Accessibility audit of a health care institute in India: Are people with disabilities being provided their rights?

Abstract

Background

Poor accessibility of health care facilities is a major barrier for differently abled people when seeking health care. Yet, accessibility is rarely audited. This study reports findings from the first assessment of the accessibility in a health care institution of national importance. This study also assumes importance from various laws and legislation that assure equality and rights for people with disabilities (PWDs). Keeping the objectives in mind, this study was performed with an aim to study the situational analysis of the health institution of national importance for assessing the compliance of hospital premises for being disabled friendly, to find any lacunae, and to suggest remedial measures based on the study finding. The aim was to conduct a content and quality review of research into the hospital experiences of PWD and to identify gaps.

Methods

This was a hospital-based cross sectional study done in a period of 30 days. The gap analysis was performed with validated checklist provided by Central Public Works Department, Government of India (CPWD).

Results

Out of total 126 pointers, 45 pointers were found to be totally compliant, 30 pointers were found to be partially compliant, and remaining 51 pointers were found to be not applicable to the hospitals.

Conclusion

This assessment of the accessibility of health care facilities showed that that it is feasible to undertake these audits on a large scale, and these audits should be repeated in other settings. It highlights important gaps in accessibility, increasing the risk of the violation of the right to health of PWDs.

Introduction

A truly inclusive society is defined as a society in which everyone can lead a self-reliant, independent, and dignified life and contribute to the nation's overall development.¹ However, inaccessible physical environments, lack of mobility and transportation, unavailability of assistive devices and technologies, and inaccessible websites and services hinder equal participation of persons with disabilities (PWDs) in mainstream socioeconomic and cultural activities.²

It is observed that PDW require more care, compassion, and empathy besides their specific and unique health care needs. These people apart from usual health care services also have an unmet need for education on health promotion, treatment, rehabilitation, and palliative care.^1,2 Therefore, the provision of adequate facilities for differently abled employees and patients in hospital settings is of utmost importance and needs to be checked and improved accordingly (Fig).

Fig.

Summary of the affirmative responses made by the subjects to the queries/questions raised by the investigators.

The global prevalence of any form of disability is about 15%, of which 110–190 million adults have a significant functional disability.³ This varies significantly between and within the countries. Access to health care in PWD is mainly hindered because of either prohibitive costs or limited availability of appropriate services.³ The prevalence of PDW is 2.21% in India; this transforms to more than 27 million people in terms of absolute numbers in the country.⁴ Consequently, PWD may experience worse access to health care services,^5,6 which is a violation of their rights, as established in the UN convention on the rights of PDW and by the Indian laws.⁷

Unfortunately, the level of awareness regarding the provisions of different services under the act is low even among health care professionals working with PWD in India.⁸

Thus, a need was felt for the creation of barrier-free environments and accessible ecosystems to help PWDs by providing equality of opportunity and an enabling environment. The Rights of Persons With Disabilities Act, 2016 (RPWD act, 2016), which is disability legislation, was passed by the Indian parliament to fulfill its obligation to the United Nations Convention on the RPWD, 2007.⁸ The RPWD act, 2016 mandates that the onus of making a building or service accessible lies on the owner of the building or service (under Section 45) to create a barrier-free environment for PWDs and to make special provisions for the integration of PWDs into the social mainstream. It was observed that dissatisfaction of PDW toward the cardinal points of accessibility transport and information and communications technology is directly related.

Under this act, the objective was to increase accessibility in public-centric buildings such as schools, hospitals, police stations, courts, tourist places, etc.

For the previously mentioned objectives, harmonized guidelines and space standards for the barrier-free built environment for PDW and elderly persons were developed by Central Public Works Department, Government of India (CPWD) with notified standards of structural accessibility (build environment), information and communication accessibility (information and communication technology ecosystem), and transport.⁹ This later became part of the Accessible India Campaign (AIC).¹⁰

Chapter VII of the act, Sections 44 to 46 deal with nondiscrimination in transport on the roads and the built environment. It enjoins on the public institutions to ensure within their economic capacity provision for making their institutions disabled friendly.^7,8

Accessibility issues in PWD have been studied using qualitative interviews and focus group discussions in the past. Individuals with disabilities report several problems and experiences that prevent their right to access basic health care services.¹¹ But an onsite assessment of health facilities for accessibility audit of health facilities has not been studied in India or similar countries abroad.¹¹

The objective of the present study was an onsite assessment of the audit of an institute of national importance for the PWDs using the checklist provided by the AIC.^12,13

The study was based on making the health care setup suitable and accessible to all people from all walks of life. The study was primarily aimed at comparing the health care step up with the standard guidelines recommended for hospitals for being differently abled friendly. This study was a combination of a Checklist Audit and a quantitative (structured questionnaire) where open- and closed-ended questions were asked to various visitors and staff of the hospital, who were differently abled in the challenges faced by them during their visit to the hospital. This mixed method research/study helped in knowing whether the existing facilities provided by tertiary care teaching hospitals were friendly to the differently abled employees and patients. Carrying out a gap analysis also helped in checking for compliance in providing access to services and facilities for differently abled patients and employees in various areas (parking, washrooms, elevators, etc.) of a hospital.

The major objectives of the study were as follows:

• 1.To observe and analyze various disabled-friendly measures being adopted at an institute of national importance, which is a tertiary care teaching institute in Western India.
• 2.To compare the existing facilities with the national guidelines (CPWD) for a barrier-free environment.
• 3.To suggest remedial measures for any deficits (if found) and any suggestions found during the study.

Materials and methods

The study was performed in two parts. Ethical clearance from the institution was taken as well as written informed consent from all the study patients/participants was also obtained prior to the study. In the first part of the study, feedback from the PWDs was collected, and in the second part of the study, the comparison of the facility with a checklist was performed; the research group team was divided into two subteams, namely team ‘A’ and team ‘B’.

Team A

A questionnaire was prepared, which was tested and validated, and the responses were collected from the staff, student's patients, and their relatives who had visited the premises. The sample size was estimated using a power of 90%, significance level of 0.05, and 95% confidence intervals. The sample size calculation can be summarized as that for variable proportion, the level of acceptable error is 5% (0.05), and the extended proportion in the population as per census is 2.2% (P = 2.2%). At 5% type 1 error rate (alpha = 0.05), the sample size is 60. This has been done for two-sided significance. For an interview, all the departments were informed about the study. For patients and external users, registration counters were notified to inform of any physically disabled patient visiting the counter for registration, and after the treatment was provided, they were interviewed by the researchers. Similarly, for internal users, the employment records of all employees were checked for PWD and were interviewed by the team. After all the responses were collected, 60 response sheets were randomly selected by the team for the study. The effective sample size came to 60 participants (36 men and 24 women, ranging in age from 19 to 60 years) with a variety of disabilities selected by team A.

Fifty percent of the participants had physical disabilities, 25% had sensory disabilities, and 21% had a cognitive disability and multiple disabilities, including combinations of physical, communicative, cognitive, psychiatric, and sensory disabilities. Four percent of the participants had congenital disabilities, whereas 20% had acquired disabilities, ranging from 2 months to 34 years from the time of onset. All the participants had disability certificates issued by a competent authority. The questionnaire consisted of open- and closed-ended questions, which were prevalidated by three hospital administrators.

Team B

The existing facilities were checked whether they were fully complying with the standard checklist of CPWD prepared for disabled persons by team B.

To reduce observer bias, blinding was followed by the principal investigator by ensuring that these teams did not interact with each other and were not aware of the individual targets.

After the individual targets were accomplished, the brainstorming sessions were organized by the principal investigators where both the teams interacted, a gap analysis was conducted, and based on the analysis, remedial measures were discussed.

Access audit checklist (from CPWD handbook by AIC) was adopted for the comparison, as this checklist is validated and is also considered a national guideline for building disabled-friendly establishments. The checklist consists of data regarding the appropriate specification and provision of disabled facilities in an institution according to the standard regulations by the authorities. From the result of the checklist gathered in this research, compliance was checked what are the provisions that already exist in the hospital and what should be the provisions that exist but do not meet the standards and what do not exist but need to be included.

The study was conducted from January 2022 to March 2022 (90 days) by the department of hospital administration.

Inclusion criteria

Only those respondents who had a disability certificate issued by a nodal agency were allowed to participate in the study.

Observation and analysis

The analysis of team A was entrusted with the responsibility of taking public and staff opinions about the challenges faced has already been discussed above.

The team observed that PWD (18.9%) needed to visit a hospital significantly more often in the year compared with people without a disability (8.91%; Pearson chi² (1) = 40.0562; P ≤ 0.001). A significant difference was seen in the experiences of hospitalization. These aspects of health care access demonstrated that PWD had a significantly higher unmet need for health care compared with people without a disability.

A total of 60 respondents were interviewed. Out of which, 3.3% were consulting doctors and residents, paramedical/supporting staff were 10.0%, medical and nursing students were 6.7%, and patients constituted approximately 80.0% of the sample size. Due care was taken to seek inputs from all members of the society using the hospital facility to have a fair idea of the challenges/issues faced by people. Out of the interviewed respondents, a total of 20 participants (66.7%) suggested that they were satisfied with the facilities; however, all admitted that there was further scope for improvement. The bifurcation of those who had suggested further improvement of facilities was further divided under various subheads such as a need for infrastructural improvements, and the responses taken were categorized and classified for further understanding of the lacunae faced by differently abled people.

Twenty respondents (63.3%) informed that the infrastructure is adequate in the majority of the areas; however, it was also suggested by respondents that some areas such as washrooms could be improved from the perspective of the limitations of disabled people or wayfinding in the hospital.

Fifty percent of the respondents answered that they were able to complete their usual duties without any assistance, as the facilities were apt and adequate for differently abled people. Of the remaining 50% of respondents, 43.3% answered that they needed assistance to complete some of their tasks only. And only the remaining 7.7% of respondents answered that they were not able to complete their duties because of the challenges they face due to being differently abled. This also may be attributed to those patients who were recently operated on for amputation, leading to disability in the respondents. It was found that 53.3% of differently abled respondents managed to visit the hospital on their own. 23.3% managed to visit a hospital with some assistance, and the other 23.3% of people were dependent on their known ones. Forty-six percent of respondents were satisfied with the telemedicine facility being provided by the hospital.

Of all the differently abled respondents, it was found that 70.0% had used hospital parking, as it was accessible to them. 23.3% of respondents said they had not used the parking yet, but they might need the same in the future. 6.7% of respondents had never used the parking.

Forty percent of the respondents did not find any special seating arrangements for differently abled, which they could use while waiting. 33.3% have not seen any such seating arrangement to date. 13.3% had found that the provision was adequate, and the other 13.3% of the respondents were not sure to answer.

Fifty two (86.7%) of the respondents said that they use the same entrance path because it did not have stairs; hence, the provision was friendly for them. 13.3% of differently abled respondents said there is no audio-visual help at the entrance, and they require assistance.

Thirty six (60.0%) of the participants of the survey agreed that the hospital's entrance path had adequate space for wheelchair users, and it is friendly for the visually impaired. 23.3% did not agree with the above statement, and 16.7% were not sure whether the entrance path is disabled friendly.

Fifty two (86.7%) of the differently abled respondents agreed that the ramps provided in the hospital are good enough to use. 13.3% of people are not able to decipher about it; they might not have accessed it.

Fifty two (86.7%) of the respondents said there is signage provided for the ease of differently abled people, but still there are many areas where the hospital has not provided any signage, and there is a need for appropriate signage. 10.0% of the respondents disagreed with the availability of signages. Of all respondents, only 4.3% agree that there are enough signages for the convenience of differently abled in the hospital.

Thirty two (53.3%) of the respondents said that the hospital lobby had adequate space for wheelchair users. 43.3% of the respondents were not wheelchair users, and they were either visually impaired or had neurological/cognitive impairment. 3.4% of the respondents did not find adequate space in the lobby; this can be attributed to the heavy crowd.

Thirty six (60.0%) of the differently abled participants of the survey denied that the reception desk or counter was lowered for the ease of wheelchair users. 6.7% of the respondents said they received enough help as per their requirements.

Fifty (83.3%) of the respondents said that the floor finishing in the hospital is slip resistant. 16.7% of the respondents were not sure of slip-resistant floors.

Forty two (70.0%) of the total respondents could access the canteen or mess services in the hospital despite their disability challenge. 20.0% did not require to use this facility, and 10.0% found it difficult to access.

Of the total participants of the survey, 66.7% disagreed that there was an accessible toilet for differently abled people. 16.7% were not sure about it, as it might be possible that they did not require disabled-friendly toilets owing to having upper limb locomotors disability or audio-visual impairment. Other 16.7% said they could access the toilets without any hassle.

According to the responses to the survey and the observation made, it was found that there is no provision of assistance alarm in the toilets for differently abled people.

It was found that out of the total participants, 66.7% of respondents found that there is no provision in hospitals for emergency evacuation of the disabled people. 33.3% of the respondents are not sure whether there is any such provision.

Most of respondents had said that the staff is not well trained to assist differently abled patients or they were not sure about it.

Team B – Apple to apple comparison of an existing facility with national guidelines, AIC (accessible India campaign checklist released by the Department of Empowerment of Persons With Disabilities Government of India).^2,9

The comparison of the facilities suggested as per their checklist and on-ground facilities was done, and the following comparison chart was observed.

Table 1 presents the comparison of compliant/noncompliant pointers.

Table 1.

Comparison of compliant/noncompliant pointers (on comparison with the CPWD Audit checklist).

As observed, out of a total of 126 pointers, 45 pointers were found to be compliant, 30 pointers were found to be partially compliant, and 51 pointers were found to not apply to the hospitals. The pointers were grouped under three major heads as shown in Table 1, Table 2.

Table 2.

Classification of pointers under the major three groups (BEA, TSA, ICESA).

Pointers subgroups	Total	Compliant	Not applicable
Built Environment Accessibility (BEA)	69	40	29
Transportation System Accessibility (TSA)	29	21	8
Information and Communication Eco-System Accessibility (ICESA)	28	14	14
	126	75	51

Table 2 provides classification of pointers under subgroups.

• •Built environment accessibility (BEA)

(Of 69 pointers in BEA, 40 were found to be compliant [fully and partially], and 29 pointers were found to be noncompliant or not applicable).

• •Transportation system accessibility (TSA)

(Of 29 pointers in TSA, 21 were found to be compliant [fully and partially], and eight pointers were found to be noncompliant or not applicable).

• •Information and communication eco-system accessibility (ICESA)

(Of 28 pointers in ICESA, 14 were found to be compliant [fully and partially], and 14 pointers were found to be noncompliant or not applicable).

On the basis of the above data and observations suggested by team A and team B, a gap analysis was done, and the following feedback was suggested.

Observations of the gap analysis

• •Ramps should be provided in the lecture halls, and toilets should be made disabled friendly.
• •Staff needs to be trained well to handle PDW effectively with good communication skills.
• •Toilets should be accessible to everyone and should be disabled friendly. It is also suggested that one toilet in each toilet complex can be modified as a toilet for PWD which has a bar, belt, and an alarm bell.
• •There should be visual instructions and illuminated signage in important areas of the hospital, which are frequently used by patients, for people with audio-visual disability.
• •The staff needs proper training and soft skills upgradation to assist the differently abled patients.
• •Audio and visual provisions for wayfinding should be made in the hospital.
• •Emergency alarms with flashlights can be provided in toilets.
• •The slope and floor of the ramp can be made wheelchair friendly.
• •Contrasting colors on stairs are required for helping those with visual deformities.
• •Facilities for the visually impaired are not enough in toilets, entrances, and other important places.
• •Provision of audio and visual announcements for ease in finding directions and instructions.
• •Drinking water taps are not at an adequate level for wheelchair-bound patients.
• •Brochures and some information about the hospital or the patient documents should also be available in braille for the visually impaired patients.
• •Training for the staff is required to evacuate disabled patients in the time of emergency.

Discussion

This study gives the current situation about disability friendliness of a 960-bedded institution of national importance. Many countries are now working toward ensuring universal health coverage for their populations. Universal health care is a value addition if it reduces catastrophic health expenditure and ensures equity and access to all segments of the population. PDW require the same range of health services for the diagnosis and treatment of disease or the promotion of health as PDW.^14,15 To the best of our knowledge, no study has been done in the north India on this magnitude; there are few studies by Nischith et al.¹⁶ and Gudlavalleti et al.¹⁴ done in southern India where it was found an interesting dichotomy as PDW report using more health services, especially in-patient care while also stating that they do not receive care when they need it. A similar observation was found in our study as well; this emphasizes that PWD have a significant unmet need for health services even though their utilization of hospital services may be higher. PWD also expressed concerns regarding the behavior of the staff at the hospital and health facilities, and similarity was also found in a previous study done by Gudlavalleti et al.¹⁴ This reveals a huge gap in the expectations of PWD and the actual provision of services. Efforts will need to be made to bridge this gap. The results of this facility-based audit identified that in many places, the institute is not geared up for the special needs and requirements of PWD. AIC audit checklist is elaborative and has multiple points, but most of them do not apply to many tertiary care health setups.

Conclusions

This assessment of the accessibility of health care facilities shows that it is feasible to undertake these audits on a large scale, and these audits should be repeated in other settings. It highlights important gaps in accessibility, increasing the risk of the violation of the right to health of PWD. Future work can focus on updating accessibility audits in other institutes by planning multicentric studies and conducting audits in other settings. There is also a need to develop trial approaches to overcoming the gaps identified in the audits, whether through incentives or by the legislature (e.g., fines).

Limitations of the study

The present study is limited to one city where the institute of national importance is located; hence, the findings cannot be generalized to the entire country. The PWD is demonstrated by records and the identification of the key informants supported by a medically trained team; however, many patients visiting the hospital without the legalized document were excluded from the study. In a small proportion of PWD, a proxy respondent provided the answers, as the person with a disability was unable to respond on his/her own. There might be a difference in perception of a PWD compared with the proxy.

Disclosure of competing interest

The authors have none to declare.