
Kumar66 point out the loophole in the ADA legislation regarding
renovation whereby building owners of fitness centers undergoing
reconstruction only have to abide by the building laws if it is
financially viable. In addition, building owners often lack awareness
of the accessibility compliance legislation and/or assume building
professionals (developers, designers and builders) will attend to
accessibility issues.16,35,41
The attitudes of building professionals concerning built envi-
ronment accessibility can also be disabling. Like legislation makers,
building professionals often have little insight into disability is-
sues.62 Building developers in particular give little thought past
minimizing the costs of their building projects.62,63 Including
accessibility features are perceived to increase the cost of the build
and detract from the building aesthetics.62,63,67 Attending to
accessibility often appears to be an afterthought,67 a box-ticking
exercise, to ensure the minimal compliance standards are met.
Furthermore, the building designers' (architects) are constrained by
their client's (building developers) budget.62 Interestingly, Imrie's68
research illustrated that architects perceive the human form as an
able-bodied ‘normal’ figure, a geometric shape, or a mechanical
object. The human body therefore is viewed as the ultimate
‘proportioning’ tool for building design rather than a person in all
their forms of embodiment. Building an enabling and inclusive
environment will require policy and legislation makers and build-
ing professionals to develop and extend their knowledge about
disability issues. With improved understanding of disability issues
and collaboration with the end-users of the built environment, an
upgrade from minimal legislative standards of accessibility may
ensue. Adopting the principles of universal design (inclusive barrier
free design for all people) to amend the current building compli-
ance legislation is strongly recommended to achieve equitable ac-
cess.22,26,65 Equitable access could then allow individuals with
disability to participate actively within an inclusive barrier-free
built environment.69
This study has limitations. We acknowledge that the psycho-
metric analysis attributed to the original Downs and Black checklist
is likely to differ because we modified instrument. The instrument
developed by Figoni et al.37 has not undergone psychometric
analysis. All of the studies that have used this tool henceforth to

Please cite this article in press as: Calder A, et al., The accessibility of fitness centers for people with disabilities: A systematic review, Disability
and Health Journal (2018), https://doi.org/10.1016/j.dhjo.2018.04.002
 A. Calder et al. / Disability and Health Journal xxx (2018) 1e12
evaluate fitness centers modified it to suit their study objectives,
thereby introducing heterogeneity across the data. Heterogeneity,
along with poor reporting of accessibility data across the studies
also meant we were unable to perform a meta-analysis.33,70 The
representativeness of fitness centers across the studies possess a
potential limitation to our study. Indeed, personal communication
from two study authors that we contacted revealed that gaining
consent from fitness center managers to evaluate their facility was
challenging. These authors suggested that many fitness center
managers did not consent because they knew their facility would
not be accessible and were therefore fearful of legal recrimination.
If the data did indeed adequately represent the fitness centers in
the study locations, it is likely the accessibility of fitness centers
may be bleaker that what is reported in our review.
Conclusion
Extensive evidence suggests that participation in physical ac-
tivity reduces the risk of secondary conditions and improves health
and well-being for people with disabilities. Fitness centers could be
ideal places for people with disabilities to engage in and meet the
recommended levels of physical activity. However, our review
study shows that physical and system access barriers limit their
ability to do so. Accessibility of fitness centers is unlikely to change
until building compliance legislation is upgraded from minimal
standards. Facilitating change warrants a collaborative approach
where policy and legislation makers, building professionals and
people with disabilities can share their respective knowledge, learn
from each other and together design inclusive and equitable fitness
center environments that can be used by all people.
Disclosures
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors. We (all
authors) have no conflicts of interests to declare.
Appendix A. Supplementary data
Supplementary data related to this article can be found at
https://doi.org/10.1016/j.dhjo.2018.04.002.
References
1. Rimmer J, Chen M, Hsieh K. A conceptual model for identifying, preventing, and
managing secondary conditions in people with disabilities. Phys Ther.
2011;91(12):1728e1739.
2. Santiago M, Coyle C. Leisure-time physical activity and secondary conditions in
women with physical disabilities. Disabil Rehabil. 2004;26:485e494.
3. van der Ploeg H, van der Beek A, van der Woude L, van Mechelen W. Physical
activity for people with a disability: a conceptual model. Sports Med.
2004;34(10):639e649.
4. Martin J. Benefits and barriers to physical activity for individuals with dis-
abilities: a social-relational model of disability perspective. Disabil Rehabil.
2013;35(24):2030e2037.
5. Billinger S, Arena R, Bernhardt J, et al. Physical activity and exercise recom-
mendations for stroke survivors: a statement for healthcare professionals from
the American Heart Association/American Stroke Association. Stroke. 2014:
1e2, 45 on-line.
6. Rolfe D, Yoshida K, Renwick R, Bailey C. Balancing safety and autonomy:
structural and social barriers affecting the exercise participation of women
with disabilities in community recreation and fitness facilities. Qualitative
Research in Sport. Exercise and Health. 2012;4(2):265e283.
7. Rimmer J. Health promotion for people with disabilities: the emerging para-
digm shift from disability prevention to prevention of secondary conditions.
Phys Ther. 1999;79(5):495e502.
8. Mulligan H, Hale L, Whitehead L, Baxter G. Barriers to physical activity for
people with long-term neurological conditions: a review study. Adapt Phys Act
Q (APAQ). 2012;29:243e265.
9. Reklaitiene D, Pozeriene J, Ostaseviciene V. The accessibility for people with
disabilities - new challenge and possibilities for fitness and recreation services
Please cite this article in press as: Calder A, et al., The accessibility of fitness centers for people with disabilities: A systematic review, Disability
and Health Journal (2018), https://doi.org/10.1016/j.dhjo.2018.04.002
11
development. Transform Bus Econ. 2016;15(2B):699e708.
10. Riley B, Rimmer J, Wang E, Schiller W. A conceptual framework for improving
the accessibility of fitness and recreation facilities for people with disabilities.
J Phys Activ Health. 2008;5:158e168.
11. Martin-Ginis K, Latimer-Cheung A, Rimmer J. A systematic review of articles
addressing factors related to physical activity participation among children and
adults with physical disabilities. Health Psychol Rev. 2016;10(4):478e494.
12. Rimmer J, Riley B, Wang E, Rauworth A. Accessibility of health clubs for people
with mobility disabilities and visual impairments. Am J Publ Health.
2005;95(11):2022e2028.
13. Rimmer J, Lai B, Young H. Bending the arc of exercise and recreation technology
toward people with disabilities. Arch Phys Med Rehabil. 2016;97(9 Suppl 3):
S247eS251.
14. Bullock C, Mahon M. Introduction to Recreation Services for People with Dis-
abilities: A Person-centered Approach. second ed. United States: Sagamore;
2001.
15. French D, Hainsworth J. 'There aren't any buses and the swimming pool is
always cold!': obstacles and opportunities in the provision of sport for disabled
people. Manag Leisure. 2001;6:35e49.
16. Lyberger M, Pastore D. Health club facility operators' perceived level of
compliance with the Americans with Disabilities Act. J Sport Manag. 1998;12:
138e145.
17. Rimmer J, Riley B, Wang E, Rauworth A. Development and validation of AIM-
FREE: accessibility instruments measuring fitness and recreation environ-
ments. Disabil Rehabil. 2004;26(18):1087e1095.
18. Rimmer J, Rowland J. Health promotion for people with disabilities: implica-
tions for empowering the person and promoting disability-friendly environ-
ments. Americal Journal of Lifestyle Medicine. 2008;2(5):409e420.
19. Rimmer J, Rowland J. Physical activity for youth with disabilities: a critical need
in an underserved population. Dev Neurorehabil. 2008;11(2):141e148.
20. Rolfe D, Yoshida K, Renwick R, Bailey C. Beyond Barriers: Women Living with Dis-
abilities and Their Participation in Community Exercise Programs; 2007 [cited 2011
10 November]. Available from: http://stargate.uwaterloo.ca/~jzelek/teaching/
syde361/ficcdat2007/Full%20Papers/GOWD/G0052.pdf.
21. Rimmer J. The conspicuous absence of people with disabilities in public fitness
and recreation facilities: lack of interest or lack of access? Am J Health Promot.
2005;19(5):327e329.
22. Bromley R, Matthews D, Thomas C. City centre accessibility for wheelchair
users: the consumer perspective and the planning implications. Cities.
2007;24(3):229e241.
23. Human Rights Commission. Better Design and Buildings for Everyone: Disabled
People's Rights and the Built Environment. Human Rights Commission New
Zealand; 2012. Available from: www.hrc.co.nz/files/4314/2397/6079/web-
Builtenv.pdf.
24. World Health Organization. World Report on Disability. Switzerland. The World
Bank; 2011 [cited 2018 5 March]. Available from: http://www.who.int/
disabilities/world_report/2011/report.pdf.
25. Green R. An introductory theoretical and methodological framework for a
Universal Mobility Index (UMI) to quantify, compare, and longitudinally track
equity of access across the built environment. J Disabil Pol Stud. 2011;21(4):
219e229.
26. Hiss B, Rauworth A. Creating an Accessible Fitness or Wellness Facility; 2007
[cited 2010 25 March]. Available from: www.ncpad.org/get/pdf/hiss_
rauworth_2007.pdf.
27. Ramot A, Lahav Y, Bendel J. Planning accessibility in the old city of Jerusalem.
In: Preiser W, Smith K, eds. Universal Design Handbook. McGraw Hill; 2010,
16.1-1.
28. University of York. PROSPERO: International Prospective Register of Systematic
Reviews. York: University of York; 2016 [cited 2016 18 October]. Available
from: www.crd.york.ac.uk/prospero.
29. Sideri S, Papageorgiou S, Eliades T. Registration in PROSPERO of systematic
review protocols was associated with increased review quality. J Clin Epidemiol.
2018. in press.
30. Stewart L, Moher D, Shekelle P. Why prospective registration of systematic
reviews makes sense. Syst Rev. 2012;(7):1.
31. Zeng X, Zhang Y, Kwong J, et al. The methodological quality of assessment tools
for preclinical and clinical studies, systematic review and meta-analysis, and
clinical practice guideline: a systematic review. J Evid Base Med. 2015;8:2e10.
32. Downs S, Black N. The feasibility of creating a checklist for the assessment of
the methodological quality both of randomised and non-randomised studies of
health care interventions. J Epidemiol Community. 1998;52:377e384.
33. Joanna Briggs Institute The Joanna Briggs Institute reviewers'manual. The
Systematic Review or Prevalence and Incidence Data 2014; 2014. Available from:
www.joannabriggs.org/assets/docs/sumari/ReviewersManual_2014-The-
Systematic-Review-of-Prevalence-and-Incidence-Data_v2.pdf.
34. Arbour-Nicitopoulos K, Martin-Ginis K. Universal accessibility of "accessible"
fitness and recreational facilities for persons with mobility disabilities. Adapt
Phys Act Q (APAQ). 2011;28:1e15.
35. Cardinal B, Spaziani M. ADA compliance and the accessibility of physical ac-
tivity facilities in Western Oregon. Am J Health Promot. 2003;17(3):197e201.
36. Dolbow D, Figoni S. Accommodation of wheelchair-reliant individuals by
community fitness facilities. Spinal Cord. 2015;53:515e519.
37. Figoni S, McClain L, Bell A, Degnan J, Norbury N, Rettle R. Accessibility of fitness
facilities in the Kansas City metropolitan area. Top Spinal Cord Inj Rehabil.
1998;3(3):66e78.
12 A. Calder et al. / Disability and Health Journal xxx (2018) 1e12
38. Gross J, Kroll T, Morris J. Accessibility of fitness centres for people with dis-
abilities in a region in North East Scotland. Publ Health. 2013;127:782e784.
39. Johnson M, Stoelzle H, Finco K, Foss S, Carstens K. ADA compliance and
accessibility of fitness facilities in Western Wisconsin. Top Spinal Cord Inj
Rehabil. 2012;18(4):340e353.
40. Nary D, Froehlich K, White G. Accessibility of fitness facilities for persons with
physical disabilities using wheelchairs. Top Spinal Cord Inj Rehabil. 2000;6(1):
87e98.
41. Pike H, Walker J, Collins J, Hodges J. An investigation of ADA compliance of aquatic
facilities in the North Texas area. Am J Health Promot. 2008;23(2):139e146.
42. Rimmer J, Padalabalanarayanan S, Malone L, Mehta T. Fitness facilities still lack
accessibility for people with disabilities. Disability and Health Journal.
2017;10(2):214e221.
43. Stoelzle H, Sames K. Disabilities Act compliance of fitness facilities in an
American metropolitan area. Int J Ther Rehabil. 2014;21(4):169e175.
44. Aldimkhi B. Accessibility of Health Clubs and Fitness Centres for People with
Disabilities in Kuwait. New Britain: Central Connecticut State University; 2009.
45. Aldimkhi B. An Assessment of the Accessibility of Fitness Facilities for People with
Physical Disabilities in Kuwait. Chicago: University of Illinois at Chicago; 2015.
46. Arbour K. Understanding and Changing Physical Activity Among People with
Spinal Cord Injury: The Role of Psychosocial and Environmental Factors. Canada:
McMaster University; 2008.
47. Koh R. Accessibility of Community Sports and Recreation Facilities for People with
Physical Disabilities in Singapore. Singapore: Nanyang Technological University;
2009.
48. Laiser A. Accessibility of Fitness and Recreation Facilities for Persons with Dis-
abilities in a Metropolitan City. University of Illinois at Chicago; 2012.
49. Langley E. Comparing Accessibility between Two Types of Fitness Centers for
People with Disabilities. United States of America: University of Illinois at Chi-
cago; 2013.
50. Stoelzle H. ADA Compliance of Fitness Facilities in the Twin Cities Metropolitan
Area. United States of America: St Catherine University; 2012.
51. Access Board. Americans with Disabilities Act Accessibility Guidelines (ADAAG)
Checklist for Buildings and Facilities; 1992 [cited 2010 17 April]. Available from:
http://www.access-board.gov/adaag/checklist/a16.html.
52. Calder A, Mulligan H. Measurement properties of instruments that assess in-
clusive access to fitness and recreational sports centres: a systematic review.
Disability and Health. 2014;7(1):26e35.
53. Rimmer J, Riley B. Accessibility Instruments Measuring Fitness and Recreation
Environments: Fitness Centre and Swimming Pool Accessibility. Professional
Version. Chicago: RERC RecTech; 2004-2006.
54. Centers for Disease Control and Prevention. NCHPAD Building Healthy Inclusive
Please cite this article in press as: Calder A, et al., The accessibility of fitness centers for people with disabilities: A systematic review, Disability
and Health Journal (2018), https://doi.org/10.1016/j.dhjo.2018.04.002
View publication stats
Communities: AIMFREE Manuals. University of Alabama; 2018 [cited 2018 24
February]. Available from: https://www.nchpad.org/426/2309/
AIMFREE~Manuals.
55. Terwee C, Mokkink L, van Poppel M, Chinapaw M, van Mechelen W, de Vet H.
Qualitative attributes and measurement properties of physical activity ques-
tionnaires. A checklist. Sports Med. 2010;40(7):525e537.
56. Access Board. Federal Register. Part II: Architectural and Transportation Barriers
Compliance Board. National Archives and Records Administration; 2002.
57. Government of Ontario. Accessibility for Ontarians with Disabilities Act; 2005.
S.O.2005, c.11 Ontario: Queen's Printer 2012-2017 [cited 2017 4 October].
Available from: https://www.ontario.ca/laws/statute/05a11.
58. Building and Construction Authority. The Code on Accessibility in the Built
Environment 2013. Singapore: Building and Construction Authority; 2013.
Available from: https://www.bca.gov.sg/BarrierFree/others/ACCESSIBILITY_
CODE_2013.pdf.
59. McDonald K, Williamson P, Weiss S, Adya M, Blanck P. DBTAC Southeast ADA
Center PAR Research Consortium. The march goes on: community access for
people with disabilities. J Community Psychol. 2015;43(3):348e363.
60. Johnston K, Goodwin D, Leo J. Understanding dignity: experiences of impair-
ment in an exercise facility. Adapt Phys Act Q (APAQ). 2015;32:106e124.
61. Pierce L. Barriers to access: frustrations of people who use a wheelchair for full-
time mobility. Rehabil Nurs. 1998;23(3):120e125.
62. Imrie R, Hall P. Inclusive Design: Designing and Developing Accessible Environ-
ments. London: Span Press; 2001.
63. Imrie R, Hall P. An exploration of disability and the development process. Urban
Stud. 2001;38(2):333e350.
64. Imrie R, Luck R. Designing inclusive environments: rehabilitation the body and
the relevance of universal design. Disabil Rehabil. 2014;36(16):1315e1319.
65. Imrie R. Universalism, universal design and equitable access to the built
environment. Disabil Rehabil. 2012;34(10):873e882.
66. Imrie R, Kumar M. Focusing on disability and access in the built environment.
Disabil Soc. 1998;13(3):357e374.
67. Mulligan K, Calder A, Mulligan H. Inclusive design in architectural practice:
experiential learning of disability in architectural education. Disability and
Health Journal. 2017;11(2):237e242.
68. Imrie R. Architects' conceptions of the human body. Environ Plann Soc Space.
2003;21:47e65.
69. Gray J, Zimmerman J, Rimmer J. Built environment instruments for walkability,
bikeability, and recreation: disability or universal design relevant? Disability &
Health Journal. 2012;5:87e101.
70. Higgins J, Green S, eds. The Cochrane Handbook for Systematic Reviews of In-
terventions. The Cochrane Collaboration; 2011.