The aging of the US population has been accompanied by an increase in the number of people with mobility-related disabilities, many of whom are pet owners.1 For example, the 2017–2018 National Pet Owners Survey estimated that 68% of US households owned a pet, and the US Census Bureau estimated that in 2017, approximately 21 million Americans had a recognized mobility-related disability.2,3 Assuming that individuals with mobility-related disabilities are as likely to own pets as are individuals without such disabilities, this means there are potentially 14 million (0.68 × 21 million) American pet owners with mobility-related disabilities. In addition, rates of disability increase with age, and by 2030, 1 in 5 residents in the United States will be of retirement age.4
Challenges faced by individuals with mobility-related disabilities include maneuvering through public spaces with a wheelchair, motorized scooter, walker, cane, or brace; maintaining balance on unsteady surfaces; opening heavy doors with limited strength; and operating doorknobs and faucets with limited dexterity. The projected growth in the number of individuals with mobility-related disabilities should encourage businesses, including veterinary practices, to more carefully consider how they can best accommodate affected individuals.
The ADA, which was passed in 1990, provides specific regulations to improve accessibility of public facilities for people with various disabilities, with the goal of prohibiting discrimination.5 All veterinary hospitals are required to follow ADA regulations. The regulations for university-based veterinary teaching hospitals (covered under Title II: State and Local Governments) differ from those for private-practice veterinary hospitals (covered under Title III: Public Accommodations).5 Still, no facilities are considered “grandfathered in” or exempt from ADA regulations, and all businesses serving the public are “required to remove architectural barriers when it is readily achievable to do so (accomplishable without much difficulty or expense), and all future alterations and construction must comply with ADA regulations.”6
For veterinary practices, accessibility barriers might discourage pet owners with mobility-related disorders from obtaining regular preventive care for their pets or prevent them from seeking veterinary care when their pets become ill. Additionally, accessibility challenges might discourage a pet owner from adopting another pet after a loss, even though pet ownership provides beneficial companionship as well as psychological and physiological benefits through the human-animal bond.7,8
To our knowledge, little is known about the types or prevalence of accessibility barriers in veterinary hospitals. Therefore, we set out to evaluate accessibility of veterinary hospitals and provide practical recommendations for improvement. The first part of this project focused on establishing baseline data on veterinarians’ awareness of accessibility barriers in their hospitals by distributing a survey online and at a local veterinary conference. The second part consisted of visiting and evaluating 10 veterinary practices in northeast Kansas to determine the current accessibility of veterinary hospitals for clients with mobility-related disabilities. The third part concentrated on providing specific suggestions for overcoming barriers to improve accessibility.
Veterinarian Accessibility Survey
To assess veterinarians’ awareness of accessibility barriers in their hospitals, a 20-question survey was created. The survey was reviewed and approved by the Kansas State University Institutional Review Board and distributed through the Kansas Veterinary Medical Association email list and at the 2018 Kansas State Annual Conference for Veterinarians. The only inclusion criterion was that participants had to be practicing veterinarians.
Fifty-nine veterinarians completed the survey. Of these, 58 (98%) reported having clients with some type of disability, with 55 of 59 (93%) having clients with mobility-related disabilities, 47 of 59 (80%) having clients with hearing disabilities, 44 of 59 (75%) having clients with cognitive disabilities, 31 of 59 (53%) having clients with visual disabilities, and 6 of 59 (10%) having clients with other disabilities (eg, speech impairment). Fifty-four of the 58 (93%) veterinarians were receptive to learning how to improve accessibility for their clients, and only 22 of 58 (38%) reported being comfortable with their current knowledge of ADA requirements for accessibility and usability.
Thirty of 59 (51%) responding veterinarians reported being aware of specific areas within their hospitals that clients may have difficulty using. The most commonly reported areas were heavy or nonautomatic front doors, small examination rooms, and inaccessible restrooms. Additionally, 39 of 54 (72%) respondents believed they had a designated parking space that was ≥ 16 feet wide, 49 of 56 (88%) reported having a step-free entrance, and 16 of 53 (30%) believed that at least a portion of their reception counter was ≤ 36 inches from the floor to allow for optimal client-staff interactions. Nineteen of 56 (34%) veterinarians reported having made accessibility improvements in their hospitals to better accommodate clients. When asked about barriers encountered in improving accessibility for clients, 21 of 59 (36%) reported expense, 15 (25%) reported lack of space, and 12 (20%) reported lack of knowledge about what is required, recommended, or helpful.
Veterinary Practice Accessibility Evaluations
To understand the types and prevalence of accessibility barriers in veterinary hospitals, 2 authors (EGW and KK) underwent training in use of the CHEC, which was developed by a team at Washington University in St Louis to evaluate how usable public spaces are for people with disabilities.9 The CHEC is not a comprehensive ADA assessment but rather a tool to raise awareness of key concerns identified by individuals with mobility-related disabilities.9
After becoming CHEC certified, the 2 authors contacted owners of veterinary practices in northeast Kansas to determine whether they would participate in a CHEC visit. All nonmobile veterinary practices were considered eligible for inclusion (eg any practice with a hospital building). Owners were given assurances of anonymity. In addition, all owners were given the option of a second visit and reevaluation with updated scoring if changes were made in response to the first visit.
For the CHEC evaluation, 46 practice features were assessed, categorized into 3 sections: entrance, building lobby and interior, and restrooms. An overall score was assigned along with individual scores for each of the 3 sections, with a score of 100 representing the highest score. In addition to the scores, an extensive individualized report was created for each practice that described strengths and offered short- and long-term suggestions to improve accessibility for clients with mobility-related disabilities; these suggestions were discussed with the owner during a follow-up telephone call with one of the authors (KK).
Ten practices consented to undergo a CHEC visit. All 10 were located within 100 miles of Kansas State University; 9 were in suburban areas, and 1 was in a rural area. Eight practices were small animal, 1 was large animal, and 1 was mixed animal.
The highest mean section score was for the building lobby and interior section (mean, 91; median, 85; range, 74 to 100), followed by the entrance section (mean, 89; median, 88; range, 69 to 100) and the restrooms section (mean, 54; median, 52; range, 22 to 100). Mean overall score was 84 (median, 78; range, 69 to 97). Although each hospital was unique, certain accessibility barriers were seen in multiple veterinary hospitals.
Veterinary hospital entrances
Seven of the 10 veterinary hospitals had appropriate, sign-designated, van-accessible parking spaces that, in conjunction with an adjacent access aisle, measured ≥ 16 feet wide (ADA standard10,11 502.2; Figure 1). Having parking spaces this wide allows clients using wheelchairs or other mobility devices to safely exit their vehicle and enter the hospital with minimal difficulty.
Photograph of a sign-designated (short arrow), van-accessible parking space near a veterinary hospital entrance. To meet the ADA standard, the parking space and adjacent access aisle must be ≥ 16 feet wide (long arrow).
Citation: Journal of the American Veterinary Medical Association 256, 3; 10.2460/javma.256.3.333
On the other hand, 3 of the 10 hospitals had gravel parking lots (ADA standard10,11 302.1). Loose gravel in parking lots can be a safety and fall hazard for people with mobility concerns and can cause increased wear and tear on wheelchair tires. Therefore, hospitals should consider paving their entire parking lot or at least a path from several of the closest parking spots to the hospital entrance.
Nine of the 10 hospitals had a clear entrance route free from level changes or with a ramp to overcome a level change. Curb cuts can be added when a change in level exists and can be beneficial both for clients with disabilities and for maneuvering gurneys carrying large patients (ADA standard10,11 402). A sign clearly indicating the route to the most accessible entrance is an easy addition, if applicable (ADA standard10,11 216.6). For added customer service, signs can be added at accessible parking spaces giving clients a telephone number to call for assistance getting themselves or their pets into the hospital. For clients known to have a mobility disability, a similar message can be provided when the receptionist confirms the client's appointment.
Nine of the 10 veterinary hospitals had appropriately wide entrance doors (≥ 32 inches measured between the face of the door and the door stop when the door is open 90°; ADA standard10,11 404.2.3). However, 4 of 10 had a high entrance threshold (≥ 0.25 inch in vertical height; ADA standard10,11 404.2.5) that could be challenging to step or wheel over safely, especially while holding a dog leash or cat carrier. For doors with a high threshold or that require a level change, installing an aluminum or rubber threshold ramp could be a cheap and easy solution to provide additional safety and ease when entering the building (Figure 2). These ramps can be purchased online or at home improvement stores. In addition, to improve accessibility for individuals who use a mobility device, there should be at least 18 inches of free space on the handle side of the door to allow for maneuvering clearance (ADA standard10,11 404.2.4).
Photographs of a veterinary hospital entrance showing a high (≥ 0.25 inch in vertical height) threshold (A) that could be challenging to step or wheel over safely, especially while holding a dog leash or cat carrier. The simple addition of a threshold ramp (B) improves accessibility.
Citation: Journal of the American Veterinary Medical Association 256, 3; 10.2460/javma.256.3.333
Six of the 10 veterinary hospitals had heavy entrance doors. Notably, having automatic or lightweight entrance doors is not required under the ADA regulations. However, heavy entrance doors decrease accessibility for clients with mobility-related disabilities. Therefore, it would be ideal for veterinary hospitals to install automatic entrance doors. If this is not possible, having a receptionist hold the door open for clients can be a helpful alternative.
Veterinary hospital lobbies and interiors
In 9 of the 10 hospitals, the reception desk did not have a portion that was accessible for individuals who use a wheelchair or scooter or are of short stature. High reception desks can be less welcoming for these individuals and can prevent effective, eye-level communication. Having a 36-inch-wide portion of the reception desk that is ≤ 36 inches from the floor is most accommodating (ADA standard10,11 904.4.1; Figure 3).
Photograph of a veterinary hospital reception desk. Notice that a portion of the desk is lower (≤ 36 inches from the floor) to allow effective, eye-level communication with individuals who use a wheelchair or scooter or are of short stature.
Citation: Journal of the American Veterinary Medical Association 256, 3; 10.2460/javma.256.3.333
The seating arrangement of a hospital lobby can be important for accessibility. Eight of the 10 veterinary hospitals had inviting lobbies with furniture arrangements that allowed space for a wheelchair to fit in a row of chairs. Providing an open location (36 inches wide Ă— 48 inches deep) for a wheelchair to fit among lobby furniture can increase client comfort and inclusion and improve hospital lobby traffic flow (ADA standard10,11 802.1.2; Figure 4).
Photographs of a veterinary hospital lobby illustrating how the lobby seating arrangement can affect accessibility for individuals who use a wheelchair. If no open space is left, a person in a wheelchair might be in the way of other clients and patients (A). Providing an open location (36 inches wide Ă— 48 inches deep) for a wheelchair to fit in line with the lobby furniture can improve client comfort and inclusion and hospital lobby traffic flow (B).
Citation: Journal of the American Veterinary Medical Association 256, 3; 10.2460/javma.256.3.333
Nine of the 10 hospitals had adequately wide (≥ 36 inches wide), unobstructed interior hallways and adequately wide (≥ 32 inches wide) interior doorways. Keeping floors clear of boxes or product displays and minimizing rugs that can be trip hazards are also helpful tips for improving safety.
Four of the 10 hospitals had interior doors (eg, examination room doors) that were heavy or had handles that might be difficult for some individuals to operate. Ideally, a door should be able to be opened in either direction with a maximum of 5 lb of force, which is approximately the force that can be exerted with 2 fingers (ADA standard10,11 404.2.9). To allow maximal usability for people with limited hand dexterity, door hardware should be operable with a single closed fist, without requiring tight grasping, pinching, or twisting of the wrist (ADA standard10,11 404.2.7). In general, lever-type handles are preferred over round door knobs (Figure 5). If replacing doors or doorknobs is not in the budget, an easy solution is to encourage veterinary staff to hold doors open for clients as they move throughout the hospital.
Photographs of a lever handle that can be operated with a single closed fist, improving accessibility (A), compared with a doorknob that requires grasping with the hand and twisting of the wrist (B).
Citation: Journal of the American Veterinary Medical Association 256, 3; 10.2460/javma.256.3.333
Veterinary hospital restrooms
Nine of the 10 veterinary hospitals that were evaluated had a restroom that was considered public and available for clients to use. Five of these 9 hospitals had restroom or stall doors that were narrower than the recommended ≥ 32 inches wide (ADA standard10,11 404.2.3) and did not have enough space to allow a wheelchair to be maneuvered in the restroom or stall. A narrow doorway might prevent individuals with mobility-related disabilities from entering or may result in them injuring their hands while attempting to enter. Even if the ideal width cannot be attained, any improvement in doorway width could be beneficial for at least some clients. Construction to rebuild a doorframe might be unrealistic, but installing offset hinges could provide an additional 1 to 2 inches in width (Figure 6).12
Photographs illustrating how use of an offset hinge (top row) can increase the width of a doorway by 1 to 2 inches (with the door open 90°), compared with the width when a conventional hinge is used (bottom row).
Citation: Journal of the American Veterinary Medical Association 256, 3; 10.2460/javma.256.3.333
Although the CHEC usability guidelines suggest bathroom stalls should measure at least 36 × 69 inches, the ADA requires 56 × 60 inches (ADA standard10,11 604.3) to allow plenty of space for a person who uses a mobility device to move around the door and access the toilet. For maximal usability of the sink and amenities, the bathroom should have open space allowing a circle ≥ 60 inches in diameter or a T-shaped space within a 60 × 60-inch square for a person using a wheelchair to turn around (ADA standards10,11 606.2 and 304.3).
Seven of 9 veterinary hospitals had 2 sturdily mounted grab bars in the restroom to help with safe transfers. Ideally, these grab bars should be 42 inches long on the side wall and 36 inches long on the rear wall (ADA standard10,11 604.5). All 9 hospitals had handles or latches on the bathroom doors that were located ≤ 48 inches from the floor. However, 4 hospitals did not have restroom features such as soap dispensers, paper towel holders, or hand dryers at an accessible height (≤ 48 inches from the floor; ADA standard10,11 308.2 and 404.2.7). In addition, 4 hospitals had vanity-style sinks that were not considered accessible. Although vanity-style sinks provide space for storage, they do not allow knee clearance space for people using wheelchairs and are therefore discouraged. The CHEC recommends a clear space under the sink of at least 29 inches, measured from the floor, for knee clearance; the ADA standards require 27 inches (ADA standard10,11 306.3).
Finally, only 6 of the 9 hospitals had restroom sink faucets that could be operated with a closed fist. Installing faucet handles that can be turned on and off with a closed fist can improve usability for clients with limited hand dexterity (ADA standard10,11 606.4).
Improving Accessibility Awareness and Encouraging Change
Of the 59 veterinarians who responded to our survey, 55 (93%) reported having clients with mobility-related disabilities. According to a CDC study,13 mobility-related disabilities are the most common type (13.7% of all disabilities), followed by cognitive disabilities (10.8%), disabilities associated with independent living (6.8%), hearing disabilities (5.9%), visual disabilities (4.6%), and disabilities related with self-care (3.7%). Veterinary practices, therefore, would find it in their own interests and in the interests of their clients to ensure that their hospitals are accessible.
The CHEC that we used in our project has been previously used to evaluate restaurants, physician offices, dental offices, and other businesses; to our knowledge, however, this was the first time it has been used to evaluate veterinary hospitals. We found that practice owners were receptive to the findings and that follow-up telephone discussions with the owners were overwhelmingly positive. Many practice owners stated that they had already made adjustments as suggested to improve accessibility, and some were considering the logistics of additional changes. One practice owner was in the process of planning a major hospital renovation and was, therefore, familiar with the ADA guidelines; nonetheless, she was grateful for the additional accessibility feedback and suggestions. In fact, during a second visit, this hospital's restroom CHEC score had improved from 41 to 100. Additional changes to participating veterinary hospitals since these visits included adding signage to designate accessible parking spaces, creating a curb cut from the parking lot, purchasing a temporary threshold ramp, scheduling placement of an automatic door, and initiating plans to renovate the hospital's restroom to improve accessibility.
Although we visited only 10 veterinary hospitals in a relatively small part of Kansas, our findings will likely be helpful to veterinarians throughout the country. The text of the ADA standards10,11 is quite extensive and can be confusing, but guidelines exist to help small business owners navigate the ADA and understand the tax incentives for increasing accessibility.14,15 Still, motivated veterinarians can perform a self-evaluation of their hospitals for accessibility and usability with one of the various checklists available online.6 As a quick resource for busy veterinarians, we also developed a flyer listing 10 ways to maximize accessibility for clients with mobility-related disorders (Figure 7). Although not all-inclusive, the list includes most of the accessibility barriers clients could encounter during a veterinary hospital visit and provides suggestions on how to maximize accessibility for clients with disabilities. Additional communication tools can help receptionists and staff optimize customer service with people with disabilities, such as using people-first language.16,17 Thinking ahead about which examination room might best suit clients with disabilities and remaining flexible when scheduling appointments for clients with disabilities who rely on various modes of public transportation are ways to promote accessibility. In addition, it is always acceptable to ask clients whether there are additional accommodations that might create a more welcoming environment.
Flyer developed by the authors listing 10 ways to maximize accessibility of veterinary hospitals for clients with mobility-related disabilities.
Citation: Journal of the American Veterinary Medical Association 256, 3; 10.2460/javma.256.3.333
Given our findings, we believe information on disability awareness should be incorporated into the veterinary curriculum and continuing education programs. Many colleges of veterinary medicine offer a practice management course that covers business aspects of veterinary practice, and it seems this would be an ideal course during which to present information on the basics of serving clients with disabilities, how to make veterinary hospitals optimally usable for clients, and relevant ADA regulations and compliance; Kansas State University has introduced this into the veterinary curriculum for the 2019–2020 school year. Similar lectures, workshops, and roundtable discussions could be offered at continuing education conferences to keep this important issue at the forefront. Finally, veterinarians can continue to promote awareness of disabilities, diversity, and inclusion and ways to improve service to all clients through various publications.18–20
Because the number of clients with mobility-related disabilities is expected to grow over the next several decades, it is important for veterinarians to be attentive to barriers in their hospitals and to make improvements in accessibility to provide optimal service. Through education, veterinarians can become more cognizant of potential barriers to people with mobility-related disabilities and can make plans for modifications to remove those barriers and improve access for all.
Acknowledgments
The CHEC training and evaluations were supported by Grant Cooperative Agreement No. DD000006 from the CDC's National Center on Birth Defects and Developmental Disabilities, Disability Health Branch.
The authors thank Ray Petty, Technical Assistance and Capacity Building Coordinator at the Great Plains ADA Center, Columbia, Mo, who provided valuable guidance on ADA regulations, and Megen Devine from Washington University School of Medicine.
ABBREVIATIONS
| ADA | Americans with Disabilities Act |
| CHEC | Community Health Environment Checklist |
References
1. Roberts AW, Ogunwole SU, Blakeslee L, et al. The population 65 years and older in the United States: 2016, American Survey Reports, ACS-38. Washington, DC: US Census Bureau, 2018. Available at: www.census.gov/content/dam/Census/library/publications/2018/acs/ACS-38.pdf. Accessed May 27, 2019.
2. Insurance Information Institute. Pet statistics. Available at: www.iii.org/fact-statistic/facts-statistics-pet-statistics. Accessed May 27, 2019.
3. US Census Bureau. Allocation of ambulatory difficulty for the civilian noninstitutionalized population 5 years and older. Available at: http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_17_5YR_B99185&prod Type=table. Accessed Jun 27, 2019
4. US Census Bureau. Older people projected to outnumber children for first time in US history. Available at: www.census.gov/newsroom/press-releases/2018/cb18-41-population-projections.html. Accessed May 27, 2019.
5. American Disabilities Act National Network. Available at: adata.org/learn-about-ada. Accessed May 27, 2019.
6. Institute for Human Centered Design. ADA checklist for existing facilities. Available at: www.adachecklist.org/doc/fullchecklist/ada-checklist.pdf. Accessed May 27, 2019.
7. Beetz A, Uvnas-Moberg K, Julius H, et al. Psychosocial and psychophysiological effects of human-animal interactions: the possible role of oxytocin. Front Psychol 2012;3:234.
8. Handlin L, Nilsson A, Ejdeback M, et al. Associations between the psychological characteristics of the human-dog relationship and oxytocin and cortisol levels. Anthrozoos 2012;25:215–228.
9. University of Kansas Research and Training Center on Independent Living. The Community Health Environment Checklist (CHEC): map the usability of sites in your community. Available at: rtcil.org/chec. Accessed Apr 25, 2019.
10. US Access Board. Guide to the ADA standards. Available at: www.access-board.gov/guidelines-and-standards/buildings-and-sites/about-the-ada-standards/guide-to-the-ada-standards. Accessed Sep 24, 2019.
11. 2010 ADA Standards for Accessible Design. Available at: www.ada.gov/regs2010/2010ADAStandards/2010ADAstandards.htm. Accessed Oct 8, 2019.
12. Eakes J. Accessibility offset hinges. Available at: www.youtube.com/watch?v=nIXhcJJXlto. Accessed Apr 26, 2019.
13. Okoro CA, Hollis N, Cyrus A, et al. Prevalence of disabilities and health care access by disability status and type among adults—United States, 2016. MMWR Morb Mortal Wkly Rep 2018;67:882–887.
14. US Department of Justice. ADA update: a primer for small business. Available at: www.ada.gov/regs2010/smallbusiness/smallbusprimer2010.pdf. Accessed Oct 8, 2019.
15. IRS tax credits and deductions. Available at: www.ada.gov/taxcred.htm. Accessed Oct 8, 2019.
16. Words Y, Image O. KU Research and Training Center on Independent Living. 2013. Available at: rtcil.org/sites/rtcil.drupal.ku.edu/files/images/general/Your%20Words%2C%20Our%20Image%208th%20Ed.pdf. Accessed May 27, 2019.
17. ADA quick tips. Available at: adata.org/factsheet/quicktips-customer-service. Accessed Oct 8, 2019.
18. Larkin M. Attention given to disabilities at diversity summit. J Am Vet Med Assoc 2016;249:250–271.
19. Larkin M. Handle with care: how veterinary teams can factor in the needs of the elderly, those with disabilities. J Am Vet Med Assoc 2018;253:822–824.
20. Larkin M. Deaf veterinarians pave their own way: schooling, first jobs proved difficult but achievable. J Am Vet Med Assoc 2009;235:1120–1123.
