DEVELOPING TOILETS of the FUTURE for DISABLED and ELDERLY PEOPLE Assistive Technology Research Series

A FRIENDLY REST ROOM: DEVELOPING TOILETS OF THE FUTURE FOR DISABLED AND ELDERLY PEOPLE Assistive Technology Research Series

The Assistive Technology Research Series (ATR) aims to disseminate and archive assistive technology research summaries widely through publishing proceedings, monographs, and edited collective works. The series aspires to become the primary world-wide source of information in assistive technology research, through publishing state-of-the-science material across all continents. ATR defines assistive technology (AT) as any tool, equipment, system, or service designed to help develop, maintain or improve a person with a disability to function in all aspects of his or her life. Assistive technology helps people of all ages who may have a broad range of disabilities or limitations. The ATR series will accept manuscripts and proposals for a wide range of relevant topics.

Editor-in-Chief : Rory A. Cooper

Editorial Board: Angel Gil Agudo, Geoff Bardsley, Robert Bingham, Christian Buhler, H.S. Chhabra, Gerry Craddock, Jin Dewen, Sten Ekman, Martin Ferguson, Shirley G. Fitzgerald, Antal (Tony) Huba, Jeffrey Jutai, Kiyomi Matsuo, Mounir Mokhtari, Johan Molenbroek, Hisaichi Ohnabe, Paul F. Pasquina, Marcia Scherer, Nigel Shapcott, Richard Simpson, Ronaldo de Souza Moraes Jr., Thijs Soede, Pierre Soto, Eric Tam, Osamu Tanaka, Julian Verkaaik, Howard Wactlar, Hans-Werner Wahl, Lloyd Walker, Jue Wang, Brian Woods, Lucas van der Woude, Yusheng Yang

Volume 27

Recently published in this series

Vol. 26. L.H.V. van der Woude, F. Hoekstra, S. de Groot, K.E. Bijker, R. Dekker, P.C.T. van Aanholt, F.J. Hettinga, T.W.J. Janssen and J.H.P. Houdijk (Eds.), Rehabilitation: Mobility, Exercise and Sports – 4th International State-of-the-Art Congress Vol. 25. P.L. Emiliani, L. Burzagli, A. Como, F. Gabbanini and A.-L. Salminen (Eds.), Assistive Technology from Adapted Equipment to Inclusive Environments – AAATE 2009 Vol. 24. P. Topo and B. Östlund (Eds.), Dementia, Design and Technology – Time to Get Involved Vol. 23. M. Cabrera and N. Malanowski (Eds.), Information and Communication Technologies for Active Ageing – Opportunities and Challenges for the European Union Vol. 22. W.C. Mann (Ed.), Aging, Disability and Independence – Selected Papers from the 4th International Conference on Aging, Disability and Independence (2008) Vol. 21. A. Mihailidis, J. Boger, H. Kautz and L. Normie (Eds.), Technology and Aging – Selected Papers from the 2007 International Conference on Technology and Aging

ISSN 1383-813X (print) ISSN 1879-8071 (online)

A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People

Edited by Johan F.M. Molenbroek Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands John Mantas Laboratory of Health Informatics, Faculty of Nursing, University of Athens, Athens, Greece and Renate de Bruin Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands Erin Ergonomics and Industrial Design, Nijmegen, The Netherlands

Amsterdam • Berlin • Tokyo • Washington, DC

ISBN 978-1-60750-751-2 (print) ISBN 978-1-60750-752-9 (online) Library of Congress Control Number: 2011929728

Publisher IOS Press BV Nieuwe Hemweg 6B 1013 BG Amsterdam Netherlands fax: +31 20 687 0019 e-mail: [email protected]

Distributor in the USA and Canada IOS Press, Inc. 4502 Rachael Manor Drive Fairfax, VA 22032 USA fax: +1 703 323 3668 e-mail: [email protected]

LEGAL NOTICE The publisher is not responsible for the use which might be made of the following information.

PRINTED IN THE NETHERLANDS

Foreword

Ivor AMBROSE Managing Director of the European Network for Accessible Tourism (ENAT) Former Project Technical Assistant to the European Commission DG Research in the fields of Ageing Population and Generic Research on Disabilities – European Commission, Brussels, Belgium

As part of its Fifth Framework Programme of Research and Technological Develop- ment, in 1998 the European Commission launched the “Key Action on the Ageing Population and Disabilities”, in order to promote research by pan-European teams on age-related problems in an ageing society. Over 120 projects were co-funded, with an EU contribution of over 190 million Euros. One of these funded projects has conducted an extensive programme of investigations and development work which provides the focal point of this book: the “Friendly Rest-Room for Elderly People” (FRR). This project directly addressed some of the most critical – but least talked about – problems of getting older: how to cope with the functional limitations that come with ageing and, in response to this, how to design adequate, safe and user-friendly rooms for toileting and personal hygiene. As an example of applied technological research and development in an area with a surprising lack of prior research, this project stands out. With its clear mission to establish the basic technical and design criteria for the toilet room and its use by older users from many parts of Europe, the project partners found it necessary to make a broad investigation into users’ and carers’ behaviour, identifying problems and difficulties; and to balance these against the technical and economic possibilities afforded by modern materials, technologies and construction techniques. An essential element in the FRR project was the involvement of older people as active participants in the work. The “Key Action on Ageing” is recognised for the ground-breaking research approach that was espoused by the Expert Advisory Group, which helped to formulate and update the Commission’s Work Programme, year on year from 1998 to 2002. This approach may be summed up with three keywords: ‘problem-solving’, ‘holistic’ and ‘multidisciplinary’. These characteristics are identified as especially desirable in the emerging field of ageing research, due to the complex and critical nature of many age- related issues. Few funded projects were able to conduct research in a way which did justice to all three of these priorities but “FRR” is one of those that did. The reader of this book is therefore encouraged to reflect, not only on the insights afforded by the particular results of this substantial work, chapter by chapter, but also on the approach which the FRR project represents, through its methods and research design, being a paradigmatic example of the “new” ageing research. This page intentionally left blank vii

Acknowledgements

The first ideas about writing a book about the sensitive topic of toileting derived from the EU-funded project ‘Friendly Rest Room’ (2002–2005), project number QLRT- 2001-00458 in the ‘Quality of Life and Management of Living Resources, Key Ac- tion 6: the Ageing Population and Disabilities’ programme. The Friendly Rest Room (FRR) project focused on the problems the population elderly and disabled experience in the toilet environment. The project was initiated in an attempt to enlarge the autonomy, independence, dignity and safety of elderly and disabled people, and thus raise their overall quality of life. Ten organisations and companies located in seven different European countries together formed the FRR project-consortium, guaranteeing a wide geographic and cultural coverage. Each consortium partner represented a different area of expertise and as a whole the consortium offered expertise in the fields of advanced robotics, rehabilitation technology and engineering, health care informatics, applied computing, ergonomics, product design, geriatrics and gerontology, sociology and ethics. As a consequence many of the FRR consortium partners have contributed to this book, approaching the topic of toileting each from their specific viewpoint. In addition others, scientists as well as some innovative entrepreneurs, who were met during the course of the project and mutually shared experience and enthusiasm for the topic, have been willing to add their stories. Their contributions have made this book complete; representing the results of recent research and development activities around the toilet environment, keeping in mind the ones challenged most; elderly and disabled. First of all the editors would like to thank all authors contributing to this book for their willingness to share their knowledge and ideas. We thank all parties, industries and research institutes involved and all of the researchers, designers, students and producers connected to the work performed during the length of the FRR project. We especially would like to name all FRR project partners, without whom this book would not be here now; Fortec (Research Group on Rehabilitation Technology, Institute Integrated Study, Vienna University of Technology); Certec (Division of Rehabilitation Engineering Research, Department of Design Sciences, Institute of Technology, Lund University); University of Athens (Health Informatics Laboratory, Faculty of Nursing); University of Dundee (Faculty of Engineering and Physical Sciences, Department of Applied Com- puting); EURAG (European Federation of Older Persons); HAGG (Hellenic Associa- tion of Gerontology and Geriatrics); SIVA (Fondazione Don Carlo Gnocchi Onlus, Ser- vizio Informazioni e Valutazione Ausili, Assistive Technology Research and Informa- tion Service); Landmark Design Holding BV; Clean Solution Kft.; and Delft University of Technology (Section Applied Ergonomics and Design, Faculty Industrial Design Engineering). The last one – as coordinator of the FRR project – also was responsible for the left time and financial investments needed to publish this book as it is. We also want to thank our EU-project officer Dr. Gesa Hansen and our project technical assistant Ivor Ambrose, who have provided the project with valuable advice and support along the way. viii

Last but not least, we would like to thank the hundreds of older or disabled participants, many of them facing physical or mental difficulties, who were involved in all the studies mentioned. Especially considering this taboo surrounded topic, we admire tremendously their courage to step forward and express their feelings about the various friendly restroom prototypes and to tell us about their habits and difficulties in existing toilet-environments in order to learn and improve.

The editors

Dr. Johan F.M. MOLENBROEK Coordinator FRR Project Associate Professor Applied Ergonomics Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands E-mail: [email protected]

Dr. John MANTAS Director of Health Informatics Laboratory, Professor of Health Informatics Faculty of Nursing, University of Athens, Athens, Greece E-mail: [email protected]

Renate DE BRUIN MSc Assistant coordinator FRR Project Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands Erin Ergonomics and Industrial Design, Nijmegen, The Netherlands E-mail: [email protected] ix

Introduction

Johan F.M. MOLENBROEKa, John MANTASb and Renate DE BRUINa,c aFaculty of Industrial Design Engineering – Delft University of Technology, The Netherlands bLaboratory of Health Informatics – Faculty of Nursing – University of Athens, Greece cErin Ergonomics and Industrial Design, Nijmegen, The Netherlands

The topic of this book concerns everybody. It is a topic that people tend to avoid in normal conversation, though daily are finding themselves confronted with: their toilet- room. It is a taboo-subject in our modern society and certainly not the thing to talk about so frankly. Well, maybe when the toilet-room is perceived through the glasses of modern architecture and interior design; there are quite a few coffee-table photo books showing the toilet-room as an architectural space in which designers can go loose on colour, mirrors and trendy accessories [1–5]. However there are only few who pay attention to the daily activity of toileting itself and the variation of human behaviours that go with it. And that is logical, because when you are young and vital, you normally do not need – and neither want – help inside the toilet area. The few who did study this topic are famous for it; the book ‘The Bathroom’ written by Alexander Kira [6] was published in 1966 – so 45 years ago – and still his work is considered the main and sole source for scientific data of human behaviour inside the bathroom, considering the different functions and the fixtures in it, like sinks, bathtubs and toilet bowls. Another source – though focusing on the issues on public toilets – is ‘Inclusive Urban Design- Public Toilets’ written by Clara Greed [7]. It provides a deep understanding of toilet issues and gives many useful suggestions and guidance to industrial designers, urban designers, architects, municipality technicians. The conclusion that can be drawn from both books is that there is a lot to improve when it comes to designing the toilet room. As a result of gender or culture the human toilet use behaviour varies tremendously. But the little variation in existing fixed ‘product’ components (toilet bowl, seat, flush, sink etc.) only allow for a few of those behaviours. And the healthy and fit human beings are able to adapt their behaviour when products fail… those who are mentally or physically challenged are not; they are left to the support of others. With it they lose a little independence, a little dignity, a little self-esteem. This book is addressing the topic of toilet design, but instead of looking at the typical able-bodied user, it takes the various needs and limited abilities of older and/or disabled people as a focus point (human centered design). Thus following the ‘Inclu- sive Design’ principle, which promises that a design that is taking into account the needs of the ones most challenged, will be beneficial to the ‘healthy’ rest as well. For the most part this book has been a spin-off of an EU-funded research and development project called the ‘Friendly Rest Room for Elderly People’ project (throughout the book the project’s acronym ‘FRR’ will be used). The FRR project was part of the Quality of Life and Management of Living Resources Programme, under Key Action 6 ‘The Ageing Population and Disabilities’ and proposal number: QLRT- 2001-00458. The project ran from 2001 until 2005 and during that period a consortium of 10 institutions in 7 European countries collaborated on the research, design and de- x velopment of a friendlier toilet for elderly/disabled users. The contributions of the FRR consortium partners to this book therefore show the results of about 5 years of empirical work in different cultures, countries and disciplines. The goal of this project was to carry out the necessary research and design, build and test prototypes for a Friendly Rest Room for older people and for persons with a disability to allow them to gain greater autonomy, independence, self-esteem, dignity, safety, improved self-care and therefore enjoy a better quality of life. The result would be a Friendly Rest Room where all the components are adjustable to the needs of older persons with varying degrees of functional impairment. The methods and technologies involved to fulfil this objective included contact-less smart card technologies with read-write capabilities, voice activation interface, motion control and sensor systems, mechanical engineering and robotic techniques, mathematical modelling, as well as ergonomic research, design for all philosophy, gerontechnology and medical and social sciences. The project involved broad user driven research, needed to define the user parameters for designing and developing the FRR systems. Users were involved in all stages of the research and problem solving process of the FRR prototype development and testing, as well as there was involvement of secondary users, care takers and rehabilitation professionals. Prototypes were tested with involvement of industrial-marketing companies and end-user organisations to improve the independence, dignity, safety, self-care and quality of life of the older persons in the European community. Since the idea for this book dates from the beginning days of the FRR project, it certainly took a long while to make it actually happen. Many excuses may be given; writing and composing a book is a time-consuming activity that often loses in the competition with other obligations in our daily living, either work or family. This time lapse has provided us as editors the opportunity to involve other ‘toilet-minded’ authors to contribute to this book as well. We believe that the book as it is gives a good overview of what has occurred in the last couple of years concerning the design and development of toilets for elderly and other physically challenged. What can be learned from these stories, hopefully will inspire all who can make a difference – designers, architects, care-providers – and proof its value in the design of future toilets. The book contains four sections, each section combining several articles written by different authors, coming from different institutions, universities or companies. Section 1 ‘General, organizational and developmental issues’ describes the issues that are shaping the base of the FRR project and the base for this book. In ‘Meeting the Challenges of Demographic Change’ by G. Dayé, the greying of society is addressed and the need to adapt products to the needs of older people. In ‘Design for All: Not Excluded by Design’ by Molenbroek, Groothuizen and de Bruin this need is marked again, reasoning that following this principle will lead to better products for us all. Then Van Berlo in ‘Experiences with Smart Homes for Older People’ shows how elderly people can benefit from new technology in their homes with examples from practice. Provided the applied technology is adapted to the needs and abilities, it can help elderly to sustain their independent living longer. The last paper of this section, ‘Health Data Security Issues’ by Mantas and Liaskos, addresses the precautions regarding safety and privacy to be thinking about when applying new technology in products and environments. Section 2 ‘The Friendly Rest Room Project’ is – as the title says – devoted to the FRR project and its outcomes. In ‘Overview of the FRR Project; Designing the Toilet of the Future’ by Molenbroek and de Bruin, a general introduction to the FRR project

xi is given. In the paper ‘When Ethical Guidance Is Missing and Do-It-Yourself Is Re- quired: the Shaping of Ethical Peer Review and Guidance in the FRR Project’ Rauhala describes what ethical challenges were faced during the project and how researchers and developers in the FRR project coped with the sensitive topic of toileting and product-testing with frail users. In ‘User-Driven Research – How to Integrate Users’ Needs and Expectations in a Research Project’ C. Dayé and Egger de Campo elaborate further on this topic as seen from sociological point of view, and in ‘The FRR-Questionnaire – Assessing Who Needs What Where’ C. Dayé illustrates of the tools that were used in the project to discover potential problems that elderly in the toilet room experience, e.g. with the fixed products or spatial dimensions. This and other questionnaires were digi- tally presented to the test persons involved. In ‘Computer Based Information Gather- ing’ by Alm et al. goes deeper into this topic. Former studies have proven that the digital questionnaire provides a feeling of anonymity more than a paper questionnaire, which seems especially useful when studying this sort of sensitive topics. In ‘Knowledge Management’ by Mantas, Liaskos and Charalampidou evaluate how the knowledge created in the project (research and project data) was managed in a file sharing-server and how a résumé thereof could be edited into a gradually growing knowledge base. In the last two papers of this section the design and development of the FRR toilet are presented: The paper ‘Rapid Prototyping of Interface and Control Software for an Intelligent Toilet’ by Magnusson et al. explains how the user interface design of the smart ‘FRR’ lift toilet was developed and tested. In ‘The Final FRR Components’ by Groothuizen et al. all other physical components of the FRR toilet environment are presented, including a new door and door handle design easy to open and manoeuvre for wheelchair users, a communication unit that is connected to the smart lift toilet to move it automatically in the preferred position (height and tilt), body supports around the toilet – horizontal as well as vertical –, a toilet seat that is enlarged to allow for an easy wheelchair transfer and stable seat, a newly designed and patented moveable ‘comfort’ washbasin, as well as wall mounted grab bars to provide for – easy to clean – balance support in every spot of the toilet room. While in Section 2 mainly the developmental outcomes of the project were discussed, in Section 3 ‘FRR Case Studies and User Tests’ the focus lies on the user research outcomes of the project. In ‘Elderly and People with Disabilities – Limitations in their Everyday Life’ by Sourtzi and Menezello an inventory of problems that elderly and disabled people daily experience in their bathroom and toilet environment is made and illustrated by three case studies from Italy. In ‘Experience of Testing with Elderly Users’ Knall, Sourtzi and Liaskos evaluate their findings of testing the product prototypes developed during the course of the project with actual users, being of age and physically challenged. In ‘Laboratory Tests of an Adjustable Toilet System with Inte- grated Sensors for Enhancing Autonomy and Safety’ Panek et al. elaborates on the approach and results of user tests held with the smart FRR lift toilet inside a laboratory environment. In ‘Concept, Setting up and First Results from a Real Life Installation of an Improved Toilet System at a Care Institution in Austria’ by Gentile et al. the same smart FRR lift toilet is main subject. In this case the smart toilet was installed in a real life setting and shows the results of user behaviour inside the toilet room, unbiased by an unnatural laboratory environment or the presence of a researcher. Section 4 ‘Aspects of Human-Product Interaction in the Toilet Environment’ gives an overview of the studies about the spatial behaviour that (elderly) people inside the xii toilet environment show, focusing on the interaction with toilet and the toilet attributes in search for data to build design guidelines for the FRR toilet. Buzink et al. describe in ‘Fall Prevention in the Toilet Environment’ the need for more appropriate fall preventive measures and explain how a model was developed to identify basic toilet activities with an increased fall risk. Next a new toilet support was developed following the guidance of this model. In ‘User Preferences Regarding Body Support and Personal Hygiene in the Toilet Environment’ by Dekker et al. the search for design guidelines continues. The paper covers the most sensitive subject of personal hygiene and the balancing problems occurring when sitting down and rising from the toilet. Tests were performed with a setup that consisted of an height adjustable toilet bowl and various adjustable supports around it. The results give insight in the preferred type and position of supports as well as more knowledge about personal hygiene routines. In ‘Biomechanical Aspects of Defecation with Implications for the Height of the Toilet’ by Snijders et al. the suitability of a higher toilet for elderly is questioned from a biomechanical point of view, followed by an anthropometric analysis to determine the optimal height range for an adjustable toilet. In Section 5 ‘Design for Improved Toilet Environments’ an overview is given of various studies – not exclusively limited to studies performed within the FRR project – which can offer valuable knowledge, techniques or inspirational stories, helpful in designing, improving or evaluating a toilet environment. In ‘Older People’s Experience of Their Bathrooms’ by Boess a report is made of design work for the interior of an assisted bathroom for older people and conclusions are drawn on a useful approach to the design of assistive environments. Molenbroek and De Bruin explore in ‘Anthropometrical Aspects of a Friendly Rest Room’ the toilet environment from anthropometrical point of view. In ‘Involvement of Users and Practi- tioners in Anticipating Future Usage with Design Models’ M.J. Rooden describes how testing product ideas with users with the help of models or mock-ups can be powerful, though what to bear in mind when doing this. Followed by ‘Key Dimensions of Client Satisfaction with Assistive Technology: A Cross-validation of a Canadian Measure in The Netherlands’ by Demers et al. in which a cross-validation of the bidimensional structure of a satisfaction measure with assistive technology is subject of study; in other words a questionnaire to assess the helpfulness or expected success of an assistive product or service. Musch and Den Hartog show in ‘Plea for Use of Lowered Toilet for All’ the development of an innovative toilet, based on the idea that the squatting position is the most natural and healthy position for defecating, especially for elderly people since they often suffer from constipation due to a predominantly sitting lifestyle. The squatting position is also favoured in ‘Alla Turca: Squatting for Health and Hygiene’ by Oya Demirbilek and explains about the cultures – in this case specifically the Turkish culture – that prefer the squat toilet. It shows many examples and closes with some modern design solutions for these types of toilets. This book is about developing a perfect toilet environment. For them; elderly and otherwise physically and/or mentally challenged individuals, because it is plain to see that standard toilets do not fulfil their needs. But actually for us all, because we all have our special needs from time to time (and sometimes all the time), since we differ from each other. We have different age, different sexes, different cultures, in short: different needs.

xiii

Nevertheless our greying society is expressing the urgent need for research data on the use behaviour and special needs of people in the toilet environment. This book hopefully will add to the knowledge needed to develop a perfect friendly rest room, a toilet of the future that enables disabled and elderly people to maintain their independence, a toilet that is more flexible to the needs of the large variety of human beings, a perfect toilet for everyone.

References

[1] Gregory ME, James S. Toilets of the World. London: Merrell Publishers Limited; 2006. [2] Del Valle Schuster C. Public Toilet Design: From Hotels, Bars, Restaurants, Civic Buildings and Busi- nesses Worldwide. Firefly Books; 2005. [3] Wenz-Gahler I. Flush! Modern Toilet Design. Birkhäuser Architecture; 2005. [4] Hudson J. Restroom: Contemporary Design. London: Laurence King Publishers; 2008. [5] Restroom Design. Daab Books. Daab Publishing; 2008. [6] Kira A. The bathroom. New and expanded edition. New York: Viking; 1976. [7] Greed C. Inclusive Urban Design: Public Toilets. Oxford: Architectural Press; 2003.

This page intentionally left blank xv

Contents

Foreword v Ivor Ambrose Acknowledgements vii Johan F.M. Molenbroek, John Mantas and Renate de Bruin Introduction ix Johan F.M. Molenbroek, John Mantas and Renate de Bruin

Section 1. General, Organizational and Developmental Issues

Meeting the Challenges of Demographic Change 3 Gertraud Dayé Design for All: Not Excluded by Design 7 Johan F.M. Molenbroek, Theo J.J. Groothuizen and R. de Bruin Experiences with Smart Homes for Older People 19 Ad van Berlo Health Data Security Issues 27 John Mantas and Joseph Liaskos

Section 2. The Friendly Rest Room Project

Overview of the FRR Project; Designing the Toilet of the Future 35 Johan F.M. Molenbroek and Renate de Bruin When Ethical Guidance Is Missing and Do-It-Yourself Is Required: The Shaping of Ethical Peer Review and Guidance in the FRR Project 49 Marjo Rauhala User-Driven Research – How to Integrate Users’ Needs and Expectations in a Research Project 60 Christian Dayé and Marianne Egger de Campo The FRR-Questionnaire – Assessing Who Needs What Where 69 Christian Dayé Computer Based Information Gathering 80 Norman Alm, Kenny Morrison, Peter Gregor, Nick Hine, Sian Joel, Katrina Hands and Marja H. van Weeren Knowledge Management 94 John Mantas, Joseph Liaskos and Martha Charalampidou Rapid Prototyping of Interface and Control Software for an Intelligent Toilet 101 Charlotte Magnusson, Norman Alm, Georg Edelmayer, Peter Mayer and Paul Panek xvi

The Final FRR Components 112 Theo J.J. Groothuizen, Atilla Rist, Marja H. van Weeren, Dries Dekker, Renate de Bruin and Johan F.M. Molenbroek

Section 3. FRR Case Studies and User Tests

Elderly and People with Disabilities – Limitations in Their Everyday Life 127 Panayota Sourtzi and Terezinha Menezello Experience of Testing with Elderly Users 141 Gunilla Knall, Panayota Sourtzi and Joseph Liaskos Laboratory Tests of an Adjustable Toilet System with Integrated Sensors for Enhancing Autonomy and Safety 151 Paul Panek, Georg Edelmayer, Peter Mayer and Wolfgang L. Zagler Concept, Setting Up and First Results from a Real Life Installation of an Improved Toilet System at a Care Institution in Austria 166 Nadia Gentile, Christian Dayé, Georg Edelmayer, Marianne Egger de Campo, Peter Mayer, Paul Panek and Robert Schlathau

Section 4. Aspects of Human-Product Interaction in the Toilet Environment

Fall Prevention in the Toilet Environment 183 Sonja N. Buzink, Renate de Bruin, Theo J.J. Groothuizen, Eva M. Haagsman and Johan F.M. Molenbroek User Preferences Regarding Body Support and Personal Hygiene in the Toilet Environment 194 Dries Dekker, Sonja N. Buzink and Johan F.M. Molenbroek Biomechanical Aspects of Defecation with Implications for the Height of the Toilet 207 Chris J. Snijders, Johan F.M. Molenbroek and Rozemarijn A. Plante

Section 5. Design for Improved Toilet Environments

Designing for Older People’s Experience of Bathing 217 Stella U. Boess Anthropometrical Aspects of a Friendly Rest Room 228 Johan F.M. Molenbroek and Renate de Bruin Involvement of Users and Practitioners in Anticipating Future Usage with Design Models 242 Theo Rooden Key Dimensions of Client Satisfaction with Assistive Technology: A Cross-Validation of a Canadian Measure in The Netherlands 250 Louise Demers, Roelof Wessels, Rhoda Weiss-Lambrou, Bernadette Ska and Luc P. de Witte

xvii

Plea for Use of Lowered Toilet for All 259 Pamela Musch and Maarten den Hartog Alla Turca: Squatting for Health and Hygiene 271 Oya Demirbilek

Subject Index 281 Author Index 283 This page intentionally left blank

Section 1 General, Organizational and Developmental Issues

This page intentionally left blank A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People 3 J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-3 Meeting the Challenges of Demographic Change

Gertraud DAYÉ1 Past Chair of the NGO Committee on Ageing – UN, Vienna, Austria and Past Director of EURAG – European Federation of Older Persons – General Secretariat, Graz, Austria

Abstract. The shifts in age-group ratios in the population are confronting all continents with new challenges. At the moment Europe is at the top of the old age statistics with the highest life expectancy rate. The changes in the age structure of the population mean new socio-political responsibilities both today and in the future. Participation of older persons in all decisions concerning them, has to apply not only for age policies and social programmes, but also for the design of all kinds of equipment, technical aids, plans for flats or homes for older persons, - including restrooms. EURAG European Federation of Older Persons, welcomes the approach of User Driven Research promoted by the European Commission, GD Research as an important contribution to bringing the European Union closer to its citizens.

Keywords. Demography, User-Driven Research, Ageing

1. Introduction

The shifts in age-group ratios in the population are confronting all continents with new challenges. The comparison between the years 1999 and 2050 illustrates the dramatic rise in the number of older people. United Nations forecasts predict an increase in the number of over 60 year olds from 10 to 22 percent by the year 2050 alone. At the moment Europe is at the top of the old age statistics with the highest life expectancy rate. In the period 1960 to 1995 life expectancy in the European Union rose by 8 years for men and 7 years for women. In 1995 almost one fifth of the population was over 60; by the year 2020 probably one in four will be in this age group. There is a particularly striking increase in the number of the very old by about 40 percent. The fact that an ever increasing number of people are reaching an advanced age and that these are often years of health and activity can be counted as a very real progress. Yet the changes in the age structure of the population mean new socio- political responsibilities both today and in the future. Both governments and society are called upon to join in facing these new demands. Demographic change calls for a new definition of the relationship between the generations. The International Year of Older Persons proclaimed by the United Nations

1 Contact Information: Gertraud Dayé, Independent Expert; Adress: Kaiser-Franz-Josef-Kai 56, 8010 Graz, Austria; Tel: +43 316 678724; Mobile: +43 650 6787240; Email: [email protected] 4 G. Dayé / Meeting the Challenges of Demographic Change in 1999 gave an important impetus to this process. It resulted in a heightened awareness that only A Society for all Ages will be in a position to tackle a common future. There are no age limits to make a social political contribution. Older people are busy every day in thousands of ways demonstrating that age is no barrier to embracing new experiences, enriching our communities and enjoying life [1]. Yet, it must not be overlooked that people as they age are confronted with deteriorating health and, often, have to cope with a restricted mobility. Consequently, supportive measures and technical aids are required in order to enable older persons to continue an active life in society even in advanced age.

2. The Importance of User Involvement Strategies

In adopting the Regional Implementation Strategy for the Madrid International Plan of Action on Ageing 2002 [2], the representatives of the Member States of the United Nations Economic Commission for Europe, gathered at the UNECE Ministerial Conference on Ageing in Berlin in September 2002, gave particular priority to: Expanding participation of older persons in society and fostering social inclusion and independent living; Ensuring equal access to high quality health and social care; as well as Supporting older persons, their families, and communities in their care-giving roles.

UNECE Member States – i.e. also all 25 Member States of the European Union - committed themselves to strive to ensure quality of life at all ages and maintain independent living. They stated that: “Older persons, especially those who are dependent on care, must be closely involved in the design, implementation, delivery and evaluation of policies and programmes to improve the health and the well-being of ageing populations.” In EURAG it is felt that participation of older persons in all decisions concerning them, has to apply not only for age policies and social programmes, but also for the design of all kinds of equipment, technical aids, plans for flats or homes for older persons, including restrooms. It has proven to be a myth that designers or producers of goods always know what is good for older persons. They might have the best of intentions; however, still they often are faced with reactions by older persons they had not expected. To illustrate this Ad van Berlo, from the foundation Smart Homes in Eindhoven, the Netherlands can be quoted [3]. He spoke about a rather unexpected outcome of their opinion polls concerning the acceptance of smart homes: “It was not so much the difficulty with the technical equipment that irritated the older users, but an aspect of importance was that most residents wanted to keep the control over their house. They wanted to overrule automatic functions or alarms. There was also a fear that the house would not be accessible or usable if the electric power would fall out.” Such findings clearly demonstrate why it is important to ask older persons (‘primary users’) and also secondary users (‘professional and informal carers’) their opinion: there may easily be aspects important to the users that experts did not think of. It is quite obvious that appliances and equipment, as well as the wide range of technical aids available, help to maintain older persons’ quality of life by enabling them to stay G. Dayé / Meeting the Challenges of Demographic Change 5 longer in their own homes, and/or to lead relatively more independent lives even if living in an older people’s home or some other institution. Technical equipment such as a more user-friendly rest-room (FRR) –forming the central subject of this book - can support more people for longer in an active community life. Thus, technical aids, or to be more concrete, the FRR will not only improve the lives of the older persons, but also prove to be cost-effective, and it might be one of a range of features and conditions that enable a quicker hospital discharge. The use of technology as a support mechanism for older persons is, of course, only one part of a whole system to re-shape services for older people in order to improve their quality of life, but it can be an efficient and cost effective part. One of the recommendations in the Implementation Strategy for the International Plan of Action on Ageing [2] says: “Care for older persons with disabilities should promote the maintenance of their maximum functional capacity, their independence and autonomy. […] In view of the strong demand for providing care at home, it is increasingly important to create effective support strategies for informal caregivers.” The development of the FRR could be one element in a wide range of supportive equipment for maintaining older persons in the community life, without their needing a professional or informal carer for their everyday needs. Thus, the FRR increases the independence, but also the dignity of older persons.

3. User-driven Research As a Way of Representing Older Persons

EURAG European Federation of Older Persons was the partner organisation in the FRR project representing the users’ interests. EURAG is an umbrella organisation of older people’s organisations in 34 European countries. Its objectives are, among others, to defend the interests of older persons, to fight for their independence and the maintenance of their quality of life. We feel that projects like the FRR project are particularly well suited to help achieve these goals:

The FRR actually contributes to older persons’ independence, thus increasing their quality of life and respecting their dignity. The FRR can also contribute to alleviating the burden of carers of older persons with restricted mobility, in particular the burden of informal carers, family members, neighbours and friends, who are frequently rather old themselves. Access to a wide range of tailor-made affordable social services that recognise that older people are not one homogeneous group, but rather have different social and cultural needs. This is essential for their well-being, whether they need support to live in their own homes or institutional care. Older persons need to be made aware of the range of social and health services as well as technical aids, such as the FRR, available in their country. This will also be a concern for the future, real-life tests are a first step in making the FRR known, presentation at specialized exhibitions should also be planned for the future. Quality of life should be enhanced by ensuring an enabling and supportive environment through appropriate housing policies, urban planning and other measures that provide affordable, barrier free, and age-friendly living 6 G. Dayé / Meeting the Challenges of Demographic Change

environments. The FRR could very well be a decisive element of such an age- friendly living environment. And, finally, it should be emphasized that the FRR project also fulfilled another very important demand formulated in EURAG: participation in decision-making.

By involving users during the whole process of developing the FRR it was guaranteed that older persons could contribute to decisions concerning them.

4. Conclusions

To summarize: User Driven Research reflects key values of socio-political relevance [4];

1. Democracy: user involvement is active democracy, as it enables persons concerned to publicly express their opinions and to actively participate in processes and developments influencing their lives. 2. Equality: research and development initiatives applying user involvement establish equality between producers and consumers in an area where usually the power lies with the producers. 3. Legitimacy: the legitimacy of a product is strengthened when it is developed in collaboration with the population group it is intended for, and even more so when the financial means used for the development of the product come from public funds. 4. Active citizenship: user involvement fosters active citizenship which is a basic condition for an effective local democracy. 5. Participation: every person has the right to participate in society and consequently in research initiatives undertaken in this society. 6. Transparency: research projects and science are elements of society and have, thus, to be transparent, clear and understandable for this society.

Thus, EURAG European Federation of Older Persons welcomes the approach of User Driven Research promoted by the European Commission, DG Research as an important contribution to bringing the European Union closer to its citizens.

References

[1] Pohlmann S. Liaison Office Ageing, Deutsches Zentrum für Altersfragen; 2001 [2] Regional Implementation Strategy for the Madrid International Plan of Action on Ageing 2002, UNECE, ECE/AC.23/2002/2/Rev.6 [3] Background Documents for a Conference entitled: “Silver Economy in Europe – New Products and Services, European State of the Art and Perspectives” Bonn, Germany, 17 February 2005 [4] Dayé C. Master thesis at the University of Graz, Department of Sociology; 2004

A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People 7 J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-7 Design for All: Not Excluded by Design

Johan F.M. MOLENBROEKa,1, Theo J.J. GROOTHUIZENb, R. DE BRUINc a Faculty of Industrial Design – Delft University of Technology, Delft, The Netherlands b Design Consultant – Groothuizen Beheer bv, Rotterdam, The Netherlands c Erin Ergonomics and Industrial Design, Nijmegen, The Netherlands

Abstract. Inclusive Design or Design for All refers to the design philosophy of including as many users groups as possible in the target population of a to-be- designed product and to be aware of the ones that are excluded. This paper explains about the history, current status and possibilities of Inclusive Design as strategy. Within the FRR-project this strategy was leading when design decisions had to be taken. The outcome is a truly Friendly Rest Room, fulfilling the needs of disabled and elderly in a non-stigmatizing manner, and thus favoured by us all.

Keywords: Inclusive Design, Design for All, Universal Design

1. Introduction

1.1. The Need to Design for All

In Europe and the Western world in general, the quality of life for its inhabitants has dramatically improved over the last couple of decades. The numbers of people that reach the age of 65 have been fast growing. For instance in the Netherlands 6% of the population in 1900 was aged 65+ to more than 12% in 2000 and perhaps 25% in 2050. Other countries in Europe show the same trend; it has to cope with a declining fertility rate and increased life expectancy [1]. As a consequence the population of Europe will slightly shrink, and importantly, will be much older. We even can speak of a double greying society; there will be more elderly and these elderly get older. Typical is the group fastest growing within the European population: the so-called ‘centenarians’, the people over 100 years of age. While in 1900 there were only a few centenarians per country, for instance in France there were around 2000 people aged 100 or older in 1990. In the European countries and Japan on average, the number of new centenarians increased at an annual rate of about 7% between the 1950s and the 1980s. In Finland and Japan this number is even growing 10% each year [2]! Because mortality risks for very old persons do not change significantly, the number of centenarians is determined mainly by the growth of potential centenarians, i.e. people who are currently in their eighties and nineties. A forecast calculation shows that the increase in the amount of centenarians is likely to continue over the next decades and will grow considerably from 2046. The first baby boomers will reach the age of 100 in

1 Corresponding Author: Johan Molenbroek, Faculty of Industrial Design Engineering, Delft University of Technology, Landbergstraat 15, 2628 CE Delft; Email: [email protected] 8 J.F.M. Molenbroek et al. /Design for All: Not Excluded by Design that year. For example The Netherlands are anticipated to have nearly 14 thousand centenarians by then [3]. Although more and more of the older people are longer fit -quite a few even climb to the top of the Mount Everest at the age of 70+ [4, 5, 6] – people surviving to the ages of 80 and 90 often are in a health situation that is very delicate. In the Netherlands at least 30% of the people aged 65+ has one or more disabilities and 50% of the people aged 90+ is demented [7]. Because of our modern healthcare people are surviving serious illnesses more often. While staying alive they often inherit one or more disabilities. It causes a growing need for services and products that can help them to maintain their quality of life and stay independently at home for as long as possible. In addition to the growing group of elderly and disabled people, currently another population is calling for attention and rises in number and severity; obese people. In many western countries almost 50% of the people are overweight. They too need products and services that are better equipped to their needs (think about for example toilet seats and supports for heavy people). In short one can conclude that the European population now more than ever is in great need for products and services ‘Designed for All’.

1.2. History of Design for All

The term Design for All (DfA) was first embraced and perhaps even initiated by the European Institute for Design for Disabled (EIDD). Soon after its establishment in 1993, the EIDD developed the mission statement: “Enhancing the quality of life through Design for All”. Design for All refers to “design for human diversity, social inclusion and equality” [8]. The practice of Design for All makes conscious use of the analysis of human needs and aspirations and requires the involvement of end users at every stage in the design process [9]. Or as put on the EDeAN Design for All Education and Training website [10]:

“Design for All is a process whereby designers, manufacturers and service providers ensure that their products and environments address users irrespective of their age or ability. It aims to include the needs of people who are currently excluded or marginalised by mainstream design practices and links directly to the concept of an inclusive society. A key feature of design for all is the emphasis placed on working with user groups representing the true diversity of users as a route to innovation and new product development.”

The Design for All philosophy developed in Scandinavia, as a logical continuation of that region’s ‘Society for All’ concept, and gradually spread through Europe [11]. Two European networks have greatly helped to promote and develop the Design for All philosophy [12]:

EIDD - Design for All Europe. In 2006 the EIDD renamed itself into ‘EIDD Design for All Europe’ and is currently a federation of 22 national en corporate design organisations [8]. Its aim is to encourage active interaction and communication between professionals interested in the theory and practise of Design for All and to build the bridges to J.F.M. Molenbroek et al. /Design for All: Not Excluded by Design 9

other communities where Design for All can make a difference to the quality of life for everyone.

EDeAN - The European Design for All eAccessibility Network. EDeAN was launched under the lead of the European Commission and the European Member States in 2002 to promote e-Inclusion; creating an information society for all. It now is a network of 160 organisations in European Union member states and its goal is to support all citizens’access to the Information Society [13].

In 2004, after ten years as the European platform on Design for All, the EIDD issued their Design for All Declaration (Stockholm Declaration 2004 [9]). In this document an appeal is made to the European institutions, national, regional and local governments and professionals, businesses and social actors to take all appropriate measures to implement Design for All in their policies and actions.

1.3. Diversity of Terminology

Comparable concepts have developed in parallel in other parts of the world. In the USA and Japan Design for All is called Universal Design. In the UK the term Inclusive Design has gained ground. Another term used, primarily in Japan and non-English speaking countries, is Barrier-free Design. It is mainly used in the field of architecture, and refers to modifying buildings or facilities so that they can be used by the physically disadvantaged or disabled. In the case of new buildings, however, the idea of barrier free modification has largely been superseded by the concept of Universal Design, which seeks to design things from the outset to support easy access [12]. In the USA Universal Design is effectively promoted by the University of South Carolina with its Centre of Universal Design [14], as well as enforced by the Americans with Disabilities Act (ADA), a civil rights law that prohibits discrimination against people with disabilities in employment, transportation, public accommodation, communications, and governmental activities [15]. An example of the success of this approach can be seen in public transport. While in Europe the numbers of people using public transport are much higher, it is rarely accessible for wheelchair users. In the USA though, all public transport is made accessible for wheelchair users. Industry in Japan is also enforced to implement Universal Design, through standards (Japanese Industrial Standard X8341 (Caring) Series) and the Law for Facilitating Mobility of Elderly Persons and Persons with Disabilities. This law integrates and enhances the Barrier-Free Transport Law (established in 2000) which promotes the creation of barrier-free environments focusing on facilities used by travellers such as public transportation organizations, and the Heartful Building Law (established in 1994) which promotes the creation of barrier-free buildings [16]. In Japan a mixture of legislative push and market pull has made industry heightened aware of the principles of Universal Design [17]. Japanese companies have embraced the inclusive agenda and its challenges, resulting in the availability of many ‘universally designed’ products on the market. In the UK the term Inclusive Design has been favoured and it is successfully propagated by the Helen Hamlyn Centre at the Royal College of Art with ‘Include’, a biennial international conference that focuses on issues central to inclusive and people- centred design [18]. 10 J.F.M. Molenbroek et al. /Design for All: Not Excluded by Design

2. Design for All in Practice

2.1. How Inclusive is Your Design Process?

Because the majority of things in our living environment are at some point in time designed by someone, you could say that if an individual has problems coping within that environment, that there is a mismatch between themselves and their environment. As Roger Coleman puts it [19]: “People are disabled by design, rather than their particular capabilities. However just as design can disable, it also can enable”. Would the characteristics and needs of this individual have been taken into account in the first place, the problems would not have occurred and hence the person would not be ‘disabled’ in his living environment. So the before mentioned ‘mismatches’ can often be eliminated or in the least reduced through appropriate user-aware design. This abstract way of expressing what Inclusive Design or Design for All is about invites to a next categorization. According to Pete Kercher products where Design for All is manifested fall under two headings: the involuntary and the intentional application of Design for All [11]. The first category is rather broader and has a very long history. It refers to products that were designed for a specific user population and accidently proved to be very useful and successful for the mainstream as well. Examples of familiar products in this category are the ballpoint pen (originally designed to cope with problems with fountain pens on high altitude [11]) and the flexible drinking straw (originally designed for children and marketed for hospitals [20]). The intentional application of Design for All refers to the design of products with a conscious mind for its future users - involving all the people that may come into contact with it one way or another – and importantly: with a conscious mind for the people that are excluded. Every stage of the design process involves users. A good example is the driverless Copenhagen metro system. The designers’ brief included installing a full-size mock-up of the carriage in Copenhagen’s main square, so that the general public could comment and suggest improvements [11]. Another way of perceiving Design for All solutions is described by Klaus Miesenberger [21]. He subdivides applications of Design for All as;

a) special features for specific target groups, which are usually seen more as assistive (e.g., ‘special’ cars for the aging population) than as mainstream features, or b) an improvement of the general usability, which most of the time is not recognised as ‘Design for All’, but as good design in general (e.g., good, accessible design of controls in cars)

When the application of Design for All is invisible, not specifically demonstrating that it aims at special user groups, it seems to be more successful:

“Explicit visibility of Design for All as a focus on non mainstream user groups is in danger of being recognised as stigmatising (e.g., mobile phones advertising for special features for aging people never met with acceptance). It sounds paradox but, the more successful Design for All is, the less recognised it seems to be.” [21]

J.F.M. Molenbroek et al. /Design for All: Not Excluded by Design 11

Summarizing the above there are several options when judging the product design process and its outcome in practice; a) There was no or little attention for the (mainstream) user population and actual product usage, only attention for sales numbers (technical or marketing viewpoint) b) There was attention for the (mainstream) user population and actual product usage, though little or no attention for special user groups c) There was involuntary application of Design for All, taking into account the characteristics of one or more special user groups, and with an outcome that is ‘stigmatizing’ and therefore not acceptable for the mainstream user population d) There was involuntary application of Design for All, taking into account the characteristics of one or more special user groups, and with an outcome useful and acceptable for the mainstream population as well e) There was intentional application of Design for All, taking into account the characteristics of the mainstream user population and special user groups incorporated, testing the outcome with representatives of these user groups and awareness about excluded user groups.

Next two questions arise when bringing groups of people who normally are excluded (based on age or disability) now into the mainstream design process: 1) Does the investment for enlarging the aimed user population beyond the mainstream population pay back and 2) how to decide on the new aimed user population boundaries for which to design?

2.2. Is the Investment Worth It?

There exists a general idea among entrepreneurs that DfA is very costly and it does not pay back the investments. Disregarding the fact that legislation in many countries simply obliges companies not to exclude people based on disabilities and the fact that that some of the ‘special’ user groups (e.g. elderly) can form huge market segments, and thus represent a huge business potential, there is of course no guarantee that the investments will pay back. One could turn the challenge into an opportunity though. There are more than enough examples of important product innovations and business successes that are due to the application of DfA, either involuntary or intentional. An example is the electrical or e-Bike (see Figure 1). This bicycle supports the normal pedalling with electromotor amplification to help the cyclist who can’t exert enough power to turn the paddle against the slope, against the wind or over long distances. The new generation e-bikes have a fashionable appearance, without any ‘elderly’ stigma and are therefore also attractive for younger people. It made them grow very popular; one out of every eight bicycles sold in the Netherlands is now an e-Bike, which is on average three times more expensive than a regular bicycle. In 2009 electric bike sales accounted for one-third of the turnover of the whole bike sector in the Netherlands [22]! This being just one example, but many ideas for product innovations and business opportunities can be found when simply looking at the world through the glasses of ‘extraordinary’ user groups, like small and big persons, the disabled and elderly, expectant mothers and children. Like Peter Laslett illustrates in his personal experiment, trying to see the world through the glasses of the elderly [23]:

12 J.F.M. Molenbroek et al. /Design for All: Not Excluded by Design

“During the month of September 1996 I recorded in my diary every instance I encountered of a designed object which needed to be redesigned if it was to serve at all adequately the purposes of someone in the Third Age2. There were plenty of those to be sure, and when I talked of my findings to others of all ages, I found that their experience was identical with my own. People at every point in the Second Age expressed their frustration and exasperation with such thing as the design of TV set controls, video tape recorders and even computers. Directions for the use of highly important things were never, never adequate, so these younger people asserted, just as I found them to be. What is worse, these directions seem to have been written in a peculiar way so as to make the reader feel ashamed to confess to himself or anyone else that he or she could not follow them. It would amount to an admission which no one dares to make: a confession of not being with it, not being in fashion.”

Other excellent examples and case studies of intentional Design for All can be found on several internet sources [10, 12, 24].

Figure 1. Invisible application of Design for All; the popular e-Bike

2.3. How to Start Designing for All?

Still the next question stands: When you are convinced about Design for All and your product has to be designed, how to proceed? The term ‘Design for All’ in itself is often misunderstood: it does not mean you actually have to design for all 7 billion people on earth. Because it conveys the message clearer, some people therefore prefer to use the term ‘Inclusive Design’ instead. The general idea is to include as many as people possible and to be aware of the people that are excluded from proper use. Figure 2 shows 8 drawings representing the normal distribution of a specific body measurement of a given population. The consecutive hatchings show how designers, consciously or unconsciously, can exclude potential users. This can be done by just designing for themselves (ego design), designing for the mean (excluding everybody else), for the small, the tall ones, designing for adjustability (and forgetting that the

2 Refers to stages of the life course, stages which are named as the First Age of socialization, education and youth; the Second Age of maturity, earning, parenthood and professional engagement; the Third that of retirement and personal fulfillment and the Fourth that of disablement, decline, dependency and death. J.F.M. Molenbroek et al. /Design for All: Not Excluded by Design 13 limits of variations are just as important), or for more types. See also [25] for an illustration of the consequences of applying these design styles in the toilet environment. These graphs are not limited to body measurements. Apart from the anthropometry aspects there could be many other aspects relevant for your design problem. It depends on the problem and context and designers should be educated to explore the aspects relevant, for example biomechanical, cognitive psychological, social or cultural aspects. It would be ideal if tools and data existed to tangle all of these aspects, however at this moment in time unfortunately those data are yet unavailable.

Figure 2. Overview of how to include or exclude people by design

2.4. DfA in the Toilet Environment: an Example

In the EU-funded FRR-project the application of DfA played a central role (see the majority of papers in this book). In the design process of its ‘user-friendly and technologically advanced toilet environment’ users were continuously involved and were asked to comment on respectively the proposed user requirements, design concepts, design models and prototypes. The idea for developing a toilet that is more ‘user-friendly’ also sprung from the Inclusive Design philosophy. Most people do not consider their toilet to be that user-unfriendly, and probably would not admit it if it was. The fact that everybody needs a toilet does not automatically imply however that all 14 J.F.M. Molenbroek et al. /Design for All: Not Excluded by Design toilets are that comfortable for all of its users. Let’s consider the following groups and the standard public toilet environment;

Wheel chair users (How to get on and off the toilet?) Rollator / Walker users (Where to park the walking aid and how to transfer to the toilet?) Blind people / people with bad eye sight (How to locate the white toilet in white-tiled background or how to locate it in the first place? Finding out how to flush the toilet is even for people who can see often a real challenge!) People with a stoma (Where to place their hygienic aids?) People who suffer from arthritis (How to lock and unlock the door?) Obese people (Toilet seats are often unstable, even for people with moderate weight. Another problem is that big buttocks do not fit small toilet seats, and bad positioning can result in a soiled seat and brim) Parents with a baby or a small child (Changing diapers can be a challenge in itself, but in a public toilet without a proper changing table it is nearly undoable. Small children on big toilets; afraid to fall in, they grasp the seat and brim, they sit not far enough and pee upwards wetting their pants, their mothers/fathers do not fit in the room, trying to clean the child they hit their heads against the paper towel dispenser, and bending over to wipe the buttocks small hands touch the floor again and never, never the hand washing utensils are on children’s height..)

And the list continues. The total number of people for whom the standard public toilet is far from comfortable might be up to more than 20% of the population. It seems a justified reason to stimulate designers, researchers and policymakers to create more DfA solutions for toilets environments.

3. Design for All: Still Some Roadblocks

3.1. Designer’s Interpretation

Unfortunately, still too many entrepreneurs, architects and designers, those who are responsible for creating our living environment, products or services, apply Design for All only as a mean to solve problems for specific user groups. They see Design for All as a special assignment to design solutions for disabled persons or elderly, for which they then rely on a limited amount of specific ergonomic data. Besides the fact that Design for All should include ergonomic data of all potential user groups, other data such as social, cultural and psychological variables are rarely involved. As Don Norman [26] puts it:

“Good design requires consideration of all aspects of human beings: the behavioural (hence Universal Design), the Visceral (hence, attractive style), and the Reflective (hence, cultural differentiation)”.

Despite the fact that some of these ‘special’ target groups can form huge market segments, and thus represent a huge business potential, industry at large is still a true J.F.M. Molenbroek et al. /Design for All: Not Excluded by Design 15 follower of the traditional product development methodologies. Many people share the impression that Design for All is the opposite of developing for specific market segments. As said earlier, Design for All principles should not be explained as ‘one design for all’ or especially not as ‘one size for all’ meaning one product for 7 billion people on earth: which is impossible because of the great variety in lifestyle and level of civilisation: for some groups a plough is really an outcome not to dig manually by hand to prepare their food. For others they need a scooter mobile to come to the spinach in the supermarket. The big and valuable differences in cultures, economies and social structures, and above all people, simply imply the need for market segmentation. Leading industries, mainly developing and producing consumer goods, use a more integrated approach. In this so-called ‘integrated product development process’ knowledge of many different human oriented disciplines, such as ergonomics, behavioural science, and user-involved research are involved. For those companies, Design for All is applied for developments of all their products and services. They now understand that new product development or improved designs (redesigns) not only benefit special groups, but all users.

3.2. Tools for Designers

A second roadblock for Design for All is formed by the lack of tools and data necessary for designers and researchers to put Design for All into practice. They need sources which depict and specify the large variety of human characteristics. Currently most sources are representing the ‘average’ user, ironically being the one individual that does not really exist. At the faculty of Industrial Design of the Delft University of Technology (the Netherlands) an interactive website named DINED [27] was developed to give designers and ergonomists insight into a large amount of body measurements of several populations, using established anthropometrical databases. Nevertheless, users of the website are not always aware of the limitations of 1D anthropometry. Only one body measurement is focused on at a time, which is usually not sufficient for everyday design issues. More difficult is it for designers and researchers to take care of relations between different variables in 2D or in 3D. An example is the elbow-height that does not correlate with thigh length, although many manufacturers of wheelchairs do seem to think so: wheelchairs with larger seat-depth usually also have higher armrests! In fact this is a wrong assumption. Because the correlation between the two variables is almost zero, the seat depth and armrest height actually should be adjustable, just as they are in office chairs. More tools, guidelines and inspirational cases for designers are available and accessible through the internet. Examples are the CEN/CENELEC Guide 6 [28] and websites of the Cambridge Group for Inclusive Design [29], Design for All Europe [30], the Centre for Universal Design [31] and the Helen Hamlyn Research Centre in London [32], also organiser of the series Include Conferences where the current state of the art in the field of Inclusive Design (Design for All) biannually is published. Even though some tools already are available for designers, still more tools are necessary, for instance to gain more insight in the variations between different user groups (e.g. a wheelchair user versus walker/rollator user), or to get more insight into 16 J.F.M. Molenbroek et al. /Design for All: Not Excluded by Design other aspects like cognitive and social characteristics that play a role in the way products are used. And maybe even more important: Designers should be properly educated to read and use these sources in a correct way!

3.3. Education

In the curriculum of leading educations for engineering, architecture, software programmers or city planners, Design for All plays in general a marginal role. On the other hand, almost all curricula for education of designers of artefacts and services include courses, which form a knowledge base to apply Design for All principles. There are a few courses known at university level. Most are mentioned at the website of the Institute of Human Centered Design in Boston [33]. From here a popular free Newsletter about Universal Design is edited by Elaine Ostroff and distributed. In this newsletter the highlights from each country are listed. One of the known courses at university level is the elective course Inclusive Design of the Industrial Design Engineering Faculty of the Delft University of Technology (the Netherlands) that is educating product designers since 1987. Students at the faculty of Architecture from the same university on the other hand receive surprisingly few or no lectures in Design for All. It seems that –despite some exceptions e.g. the University of Buffalo where Prof Edward Steinfeld initiated IDEA Center for Inclusive Design and Environmental Access [34] – still much is to gain in educating future designers, architects and planners about Design for All.

4. Conclusions

Design for All or Inclusive Design can be considered a design philosophy with the aim to design products and services for the widest possible audience. In the "world of design", mainly the responsibility of (industrial) designers, architects and city planners, but also ergonomists and behavioural scientists, the practise of the principles of Design for All is rapidly growing. It must be stressed that applying Design for All principles should be evident for all ‘public’ products and services. People, users cannot avoid nor choose public services or components of the public building environment. Many governmental organisations, city councils or policy makers are not aware of the great responsibility they have concerning the access of public products, services and space. It is surprising how many public buildings, even newly created, do not offer accessibility for all. An increasing number of design firms and in-house design departments offer services related to the principles of Design for All. Governments increasingly understand the importance of creating a ‘non-excluding’ society, offering equal opportunities and improvement of quality of live for all, organising conferences, workshops and setting up organisations with the task to select best practices and give awards to designs or environments that pay special attention to Design for All aspects. But in spite of all these initiatives and achievements, Design for All is still a ‘special kind of design’, a design for a ‘special’ target user group. Should we not all expect that the main principles of Design for All, the principle of trying not to exclude anybody, would be a normal designers’ objective? For some design schools, such as the Faculty of Industrial Design Engineering at the Delft University of Technology, ‘human centred design’ and ‘sustainable J.F.M. Molenbroek et al. /Design for All: Not Excluded by Design 17 wellbeing’ is the core of their curriculum. Hopefully, educations for business management, marketing, engineering and business administration will pay more attention to the role of integrated design and development processes and the principle of Design for All. This could be a sustainable strategy for improvement of the quality of live. For product designers, and the many professions involved in designing our living environment, it should not be required to follow a special Design for All education though. Designers, and certainly product designers, should always try to include as many users in the use of their products. This implies that they should also be aware of whom they exclude. It should not be what you have been told or some tools you can use, but a basic mentality of every designer. Design aims to fulfil future needs, which are nowadays aimed at the quality of life of the whole human race: Design for All. As Susan Szenas, editor-in-chief of the Metropolis magazine, expressed it in her keynote speech at the conference Designing for the 21st century (Rio de Janeiro, 2004):

“The time is coming for building that road to a design that no longer needs to call itself ‘sustainable’ or ‘universal’ - just good, need-oriented, environmentally sensitive design. Just design. Design with justice at its core.” [35]

References

[1] Summaries of EU legislation. The demographic future of Europe – from challenge to opportunity. [Internet] 2008 [update 2008 Dec 10, cited 2011 Feb 2] Available from: http://europa.eu/legislation_summaries/employment_and_social_policy/situation_in_europe/c10160_en .htm [2] Vaupel JW, Jeune B. The emergence and proliferation of centenarians. Monograph, The MaxPlanckInstiture, Germany; 2000. Available from: http://www.demogr.mpg.de/Papers/Books/Monograph2/the%20emergence.htm [3] CBS Statistics Netherlands. Web magazine. More male centenarians. [Internet] 2010 Sep 16 [cited 2011 Feb 2] Available from: http://www.cbs.nl/en- GB/menu/themas/bevolking/publicaties/artikelen/archief/2010/2010-3205-wm.htm [4] BBC News. 70-year-old claims Everest record. [Internet] 2003 May 22 [cited 2011 Feb 2] Available from: http://news.bbc.co.uk/2/hi/south_asia/3049603.stm [5] Katsusuke Yanagisawa, Oldest to Climb Mount Everest. [Internet] 2008 Jan 28 [cited 2011 Feb 2] Available from: http://katsusukeyanagisawa.blogspot.com [6] EverestNews.com. Everest 2008: A 77 year old man Summits Everest. [Internet] Available from: http://www.everestnews.com/everest2008/76yearoldeverest01152008.htm [7] Statline, Centraal Bureau voor de Statistiek.[Internet] 2011 [cited 22 Feb 2011]. Available from: http://statline.cbs.nl/statweb/ [8] About EIDD. EIDD Design for All Europe. [Internet] 2008 Jan 25 [updated 2010 Oct 28; cited 2011 Jan 26]. Available from: http://www.designforalleurope.org/About-EIDD [9] European Institute for Design and Disability. The EIDD Stockholm Declaration 2004. 2004 [cited 2011 Jan 26]. Available from: http://www.designforalleurope.org/Design-for-All/EIDD- Documents/Stockholm-Declaration [10] EDeAN European Design for All e-Accessibility Network. Design for All Education and Training. [Internet] 2011 [cited 2011 Feb 8] Available from: http://www.education.edean.org [11] Interview with Pete Kercher. EIDD Design for All Europe. [Internet] 2007 Nov 7 [updated 2008 Apr 8; cited 2011 Jan 26]. Available from: http://www.designforalleurope.org/Design-for-All/Articles/ [12] Universal Design. Wikipedia, the free encyclopedia. [Internet] 2011 Jan 22 [cited 2011 Jan 27] Available from: http://en.wikipedia.org/wiki/Universal_design [13] European Design for All e-Accessibility Network (EDeAN). Available from: http://www.edean.org [14] The Center for Universal Design. North Carolina State University. [Internet] 2008 [cited 2011 Feb 1] Available from: http://www.design.ncsu.edu/cud 18 J.F.M. Molenbroek et al. /Design for All: Not Excluded by Design

[15] Americans with Disabilities Act, Disability Resources. United States Department of Labor. [Internet] 2011 [cited 2011 Feb 1] Available from: http://www.dol.gov/dol/topic/disability/ada.htm#doltopics [16] NEC Corporation. Design, Universal Design, The need for Universal Design. [Internet] 2011 [ cited 2011 Feb 2] Available from: http://www.nec.co.jp/design/en/ud/index.html [17] Macdonald AS. Universal Design in Japanese Technological Industries. In: Clarkson J, Langdon P, Robinson P, editors. Designing Accessible Technology. London: Springer-Verlag; 2006 [18] Helen Hamlyn Centre. Royal College of Art. About us. [Internet] 2010 [updated 2010 Sep 21, cited 2011 Feb 2]. Available from: http://www.hhc.rca.ac.uk/ [19] Coleman R. Designing for Our Future Selves. In: Preiser WFE, Ostroff E, editors. The Universal Design Handbook. New York: McGraw-Hill; 2001 [20] Joseph Friedman. Wikipedia, the free encyclopedia. [Internet] 2011 Feb 4 [cited 2011 Feb 8] Available from: http://en.wikipedia.org/wiki/Joseph_Friedman#Invention_of_the_flexible_straw [21] Miesenberger K. EDeAN Publication 2009, Principles and Practice in Europe for e-Accessibility [Internet]. 2009. Chapter 1, Design for All Principles; p.15-25. [cited 2011 Jan 26]. Available from: http://www.edean.org/Files/EDeAN_Publication_2009.pdf [22] Bike Europe, Website for Bike Professionals. Facts & Figures, Market Reports, The Netherlands 2009: E-Bike Dictates Dutch Market. [Internet] 2010 Jul 1 [cited 2011 Feb 16]. Available from: http://www.bike-eu.com/facts-figures/market-reports/4267/the-netherlands-2009-e-bike-dictates-dutch- market.html [23] Laslett P. Design Slippage Over the Life-Course. In: Graafmans J, Taipale V, Charness N, editors. Gerontechnology: A Sustainable Investment in the Future, Studies in Health Technology and Informatics, Vol. 4. Amsterdam, The Netherlands: IOSPress; 1998. [24] Inclusive Design Education Resource. The Design Council and the Helen Hamlyn Research Center [Internet]. 2011 [cited 2011 Jan 26]. Available from: http://www.designcouncil.info/inclusivedesignresource [25] Molenbroek JFM, Bruin R de. Anthropometrical Aspects of a Friendly Rest Room. This volume. [26] Norman DA. The Design of Everyday Things. New York: Basic Book;1988 [27] Molenbroek JFM. DINED. Interactive tool for selecting mainly Dutch data about body dimensions. [Internet] 2009 Oct 17 [cited 2011 Feb 22] Available from: http://www.dined.nl [28] CEN/CENELEC Guide 6: Guidelines for standards developers to address the needs of older persons and persons with disabilities [Internet] 2002 [cited 2011 Feb 22] Available from: http://www.cen.eu/boss/supporting/Reference%20documents/guides/Pages/default.aspx [29] Inclusive Design Toolkit. BT. [Internet] 2011 [cited 2011 Mar 15]. Available from: http://www.inclusivedesigntoolkit.com/ [30] EIDD Design for All Europe. [Internet] 2011 [ cited 2011 Mar 15] Available from: http://www.designforalleurope.org [31] The Center for Universal Design, Environments and Products for All People. NC State University. [Internet] 2011 [cited 2011 Mar 15]. Available from: http://www.design.ncsu.edu/cud/ [32] Include Conference. Helen Hamlyn Centre for Design, Royal College of Art. [Internet] 2011 [cited 2011 Mar 15] Available from: http://www.hhc.rca.ac.uk/448/all/1/include-conference.aspx [33] Institute for Human Centered Design (www.humancentereddesign.org) . [34] Center for Inclusive Design and Environmental Access. [Internet] 2009 [cited 2011 Feb 22] Available from: http://www.ap.buffalo.edu/idea/ [35] Szenasy S. Keynote speech. In: Sandhu J, editor. Proceedings Inclusive Design Research Associates, Ltd. Designing for the 21st Century III, An International Conference on Universal Design; 2004 Dec 7- 12; Rio de Janeiro, Brazil.

A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People 19 J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-19 Experiences with Smart Homes for Older People

Ad VAN BERLO1 Smart Homes Corporation, Eindhoven, The Netherlands

Abstract. In the Netherlands, in the late 90’s a first pilot with 120 smart home apartments for independent living of senior citizens was realised. The home automation consisted of all sorts of applications for safety & security, care and comfort. The first experiences showed that several mistakes in human interfacing and layout still occurred and clearly tempered the enthusiasm of many residents. Overall however, there is feeling of satisfaction and security among them.

Keywords. Home automation, Safety, Security, Care, Comfort, Experiences

1. Introduction

The terms 'smart homes', 'intelligent homes', and 'home networking' have been used for more than a decade to introduce the concept of networking devices and equipment in the house. According to the Smart Homes Corporation, the best definition of smart home technology is: the integration of technology and services through home networking for a better quality of living. Areas of application are: home automation & energy control, information & communication, working & productivity and entertainment. These areas particularly refer to the technical network islands, which regularly exist apart from each other. With reference to the definition up to present time, the implementation of complete smart homes with all network islands is limited to some demonstration houses and high-end luxurious villas. In Europe demonstration houses have been built in a.o. London, Milan, Zurich, Duisburg and Eindhoven. Looking at houses with single network islands, there is a different situation. Home automation and energy control has been implemented in some thousands of houses Europe wide [1,2]. If simple standalone plug and play tools for controlling lights (for instance X10 tools) are accounted for as smart home technology, many thousands of homes all over the world may be called smart. For achieving "intelligence", however, one really needs a network with sensors, actors and software and not single stand-alone solutions. Single networks in the other application domains are particularly coming up in the working and productivity area. Here, PC-networking is meant, where all PC's in the house, the printer, scanner, PDA etc. are linked to each other via an ethernet network, including firewall protection and the use of a server.

1 Contact Information: Ad van Berlo, Smart Homes Corporation; Address: PO Box 8825, 5605 LV Eindhoven, The Netherlands; Website: www.smart-homes.nl; Email: [email protected]

20 A. van Berlo / Experiences with Smart Homes for Older People

In this paper, the review on smart home technology will be limited to the area of home automation, as this is the area of most interest for older people so far.

2. Home Automation for Older People

Only recently, several projects with smart technology in the houses of older people have been realised or started. The Smart Homes Corporation has been initiator and consultant for many of these projects in the Netherlands. In 1997, in the Province of North-Brabant in the Netherlands, it was felt that demonstration projects were needed for those people who would have a clear benefit: older people who want to be independent and out of care as long as possible. The purpose of doing demonstration projects was to identify the real wishes and needs of older people themselves, to find solutions from the technology offer on the market and to try to understand which extra steps would be involved in the building process. Five projects spread over the province (2,3 million inhabitants) with in total 120 apartments of around 70 - 80 m2 were initiated for senior housing. From the beginning (early 1998) senior citizens were involved to express their wishes and needs. All five projects were subsidised as far as consultancy and project leadership by the Smart Homes Corporation concerns. In 2000, all five projects were finished and older citizens are actually living now in the houses. In the five demonstration projects and those that followed, the applications were not always the same. However, 80% of the applications in each project are from the following list:

Safety & Security Access control Intruder alarm Smoke alarm Automatic lighting at night Automatic cooker switch off Care Active person alarm Passive person alarm Authorised access to the apartment for the care worker Comfort Automatic lighting Automatic screens and curtains

The projects differ from each other that for instance in one project there are no automatic curtains and in the other there is no intruder alarm. The implemented technology varies widely. This is due to the fact that there are many suppliers of bus- systems and safety alarm systems, many installers with different views and preferences and of course due to the fact that the amounts of investment differ from project to project. Basically, one can speak of home automation when there is a bus-system involved, which acts as the electronic nervous system of the house. There are many proprietary systems on the market. In Europe, there are efforts made to make a leading standard for bus-systems, but after many years this is still a slow ongoing process.

A. van Berlo / Experiences with Smart Homes for Older People 21

3. Applications

3.1. Safety & Security

3.1.1. Access Control Top priority for many older people is the feeling of living safe and secure in their own house. Therefore, one likes to know who is at the central access door of the flat and at the front door of the own apartment, before one opens the door. In many projects, this access control is facilitated via remote control by phone, on TV and electronic locks on central access door and own apartment door (see Figure 1 and 2).

3.1.2. Intruder Alarm To extend the feeling of safety and security there can be installed an intruder alarm. This alarm can be easily activated and deactivated by means of an proximity key (see Figure 3).

3.1.3. Smoke Alarm A smoke detector is installed in all projects, most frequently near or in the kitchen. In some cases there are also smoke detectors in living room and bedroom. If smoke is detected an alarm signal is given to a call centre automatically. First, the call-centre operator will speak to the tenant via the safety alarm phone to verify whether there is a real fire.

Figure 1. The tenant opens the front door via Figure 2. Access control via TV and alarm phone magnetic card

22 A. van Berlo / Experiences with Smart Homes for Older People

Figure 3. The tenant switches intruder alarm on / Figure 4. Passive infrared sensor (PIR) with night off via proximity key light

3.1.4. Automatic Lighting at Night In all houses this is a common application. Older people have a more frequent nightly toilet visit than younger people. With automatic light switching on when the legs are put out of the bed, one can better orientate and find the way to the bathroom without risks of falling. There are many technical ways of carrying out this application: dimmed lights near the bed, light under the bed or lights in the hall or the room next to the bedroom. In most cases there is a passive infrared sensor (PIR) close to the bed or under the bed (see Figure 4). In one case a bed mat is used.

3.1.5. Automatic Cooker Switch Off In most cases the electric or gas cooker can be switched off via an extra button, which also switches off the light on the working area (see Figure 5). On the other hand the cooker cannot be used if the light on the working area is not switched on. If the resident leaves the house, the cooker is always automatically switched off. The same is true when the tenant goes to bed and uses the button "everything off" above the bed.

Figure 5. Extra button next to the electrical cooker

A. van Berlo / Experiences with Smart Homes for Older People 23

3.2. Care

3.2.1. Active Person Alarm In all houses where senior citizens live, an active person alarm phone is installed. This phone dialler is used for automatic transfer of all signals that could occur in the house: active person alarm, passive person alarm, smoke alarm and intruder alarm. The tenant is free to wear the pendant or bracelet for active alarm. In practice however, most tenants do not wear it.

3.2.2. Passive Person Alarm Since most tenants do not wear a pendant for active person alarm, in all smart homes for older people the concept of passive person alarm has been introduced. This means that the house continuously detects movement of the resident and automatically warns the call-centre if no movement has been detected for more than the installed period (for instance 3 hours). Of course the house must "know" if the resident is at home or not, or is sleeping at night. Several solutions were introduced to "let the house know" what the resident is doing (or whether it is night or daytime): buttons at the front door and buttons above the bed (see Figure 6). An ideal solution however, without extra button- push action for the resident, has not been found yet.

Figure 6. One of the chosen solutions: a simple switch ‘day / night’ above the bed

3.2.3. Authorised Access to the Apartment for the Care Worker If care is needed in one of the apartments of a flat, which is located somewhere in town, the care worker needs the key of the front door of the resident. In most villages, an extra key is often given at neighbours or children. But when the front door is well locked, it is not always possible to open it with this key. In cities, many residents do not have an address where they can leave the key of their home. In this case, the care

24 A. van Berlo / Experiences with Smart Homes for Older People worker must bring a bunch of keys of all the apartments where care is needed. This is not a safe situation, since criminals can get easy access to the various apartments if they take these keys. Therefore, the concept of electronic locks was introduced, where care workers get access to the individual apartment when they arrive. Different technical solutions have been worked out, where the care worker –just like the resident- can get automatic access.

3.3. Comfort

3.3.1. Automatic Lighting Apart from the safety aspect, automatic lighting of areas is used from a comfort point of view. If one enters the house, light is automatically switched on in the evening or night. The light in the bathroom and toilet is also switched on automatically. In some apartments PIRs are used which can be simply activated or de-activated (see Figure 7).

3.3.2. Automatic Screens and Curtains Automatic screens are more common than automatic curtains. In most projects the latter is an option, for which the residents have to pay themselves (see Figure 8).

Figure 7. PIR in the bathroom for automatic light Figure 8. Automatic curtain

A. van Berlo / Experiences with Smart Homes for Older People 25

4. Experiences and Reactions of Older Residents

The demonstration projects were carried out in order to gain more insight in real wishes and needs and actual use of smart home technology by the older residents: to find solutions from the technology offered on the market and to learn about the process of implementation. Here, only the first results of interviews with the residents will be reported. Starting point was that the residents, who moved to new built apartments, should be able to stay in their new dwelling for the rest of their lives. The age of the residents varied between 62 and 85. A majority was living alone, but there were many couples as well. They live fully independent, but if care would be needed, they will receive it from the regional Home Care organisation. Only, if a resident should require intensive nursing care, a move to a nursing home is foreseen. All apartments were designed with two bedrooms, a bathroom, a living room and a connected separate kitchen. The flats vary between 18 and 80 apartments. For all residents the move to the new apartment meant a reduction in available space and the abandoning of the garden, but they all strongly desired the new living space. Reasons were that some residents did not feel safe and secure in their old house anymore, that it was too big to maintain or that they expected an increasing need for care. Moving to a smart home was not their purpose, because they did not know about the existence and the facilities in it. The smart homes were simply offered because it was their turn on the waiting list of the Dutch housing regulation system. A general comment of many residents was that moving into a new house with different functions, such as switching the house "on/off", automatic lights, intruder alarm, etc. was extra difficult. They would have preferred a gradual introduction of the new functions after they were accustomed to the house. For couples, the passive alarm was not desired yet. In these cases the installers turned this application off. For the single person households, in most cases, the maximum time for inactivity was desired at 4 hours. This was due to the fact that some persons do not move out of the chair for 2 - 3 hours or longer. In the first month of their stay in the new house, many persons forgot to switch the house "on/off", which resulted in many false alarms for either inactivity or intrusion. In most apartments the number of false alarms was after a month reduced to zero. But many residents still do not like the extra handling. They are forced to think about it all the time and that does not contribute to the feeling that a smart house does everything automatically. Another aspect of importance is that most residents want to keep the control over their house. They want to overrule automatic functions or alarms. It is also a fear that the house is not accessible or usable if the electric power fails. In the layout of outlets and buttons and the programming of functions, the installers still make mistakes. Often this makes the applications not understandable or not usable. In the mean time most of the programming issues have been solved, but an improvement of the buttons or optimal placing of outlets is not always possible (see Figure 9 and 10). Despite the aforementioned shortcomings there is an overall feeling of safety and security among the residents of the demonstration projects. One feels protected and has a guarantee on follow up if something happens. Those residents who still feel well and active do not want all applications to be active from the beginning. They are very satisfied with the options in the house in case they really need it.

26 A. van Berlo / Experiences with Smart Homes for Older People

Figure 9. Two bed cords too close to each other: Figure 10. The buttons are almost behind the bed one for active alarm, one to switch off the lights furniture

5. Conclusions

Real smart homes with all network islands and possible applications are limited to demonstration houses so far. Home automation is implemented in thousands of houses world wide, but is still in its infancy. Several economic and socio-cultural factors will cause changes in society, which are favourable for a breakthrough of smart home technology. There are also important technical drivers, such as internet, broadband and wireless solutions. Older persons and in many cases also older people with a minimal pension, have been the "test" group for starting demonstration projects with home automation in the past years. They have clearly outspoken needs and wishes. The implementation of the first generation of demonstration projects, with emphasis on safety & security, care and comfort, showed that mistakes in human interfacing and layout still occur and temper the enthusiasm of many residents. Overall however, there is feeling of satisfaction and security among them. Other factors still account for the slow progress: costs, lack of standardisation and missing skills at installers. The Internet, broadband and wireless solutions are keywords in an irreversible move to further introduction of smart home technology. The question is at which speed of progress. But it is absolutely certain that in the near future all houses will be connected to the electronic highway. It is only logical that these houses will be smart themselves by networking all devices and equipment in order to get maximal benefit and fun. The benefit and usefulness has been demonstrated in the “smart homes for older people”.

References

[1] Berlo A van, Vermijs P, editors. Domotica opent deuren [in Dutch]. Akon Series. Ouder worden in deze tijd. Volume 3, 1993. [2] Berlo A van. Veilig en comfortabel wonen [in Dutch]. Akon Series. Ouder worden in deze tijd. Volume 9, 1994

A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People 27 J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-27 Health Data Security Issues

John MANTAS1, Joseph LIASKOS Laboratory of Health Informatics – Faculty of Nursing, University of Athens

Abstract. Health data are considered as personal and sensitive. The storage, process, access and communication of health data through health information systems, require appropriate methods that will ensure their privacy, confidentiality, integrity and other aspects of security. Methods to provide security are part of most computer systems, but healthcare systems are distinguished by having especially complex considerations for the use and release of information. Availability, accountability, authentication, authorization, perimeter definition, role-limited access control are key functions that need to be considered, Different types of information kept in the health care records have different rules for release, as determined by laws and by institutional policy following legal and ethical considerations.

Keywords. Health Data, Information Systems, Confidentiality, Computer Security

1. Introduction

Health care records contain much information about patients. These documents and databases include reasonable innocuous data ranging from height and weight measurements, blood pressures, and notes regarding bouts with the flu, cuts, or broken bones to very privacy-sensitive information about topics such as fertility and abortions, emotional problems and psychiatric care, sexual behaviours, sexually transmitted diseases, human immune-deficiency virus (HIV) status, substance abuse, physical abuse, and genetic predisposition to diseases. The health care record may contain these privacy-sensitive data. Health information is considered to be confidential, and access to this information must be controlled because disclosure could harm us, for example, by causing social embarrassment or prejudice, by affecting our insurability, or by limiting our ability to get and hold a job. Health data also must be protected against loss [1]. If we are to depend on electronic health care records for care, they must be available whenever and wherever we need care, and the information that they contain must be accurate and up to date. Orders for tests or treatments must be validated to ensure that authorised providers issue them. The records must also support administrative review and provide a basis for legal accountability. These requirements touch on three separate concepts involved in protecting healthcare information [2]:

1 Corresponding Author: John Mantas, Laboratory of Health Informatics, Faculty of Nursing, University of Athens, Papadiamantopoulou 123, 115 27, Athens, Greece; Email: [email protected] 28 J. Mantas and J. Liaskos / Health Data Security Issues

Privacy refers to the desire of a person to control disclosure of personal health and other information. It is defined as the right of individuals to be left alone and to be protected against physical or psychological invasion or the misuse of their property. It includes freedom from intrusion or observation into one's private affairs, the right to maintain control over certain personal information, and the freedom to act without outside interference” [3]. Confidentiality applies to information—in this context, the ability of a person to control the release of her personal health information to a care provider or information custodian under an agreement that limits the further release of that information. It is defined as the “status accorded to data or information indicating that it is sensitive for some reason, and therefore it needs to be protected against theft, disclosure, or improper use, or both, and must be disseminated only to authorized individuals or organizations with a need to know” [3]. Security is the protection of privacy and confidentiality through a collection of policies, procedures, and safeguards. Security measures enable an organisation to maintain the integrity and availability of information systems and to control access to these system’s contents.

Privacy of information collected during health care processes is necessary because of significant economic, psychological, and social harm that can come to individuals when personal health information is disclosed [4]. The disclosure of patients’ sensitive information about sensitive health data such us mental health, sexually transmitted diseases, adolescent care [5], drug addiction and genetic fingerprints creates many ethical problems [6].

2. Health Data Security

Data security is defined as the “result of effective data protection measures; the sum of measures that safeguard data and computer programs from undesired occurrences and exposure to accidental or intentional access or disclosure to unauthorized persons, or a combination thereof; accidental or malicious alteration; unauthorized copying; or loss by theft or destruction by hardware failures, software deficiencies, operating mistakes; physical damage by fire, water, smoke, excessive temperature, electrical failure or sabotage; or a combination thereof. Data security exists when data are protected from accidental or intentional disclosure to unauthorized persons and from unauthorized or accidental alteration”[3]. Concerns about and methods to provide security, are part of most computer systems, but healthcare systems are distinguished by having especially complex considerations for the use and release of information. In general, the security steps taken in a healthcare information system serve five key functions: [2], [7]

Availability should ensure that accurate and up-to-date information is available when needed at appropriate places. Accountability should help to ensure that users are responsible for their access to and use of information based on a documented need and right to know. J. Mantas and J. Liaskos / Health Data Security Issues 29

Authentication and authorization are processes that should ensure the correctness of the claimed identity and give permissions and privileges to do specific actions. Perimeter definition should allow the system to control the boundaries of trusted access to an information system, both physically and logically. Role-limited access should enable access for personnel to only that information essential to the performance of their jobs and limits the real or perceived temptation to access information beyond a legitimate need.

In all these functions the role the human factor (i.e. administrators, health care providers and patients – users of the health data) is very important. There is a great need that all health data users should understand and have effective control over appropriate aspects of information confidentiality and access.

2.1. Availability

The primary approach to ensuring availability is to protect against loss of data by performing regular system backups. Because hardware and software systems will never be perfectly reliable, information of long-term value is copied onto archival storage, and copies are kept at remote sites to protect the data in case of disaster. For short-term protection, data can be written on duplicate storage devices. If one of the storage devices is attached to a remote processor, then additional protection is conferred. Critical medical systems must be prepared to operate even during environmental disasters. Therefore, it is also important to provide secure housing and alternative power sources for CPUs, storage devices, network equipment, and so on. It is also essential to maintain the integrity of the information-system software to ensure availability. Backup copies provide a degree of protection against software failures; if a new version of a program damages the system’s database, the backups allow operators to rollback to the earlier version of the software and database contents [2].

2.2. Accountability

Accountability for use of health data can be promoted both by surveillance and by technical controls. The knowledge from health care professionals that their actions in accessing and using data records are being watched, (e.g. through scanning of access audit trails in log files), serves as a strong impediment to abuse [2]. The technical controls to ensure accountability include two major functions: authentication and authorisation. The user is authenticated through a unique identification process, such as, for example, name and password combination. The authenticated user is authorised within the system to perform only certain actions appropriate to his role in the healthcare system—for example, to search through certain health care records of only patients under her care.

2.3. Authentication and Authorisation

Authentication is the major means of defence used in the security of information systems, in order to verify that a claimed user identity is indeed correct. The main 30 J. Mantas and J. Liaskos / Health Data Security Issues approaches to user authentication are something the user knows (e.g. password or PIN), something the user has (e.g. a card, digital signature or other token) and something the user is (e.g. a biometric characteristic such as fingerprints, voice, DNA, etc.) [8]. Something that determines the place the user exists (e.g. telephone number, IP address) may also be used as an authentication means. Authentication is a communication security service, which provides the basis for important application security services like authorisation and access control [9]. Authorization is the means to define who can access what information. Authorization process allows access to resources only to those permitted to use them. An authorization mechanism is an integral part of most commercial database systems [10]. Each authenticated user is permitted to do specific pre-defined actions on the data, which they are deriving by his specific role. Authentication and authorisation can be performed most easily within an individual computer system, but, because most institutions operate multiple computers, it is necessary to co-ordinate these access controls consistently across all the systems. Enterprise-wide access-control standards and systems are available but have been deployed to only a limited extent. Tools for applying authentication include digital signatures, encryption, and access control lists [9].

2.4. Perimeter Definition

Perimeter definition requires that you know who your users are and how they are accessing the information system. For healthcare providers within a small physician practice, physical access can be provided with a minimum of hassle using simple name and password combinations. If a clinician is travelling or at home and needs remote access to a health care record, however, greater care must be taken to ensure that the person is who he claims to be and that communications containing sensitive information are not observed inappropriately. But where is the boundary for being considered a trusted insider? Careful control of where the network runs and how users get outside access is necessary. Most organisations install a firewall to define the boundary: All sharable computers of the institution are located within the firewall. Anyone who attempts to access a shared system from the outside must first pass through the firewall, where strong authentication controls are in place. Having passed this authentication step, the user can then access services within the firewall (still limited by the applicable authorisation controls). Even with a firewall in place, it is important for enterprise system administrators to monitor to ensure that the firewall is not bypassed—for example, a malicious intruder could install a modem on an inside telephone line or load unauthorised software [2]. Strong authentication and authorisation controls depend on cryptographic technologies. Cryptographic encoding is a primary tool for protecting data that are stored and are transmitted over communication lines. Two kinds of cryptography are in common use—secret-key cryptography and public-key cryptography. In secret-key cryptography, the same key is used to encrypt and to decrypt information. Thus, the key must be kept secret, known to only the sender and intended receiver of information. In public-key cryptography, two keys are used, one to encrypt the information and a second to decrypt it. Because two keys are involved, only one need be kept secret. The other one can be made publicly available. This arrangement leads to important services in addition to exchange of sensitive information, such as provision of digital signatures (certifies authorship), content validation (indicates the contents of J. Mantas and J. Liaskos / Health Data Security Issues 31 a message have not been changed), and no repudiation (indicates that an order or payment for goods received cannot be repudiated). Under either scheme, once data are encrypted, a key is needed to decode and make the information legible and suitable for processing [7]. Keys of longer length provide more security, because they are harder to guess. Because powerful computers can help intruders to test millions of candidate keys rapidly, keys of 56-bit length are no longer considered secure, and keys of 128 bits are entering service. If a key is lost, then the information encrypted with the key is effectively lost as well. If a key is stolen, or if too many copies of the key exist for them to be tracked, then unauthorised people may gain access to information. Holding the keys in escrow by a trusted party can provide some protection against loss. Cryptographic tools can be used to control authorisation as well. The authorisation information may be encoded as digital certificates, which then can be validated with a certification authority and checked by the services so that the services do not need to check the authorisations themselves. Centralising authentication and authorisation functions simplifies the co-ordination of access control, allows for rapid revocation of privileges as needed, and reduces the possibility of an intruder finding holes in the system [2, 7].

2.5. Role-limited Access Control

Role-limited access control is based on extensions of authorisation schemes. Even when overall system access has been authorised and is protected, further checks must be made to control access to specific data within the record. Α health care record is not partitioned according to external access criteria, and the many different collaborators in health care all have diverse needs for, and thus rights to, the information collected in the health care record. Examples include the following [2]:

Patients: the contents of their own health care records. Community physicians: records of their patients Speciality physicians: records of patients referred for consultations. Public health agencies: incidences of communicable diseases Medical researchers: anonymous records or summarisation of data for patient groups Billing clerks: records of services, with supporting clinical documentation as required by insurance companies Insurance payers: justifications of charges

Different types of information kept in the health care records have different rules for release, as determined by law and as set by institutional policy following legal and ethical considerations. Based on institutional policy, such notations might be masked before release of records for research purposes. Depending on the study design, the patient’s name and other identifying information might also be masked. Data protection law in most European countries requires that data be held only for a defined purpose, and for no longer than is necessary [11]. Health data can be used for purposes of administration, audit and performance review but patient identifiers should preferably be removed beforehand so that individual's identity is not revealed by unusual combinations of apparently anonymous data [7]. 32 J. Mantas and J. Liaskos / Health Data Security Issues

3. Conclusion

To protect the confidentiality of health care records against inappropriate release to collaborators, the records should be inspected before release, but such checking requires more resources than most healthcare institutions are able to devote. To date, relatively few resources have been devoted to system security and ensuring confidentiality of healthcare data; most such resources are used to resolve problems after a violation is reported. Even minimal encryption is rarely used because of the awkwardness created in handling the keys and accessing the data. Concerns over privacy protection are increasing, however, and such concerns are beginning to be supported by legal requirements of responsible trusteeship by collectors and holders of health care records. To respond to these new requirements, we need better tools to protect privacy and the confidentiality of health information. Each country in E.U. but also European commission [12] tries to protect people’s right for a safe handling of personal data stored in an EPR by setting the minimum necessary requirements for each health organization that uses it and by creating laws and ethical regulations for the same purpose. Moreover, the American "Health Insurance Portability and Accountability Act" of 1996 mandated the development of standards to protect the confidentiality and security of patient medical records [13].

References

[1] Bakker A. Data protection and confidentiality. Studies in Health Technology and Informatics. 2002;65:450-64. [2] Wiederhold G, Rindfleisch TC. Essential Concepts for Biomedical Computing. In: Shortliffe EH, Cimino JJ, editors. Biomedical Informatics: Computer Applications in Health Care and Biomedicine. 3rd ed. New York (NY). Springer; 2006. p.186-232. [3] American Society for Testing and Materials Committee E31 on Healthcare Informatics, Subcommittee E31.17 on Privacy, Confidentiality, and Access. Standard guide for confidentiality, privacy, access, and data security principles for health information including computer-based patient records. Philadelphia, Pa.: ASTM, 1997:2. Publication no. E1869-97. [4] Barrows RC Jr, Clayton PD. Privacy, confidentiality, and electronic medical records. Journal of American Medical Association. 1996;3(2):139-48. [5] Council on Scientific Affairs. Confidential health services for adolescents. Journal of American Medical Association. 1993;269:1420-1424. [6] Annas GJ. Privacy rules for DNA databanks: protecting coded future diaries. Journal of American Medical Association. 1993;270:2346-2350. [7] Rindfleisch TC. Privacy, information technology, and health care. Communications of the ACM. 1997;40(8):92-100. [8] Wood HM. The use of passwords for controlled access to computer resources. NBS Special Publications, US Dept. of Commerce/NBS. 1977;500–509. [9] Blobel B, Roger FF. A systematic approach for analysis and design of secure health information systems. International journal of medical informatics. 2001 Jun;62(1):51-78. [10] Rabitti F, Bertino E, Kim W, Woelk D. A model of authorization for next-generation database systems. ACM Transactions on Database Systems (TODS). 1991;16(1):88-131. [11] European Official Journal (European Parliament). Directive on personal data protection. EEC: Brussels. 1990. [12] European Commission. Ethical review of research proposals. 2007 [cited 2009 May 5]. Available from: http://ec.europa.eu/research/science-society/index.cfm?fuseaction=public. topic&id=73. [13] US Department of Health and Human Services, Office for Civil Rights. Summary of the HIPAA privacy rule. [cited 2007 Feb 2]. Available from: http://www.hhs.gov/ocr/privacysummary.pdf.

Section 2 The Friendly Rest Room Project

This page intentionally left blank A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People 35 J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-35 Overview of the FRR Project; Designing the Toilet of the Future

Johan F.M. MOLENBROEK1 and Renate DE BRUIN Faculty of Industrial Design Engineering – Delft University of Technology, Delft, The Netherlands

Abstract. Although the topic still is surrounded by taboos in our modern society, the toilet area recently is becoming more and more subject of study and even redesign. The objective of the EU funded project ‘Friendly Rest Room’ (2002- 2005) was to provide recommendations for improving the toilet area, in particular focussing on the special needs of elderly and disabled, by performing several user studies and exploring the potential of assistive technologies. The 10 project partners from 8 different European countries assured as well a multidisciplinary as multicultural vision on the subject matter. This chapter describes the approach that was chosen and in more detail the different ergonomic user studies that were performed. Problems and experiences with regards to ethics and cultural differences will be discussed. The results are presented in a basic list of user problems and illustrated by the first product development steps of the ‘toilet of the future’.

Keywords: Applied Ergonomics, Inclusive Design, Toilet, Rest Room, Elderly, Disabled, Assistive Technologies, Ethics, Cultural Differences

1. Introduction

In our daily live we are increasingly being supported by the application of new technologies, from self-thinking washing machines to ‘personal assisting’ mobile phones. These modern machines often do not resemble their earliest versions at all and usually for the better (everybody who has washed by hand and board once will immediately agree). There is however one essential appliance we use multiple times every day which somehow escaped this modernisation: our toilet. The toilet that is most commonly used in the western society is the ‘sitting-type’ toilet referring to the sitting posture one has when using it. This type of toilet looks not so much different to the first patented design for a water closet by Alexander Cummings in 1775[1]. Except for some improvements regarding water flush and sewage, the toilet basically has not changed since [2]. This is illustrated by the toilet bowl from 1910 in figure 1. Apparently the design of the toilet is satisfactory to the majority of mankind, or maybe not? For a fact there are in the market a whole collection of products available that cunningly respond to shortcomings of the standard toilet; toilet brushes, toilet

1 Corresponding Author: Johan Molenbroek, Faculty of Industrial Design Engineering, Delft University of Technology; Address: Landbergstraat 15, 2628 CE Delft; Email: [email protected] 36 J.F.M. Molenbroek and R. de Bruin / Overview of the FRR Project fresheners, toilet seat cleaners, toilet seat paper, toilet seat raisers for elderly, child toilet seats, toilet chairs, special soft toilet seats, toilet arm support bars, toilet back support bars, turning aids, stand-up toilet mechanisms, toilet paper tongs etc. From this collection ‘add-ons’ alone one can conclude that the current toilet design clearly does not cover for all the user’s needs. Especially when it comes to hygiene, comfort and safety for children, elderly and disabled our ‘modern’ toilet is pitifully failing. The rise in the ageing population will almost certainly blow up the difficulties even further. Not only the safety of older persons is at stake, since the risks of falling in the toilet area are high [3], also health care workers that assist elderly and disabled in their daily routines are suffering from a bad toilet design. They often have to work in difficult postures when transferring patients to and from the toilet and as a result back pains are a common noted complaint [4,5]. Clearly more research can and should be done to improve the toilet area. It is necessary to map the actual needs of the user, based on behaviour, habits and culture, the needs of caretakers etc. Study results should be translated into a toilet design that integrates all functions and offers a total approach instead of designing tools to overcome the flaws of existing sanitary. The use of new technologies in this toilet design makes sense: the modernisation of our toilet can begin.

Figure 1. A toilet bowl from ca. 1910

J.F.M. Molenbroek and R. de Bruin / Overview of the FRR Project 37

2. The Friendly Rest Room Project

2.1. General Objectives

The Friendly Rest Room (FRR) project (2002-2005) was initiated in an attempt to enlarge the autonomy, independence, dignity and safety of elderly and disabled people, and thus raise their overall quality of life. The FRR project was partially funded by the European Commission as project QLRT-2001-00458 in the ‘Quality of Life and Management of Living Resources, Key Action 6: the Ageing Population and Disabilities’ programme. The user group elderly and disabled was chosen because of the obvious problems this group encounters in the current toilet design. The general idea was though that a toilet that suits the elderly and disabled, will also suit the young and healthy. This approach – Inclusive Design or Design for All (ensuring that the needs of the widest possible audience, irrespective of age or ability are addressed [6]) - was followed in the FRR project and now forms the first step in adapting our toilet design to the modern ages. The FRR project aims at developing a user-Friendly Rest Room for the elderly and persons with limited abilities, which is facilitated by recent sociological, ergonomic and anthropometrical studies and technology developments. A more user-friendly layout of the room will be combined with a more user-friendly design of sanitary modules. A ‘smart’ toilet that will compensate the special needs of the user in a friendly way and increase their pleasure in life is the desired result [7]. The objectives of the FRR-consortium are in short:

To develop Quality of Life products for the ageing population and people with limited abilities To generate knowledge and understanding regarding toileting, personal care and hygiene, and accident prevention To establish an independent consortium to implement additional research and development projects in the domain of ‘caring homes for independent living’

2.2. Project Partners

Ten organisations and companies located in seven different European countries together form the FRR project-consortium, guaranteeing a wide geographic and cultural coverage. Each consortium partner represents a different area of expertise and as a whole the FRR consortium offers expertise in the fields of advanced robotics, rehabilitation technology and engineering, health care informatics, applied computing, product systems and ergonomics, product design and development, geriatrics and gerontology, sociology and ethics. An overview of the consortium partners is given in table 1.

2.3. Process

Research activities and design and development activities have taken place simultaneously in this project. The research objectives can be divided into two parts; 38 J.F.M. Molenbroek and R. de Bruin / Overview of the FRR Project

Table 1. The project-partners of the Friendly Rest Room project

FRR Consortium partners Abbrev. Organisation / Company Residence Area of expertise DUT Section Applied Ergonomics and Delft, The General Ergonomics, Design, Department Industrial Netherlands Anthropometrics and Bio- Design, Faculty of Industrial mechanics, Informational Design Engineering, Delft ergonomics, Safety studies and the University of Technology Application of Product Ergonomics to Design Projects FORTEC Research Group on Vienna, Austria Electrical Engineering, Rehabilitation Technology, Informatics, Biomedical Institute Integrated Study, Engineering and Precision Vienna University of Mechanics Technology CERTEC Division of Rehabilitation Lund, Sweden Rehabilitation Engineering and Engineering Research, Design, Human Machine Department of Design Sciences, Interaction Institute of Technology, Lund University EURAG European Federation of Older Graz, Austria Social Science, User Needs of Persons Elderly UOA Health Informatics Laboratory, Athens, Greece Health Care Informatics, Health Faculty of Nursing, University Informatics Education and of Athens Standardisation UNIDUN Faculty of Engineering and Dundee, United Computer-based System Design , Physical Sciences, Department Kingdom Computer-based Interviewing of Applied Computing, Techniques University of Dundee LM Landmark Design Holding BV Rotterdam, The Industrial Design, Inclusive Design Netherlands SIVA Fondazione Don Carlo Gnocchi Milan, Italy Medical, Social and Vocational Onlus, Servizio Informazioni e Rehabilitation, Assistive Valutazione Ausili, Assistive Technology, Education and Technology Research and Information Information Service HAGG Hellenic Association of Athens, Greece Health and Social Welfare, Gerontology and Geriatrics Gerontology and Geriatrics, Health Promotion CSO Clean Solution Kft. Debrecen, Development and Implementation Hungary of Assistive Products for Elderly and Disabled

J.F.M. Molenbroek and R. de Bruin / Overview of the FRR Project 39 the first objective was to gather general knowledge about the problems elderly and disabled encounter in the toilet area. This knowledge then was translated into a set of design specifications gradually building up during the course of the project. The research activities that have been performed in this regard are:

General literature study, Interviews with elderly, disabled and their caretakers about the toilet environment (CERTEC, FORTEC, EURAG, LM, TUD, UOA, HAGG) Multiple case-studies of elderly and disabled in their home toilet environment (SIVA), Questionnaire on toilet issues amongst elderly and disabled (EURAG), Development of a computer based interview tool (UNIDUN), Questionnaire on body posture during toileting and cleansing (LM), Study into user needs and preferences regarding illumination within the toilet area (CERTEC) Behavioural study of independently living elderly in their home toilet environment (TUD) Study into comfort of the toilet seat (TUD), Study into fall prevention in the toilet area (TUD). Behavioural study into the preferences of support bars near the toilet bowl (TUD) and Behavioural study on body posture during dressing/undressing, toileting and cleansing (TUD).

The second objective was to study whether the design solutions based on the growing design specifications were fulfilling the user needs and preferences and whether they indeed formed a solution that enabled elderly and disabled to use the toilet more safely and independently. This was done by testing several successive FRR prototype generations at 5 European test sites, the so called User Research Bases (URB). An overview of the URBs and the different test stages is given in table 2.

Table 2. Overview of URBs and the different successive prototype stages tested

Organisation / Residence Prototypes stages Company EPT(1) APT(2) BPT(3) PPPT(4)

URB Athens UOA, HAGG Athens, Greece X X X X

URB LUND CERTEC Lund, Sweden X X X X

URB Vienna FORTEC, Vienna, Austria X X X X EURAG

URB Delft DUT, LM Delft, The X Netherlands

URB Italy SIVA Milan, Italy X (1) Engineering ProtoType, (2) Alpha ProtoType, (3) Beta ProtoType, and (4) PreProduction ProtoType 40 J.F.M. Molenbroek and R. de Bruin / Overview of the FRR Project

In these URBs the FRR prototypes or parts of the prototypes were tested by in total more than 230 test persons from the user group of elderly and disabled. Next, the general design and development objective was to translate the needs and preferences of the users into concrete product proposals. Developing a fully market ready Friendly Rest Room within the lifespan of the project was not feasible within the scope of this project, the results rather should serve as a basis for further developments of user-friendly restroom products. The designers of the FRR (LM) aimed at creating a coherent environment in which the user feels at ease and in control, masking the technology which is used to make the environment adaptable to special needs. The design had to be culturally independent since the FRR should be used in the whole of Europe, and of course -while aiming principally at the user group elderly and disable- it should be accessible to as many users as possible. The design process started with the thorough inventory of user needs and problems regarding the toilet area. Literature study was used, but additional and very important information was gained from the performed observations and interviews. After analysing the findings the first idea sketches were made, which were shown to users and experts. Their feedback was incorporated into the designs and subsequently the first prototypes were built and tested with actual users in a laboratory situation. These user test results were again incorporated into the designs, the redesigns were again evaluated by users and experts, and another series of (adapted) prototypes were built and tested. The cycle of ‘design-evaluation-prototype-user test’ has been run through several times before the final FRR design was a fact. With every step the knowledge about user needs, preferences and problems in the toilet area grew, and the necessary design specifications of the user-friendly toilet area became more precise. The prototypes were constructed and produced by the production company (CSO) in the final materials as much as possible, though sometimes less expensive and/or easier to process, materials, like MDF or steel, also were used. The end result is a well thought-out layout of the toilet room, combined with a more user-friendly design of sanitary modules, which are perfectly in tune with each other, and addition of ´smart´ parts that automatically can adapt to compensate for the special needs of the user (see figure 2).

2.4. Ethics and Cultural Differences

An ethical committee was appointed for the project and advised the project on sensitive aspects of testing the FRR prototypes with elderly and/or disabled. Test subjects were always informed beforehand by means of a paper information kit and short before the user test subjects were instructed verbally by one of the researchers and asked to sign an informed consent. It was made clear to the test persons that they could end the test session on any point of time and that they were not obliged to answer questions they felt embarrassed with. The set up of URBs located in different European countries was to gain test results that would mirror the different toilet habits, preferences and needs all over Europe.

J.F.M. Molenbroek and R. de Bruin / Overview of the FRR Project 41

Figure 2. Final design of a Friendly Rest Room

3. Ergonomic User Studies

Being the project’s expert in the field of user-product interaction and translating ergonomic user needs into product specifications, Delft University of Technology (DUT) carried out several ergonomic user studies. Three of them will be described in more detail. 42 J.F.M. Molenbroek and R. de Bruin / Overview of the FRR Project

3.1. Study into Comfort of the Toilet Seat

In this study the objective was to define variables in the experience of comfort while sitting on a toilet seat. The test was conducted at a local DIY store. Subject were randomly selected by asking people shopping at the store to participate in the research. In total 20 persons participated (11 males and 9 females). The test set up consisted of six toilet seats fixed on toilet bowls that differed with regards to shape and dimensions, except for 2 seats that only differed in colour. After a short introduction subjects were asked to try the seats, with clothing. The seats were presented in different order to the subjects to avoid any carry-over-effects. The subjects were asked to describe the comfort of each seat and to compare and rank them. Following a short questionnaire was filled out. Test results showed that the subjects could feel the difference in comfort between the seats and could distinguish several critical seat dimensions; slope and shape of the seat borders, shape and size of the hole, rounding of edges and total seat length and width. Surprisingly the seats that only differed in colour were rated very differently on the above dimensions, suggesting that to a certain extent visual aspects influence the experience of comfort.

3.2. Behavioural Study into the Preferences of Support Bars near the Toilet Bowl

The objective of this study was to collect both qualitative and quantitative information on the preferences of elderly users regarding the use and position of three different types of supports. In the preparation phase the test set up was evaluated by performing a pilot test with 5 student subjects that wore limiting braces and other gear to simulated old age. A typological sample (stature, body mass, pulling force) was selected from a group of elderly earlier involved in gerontology studies at DUT. A total of 15 subjects participated in the study, 6 males and 9 females, age 58-79 yr. The test was partly recorded on video. A test frame was developed around a height adjustable toilet with three types of adjustable supports; a horizontal front support, vertical front supports and horizontal side supports. Subjects were asked to sit down and stand up using the supports at various positions after having set the toilet at a comfortable height. For each type of support the subjects had to indicate the most comfortable position. They were also asked to point out which of the supports they would prefer in each step of the toilet act (sitting down, cleaning, and standing up). The results incorporate quantified data on the absolute positions that were preferred during the different operations of toileting. Most subjects stated that sitting down and standing up is easier with than without the supports. This applies to all three types of support. The horizontal front supports showed some disadvantages though, for several subjects experienced feelings of confinement. For standing up and sitting down 50% of the subjects preferred the vertical supports (n=7). The horizontal bars were also chosen for standing up and sitting down, but subjects showed equal preference for the front support and the side supports. With regards to cleaning activities the vertical supports and the side supports were equally preferred. Some subjects indicated that they did not have a preference for any particular support when cleaning their body parts [8]. J.F.M. Molenbroek and R. de Bruin / Overview of the FRR Project 43

3.3. Behavioural Study on Body Posture During Dressing/ Undressing, Toileting and Cleansing

In this study the objective was to gain insight in the use patterns and preferences regarding different methods of perineal hygiene after using the toilet. In the second part of the previous described study subjects were asked to pretend to go to the toilet in the laboratory toilet environment. They were asked to act as they would do normally, undress (to the level of underpants), sit down, simulate cleaning their intimate body parts with different types of cleaning utilities, stand up and dress again. Standard ethical guidelines were followed: Subjects were carefully prepared, orally, in written and by means of informed consent. Additional ethical measures were taken to decrease the feeling of discomfort when subjects had to undress; during the actual user test female test subjects were accompanied by female researchers only and similarly male subjects were accompanied by male researchers. The final part of the test consisted of a multiple-choice picture questionnaire, which addressed common toilet behaviour and postures during toileting including cleaning activities. A special multiple-choice picture questionnaire was used to explain the postures precisely, and to make filling the questionnaire easier and less embarrassing. The results of the test revealed valuable insights into the behaviour patterns of different toilet activities including methods for perineal cleansing [9].

4. Results

In the FRR project new scientific, technical and professional knowledge has been gained about user problems and needs extracted from user involved testing and research, behavioural aspects concerning toileting and personal hygiene, the perception of safety, requirements with regard to assistive technologies, ergonomic and anthropometric data on elderly, the use of “inclusive design" principles and the use of computer based interviewing. This knowledge was translated in a pre-production prototype of a restroom / toilet environment, which includes a range of innovative solutions for improving the user friendliness. The prototype includes amongst others a highly accessible space saving door, a "design for all" door handle, an individual adjustable toilet module, different types of grab bars to offer body support and guidance while moving or while using the toilet, a system for supporting sitting down or standing up, a manual control interface and a wash basin for personal hygiene while using the toilet. Services offered provide control and monitoring functionalities, user interfaces, illumination functions for rest rooms, multilingual voice control and output functions, emergency and alarm functions, smart card technology for storing individual data, sensor systems for monitoring user activities and system software for control and interfacing [10]. An illustration of how the knowledge about user needs and problems was translated into a user-friendly restroom design is given by a description of found user problems and the corresponding FRR design solution ordered by the four general user areas (see figure 2) that can be distinguished in the toilet environment. See table 3a-3d.

44 J.F.M. Molenbroek and R. de Bruin / Overview of the FRR Project

Table 3a. User problems in the user area ‘environment’ and the corresponding FRR design solutions

Difficult to store Walking stick, The support surfaces of the toilet seat personal belongings sanitary towels, can also be used to put down personal stoma requisites belongings or handle sanitary provisions Difficult to distinguish Diminished sight The colours of floor, wall, sanitary the sanitary from the components and essential controls have environment and floor been chosen to contrast with each other from wall or otherwise a contrasting band of colour is put on wall and skirting-board. ENVIRONMENT This makes it easier to judge the dimensions of the toilet area and locate its components and controls.

Table 3b. User problems in the user area ‘access’ and the corresponding FRR design solutions

User User problem Underlying cause FRR design solutions area Difficult to locate the Diminished sight A special FRR accessibility sign in toilet in (semi)public sharp contrasting colours that is placed environment at eye level on the outside of the door Difficult to see from a Walking limitations An illuminated lock-unlock indicator distance whether a toilet which is integrated in the top of the is in use doorframe as well as the door handle Difficult to open the door Diminished arm A special triangular shaped and large force, use of walking door grip1 makes it easier to open the aid or wheelchair door from a wheelchair, with one hand or with an elbow

ACCESS ACCESS Difficult to manoeuvre Diminished arm A door2 with hinges around two points through the door opening force, use of walking slides in a top rail, resulting in a aid or wheelchair sideways and inwards moving door. Less space is needed when turning, hence a larger door width is possible. Movement of the door is very light. Difficult to lock the door Psychological: fear A floor fall monitoring system that of accidents or death senses unusual user movements or stillness combined with an alarm system

Table 3c. User problems in the user area ‘commute’ and the corresponding FRR design solutions

Difficult to move to Wheelchair, walking Different spatial dimensions are chosen the toilet: too little aid for wheelchair (1.90x2.50m) and manoeuvring space walking aid (1.20x1.80m) and as less objects as possible on or near the floor e.g. hanging toilet bowl Difficult to move to Walking limitations The toilet area is circumcised by a wall the toilet: large space mounted support bar, which makes the

COMMUTE without any support path from door to toilet provided with continuous support. The bar has an extruded shape with no external mounting points and a rounded inside, which makes it very easy to clean.

J.F.M. Molenbroek and R. de Bruin / Overview of the FRR Project 45

Table 3d. User problems in the user area ‘toilet’ and the corresponding FRR design solutions

Difficult to undress, Loss of balance, Vertical toilet support bars offer support turn round and sit diminished muscle while standing, turning and sitting down. down flexibility The bars can rotate in a horizontal plane to accommodate to different user dimensions or can be moved entirely sideways to have them out of the way. The toilet2 that can be adapted in height and angle automatically by means of remote control or voice activation. Difficult to undress Wheelchair Combined with the automatic toilet; and transfer to toilet A toilet seat with extra support surfaces adjacent to the seat, the total forming a rectangular shape, is facilitating the independent transfer from wheelchair to toilet and vice versa. Difficult to sit stable Paralyses Combined with the automatic toilet; on toilet Horizontal toilet support bars offer support when sitting on the toilet and can be automatically adapted in height TOILET TOILET and width by remote control or voice activation. Difficult to clean Loss of balance, Combined with horizontal body support intimate body parts diminished muscle bars; flexibility A moveable washbasin can be used to clean hands or body parts while seated on the toilet. The washbasin is equipped with faucet and shower function. Underneath the basin an additional light source improves visibility while cleaning intimate body parts. Difficult to stand up Diminished force, Combined with vertical and horizontal and dress loss of balance, support bars, transfer toilet seat and diminished muscle automatic toilet; flexibility The curved ending of the horizontal support bars is facilitating a natural hand grip when standing up. (1) Earlier developed product by LM, (2) Earlier developed product by CSO

The final FRR pre-production prototype was tested and evaluated by elderly and disabled test persons at 5 different URBs and demonstrated at the Rehacare Fair in Dusseldorf, Germany, November 2004 (see figure 3). The most essential parts of the final prototype were also installed in day-care centre for MS patients ‘Caritas Socialis’ in Vienna, Austria, January 2005 and effectively tested for 39 days by patients (n=29) and nurses (n=12). The test results showed a high degree of satisfaction amongst users, as well as a positive effect on the perception of autonomy, safety and dignity amongst users [11]. In conclusion we can say that the objectives of the project have been reached. 46 J.F.M. Molenbroek and R. de Bruin / Overview of the FRR Project

5. The First Friendly Rest Room: Toilet of the Future?

The FRR project has been a unique and successful project with regards to several aspects. First of all knowledge and understanding has been gained about toileting, accident prevention, personal care and the application of new technologies in the toilet environment. Secondly several prototypes of user friendly rest rooms have been developed, built and tested with elderly and disabled test users. However, what has not been attended to might be even more interesting. For instance topics as; general user behaviour in the toilet, including habits, rituals, cultural differences; the experience of hygiene; the experience and acceptance of new technology; standards and building regulations; influence of architects and real estate developers; socio-economical issues on financing; application of innovative materials; all have been studied little or not at all. Partly this can be explained by the lack of time and resources within the project’s parameters. For the other part it was caused by a hidden problem: the taboo subject matter. The problem was not that the test persons were unwilling to participate. They were on the contrary remarkably straightforward about their habits and problems, perhaps being less embarrassed by the subject of toileting when faced every day with problems or even the need for personal assistance in this private area. The sensitivities lay with the researchers themselves. Despite that test persons were carefully prepared the – usually young and healthy – researchers found it inappropriate to ask them about their toileting habits. The fact that test persons were older and disabled persons, for whom a lot of respect was felt, made it even more inappropriate. The extent to which

Figure 3. Final prototype of a Friendly Rest Room J.F.M. Molenbroek and R. de Bruin / Overview of the FRR Project 47 the taboo subject influenced the researchers differed culturally, as in some European countries it was more an issue than in other, though it was to a certain amount present in every country. The multiple-choice picture questionnaire on toilet postures as a result was vividly rejected by some of the project partners because of the drawn pictures of body postures which were regarded unacceptable [12]. Nevertheless it is essential in user centered design to know everything about the reality of user behaviour, and as a derivative about the needs and problems of the user group. This is even more important when a topic is concerned that is generally not spoken about, like toileting. The user problems with toileting that were found in this project, were found more or less in passing, for instance through remarks of subjects during the prototype testing. Another pitfall for user centered design, encountered in the project and caused by the taboo subject, is that researchers to avoid talking in detail about the topic of toileting are letting the test users simply decide that a product is good or not, but never ask why. It is undisputed that of all things the why question in particular has to be answered in order to come to a truly user centered design. The risk is –especially in innovative products for instance when new technologies are applied- that test users tend to agree with solutions they are familiar with, not necessarily being the best solution from an ergonomic point of view. So is a user-friendly rest room still staying in the future? Although the project’s objectives have been reached, the final prototype still is far from market ready and many areas of study are yet to be explored. For this reason it may come to no surprise that the final tests also revealed a lot of unanswered questions regarding technology, costs, safety, hygiene, and brought many supplementary suggestions for improvement. Concluding, there still is a long road of research and development to go before we can truly say our toilet environment is adapted to the requirements of modern time; designed for all, irrespective of age or ability. Though now the first step is made.

References

[1] Horan JL. The Porcelain God. A social history of the toilet. London: Robson Books Ltd; 1996. [2] Möllring B. Toiletten und Urinale für Frauen und Männer, die Gestaltung von Sanitärobjekten und ihre Verwendung in öffentlichen und privaten bereichen. Dissertationsgeschrift, Fakultät Bildende Kunst, Universität der Künste Berlin; 2003. [3] Buzink SN, Molenbroek JFM, Haagsman EM, Bruin R de, Groothuizen ThJJ. Falls in the toilet environment: a study on influential factors. Gerontechnology. 2005;4:15-26. [4] Kothiyal K, Yuen TW. Muscle strain and perceived exertion in patient handling with and without a transferring aid. Occupational Ergonomics. 2004; 4:185-197 [5] Garg, A, Owen BD, Carlson B. An ergonomic evaluation of a nursing assistants' job in a nursing home. Ergonomics. 1992;35:979- 995. [6] Molenbroek JFM, Veenstra R, Stephan CA, Swarte G. Design for All in werksituaties, inventarisatie van werkaanpassingen. The Hague: Ministerie van SZW. Werkdocumenten no. 202. [7] Bruin R de, Molenbroek JFM, Groothuizen ThJJ, Van Weeren M. On the development of a friendly rest room. In: Proceedings of Include: Inclusive design for society and business Conference, Helen Hamlyn Research Centre, Royal College of Arts. 2003;London. [8] Dekker D, Buzink SN, Molenbroek JFM, Bruin R de. Hand supports to assist toilet use among the elderly. Applied ergonomics. 2007;38(1):109-118. [9] Buzink SN, Dekker D, Bruin R de, Molenbroek JFM. Methods of personal hygiene utilized during perinal cleansing: acceptance, postures and preferences in elderly Dutch citizens. Tijdschrift voor Ergonomie. 2006;31(3):36-44. [10] Groothuizen ThJJ, Rist A, Van Weeren M, Dekker D. The Final FRR Components. This volume. 48 J.F.M. Molenbroek and R. de Bruin / Overview of the FRR Project

[11] Gentile N, Dayé C, Edelmayer G, Egger de Campo M, Mayer P, Panek P, Schlathau R. Concept, Setting Up and First Results from a Real Life Installation of an Improved Toilet System at a Care Institution in Austria. This volume. [12] Dayé C. Sitzen Sie bequem? Zur Bedeutung soziologischer Perspektiven in der Technikentwicklung am Beispiel eines interdisziplinären EU-Projekts [Diplomarbeit]. Institut für Soziologie, Karl-Franzens- Universität Graz: Graz; 2004. A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People 49 J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-49 When Ethical Guidance Is Missing and Do- It-Yourself Is Required: The Shaping of Ethical Peer Review and Guidance in the FRR Project

Marjo RAUHALA 1 fortec – Research Group on Rehabilitation Technology Institute “integrated study” – Vienna University of Technology, Vienna, Austria

Abstract. The purpose of this paper is to describe and discuss the approach for the tasks of ethical peer review and ethical guidance which was adopted in the project Friendly Rest Room for Elderly (FRR). Two aspects of user involvement were of special concern for the ethical reviewers: first of all, the target group consisted of potentially frail (or, vulnerable) users, and, second of all, problems relating to toileting and personal hygiene are considered taboo subjects in most regions of Europe. A mixture of a normative and empirical approach to ethics was adopted for guiding the project's user involvement. Ethical guidelines and principles relevant for the FRR context were identified and empirical work was performed to study their implementation. As methods for data collection, participant observation of prototype trials and interviews with users and developers were applied. In addition, the ethical peer reviewers participated closely in the drafting of information materials for users and in planning and designing of the user trials. In designing the user tests, much attention was paid to efforts to lessen the taboo effect faced by participants who were asked in the presence of a research team to talk about their toileting routines and difficulties. In this paper, the normative and empirical work performed by the ethical review team in the FRR project is described and key observations are discussed. In conclusion, the main lessons learned in the continuous process of ethical peer review in the FRR project are presented.

Keywords. Ethics, Peer Review, Ethical Guidance, User Involvement, Assistive Technology, Potentially Vulnerable Users.

1. Introduction, Background, and Approach

At the time when the Friendly Rest Room project was about to commence, few research and development projects outside the medical and health care realm that were financed within the European Commission’s framework programs had been requested to incorporate a systematic ethical peer review process in their work. The 5th European Community Framework Programme placed ethics very high on its agenda in general,

1 Contact Information: Marjo Rauhala, fortec - Research Group on Rehabilitation Technology, Institute “integrated study”, Vienna University of Technology, Favoritenstrasse 11/029, A-1040 Vienna, Austria; E- mail: [email protected]; Website: http://www.fortec.tuwien.ac.at ; Tel: + 43 1 58801-42 918; Fax: + 43 1 58801-42 999. 50 M. Rauhala / The Shaping of Ethical Peer Review and Guidance in the FRR Project explicitly stating in various official documents the need of all its research activities to respect an ethical framework (see [1]). The FRR project was predominantly a technology research and development project which was financed in the Thematic Programme ‘Quality of Life and Management of Living Resources’ and its Key Action 6 called ‘the Ageing Population and Disabilities’. The three partners who were responsible for carrying out user studies and trials with prototypes were technical universities without established procedures for research clearance. The FRR project’s consortium had to react on a short notice to the financier’s demand to construct a framework for ethics for the entire duration of the project. In finding a solution, the consortium faced a major challenge: there was little formal guidance available with regard to developing an ethical framework for a technology R&D project like the FRR. A number of questions surfaced. Given the context of toileting, what ethical issues would need to be addressed? How to help engineers and developers with little previous exposure to research ethics identify relevant ethical issues and to address them at an appropriate time in the project’s trajectory? What kind of documentation would be needed? Who should translate the relevant, more abstract ethical principles into action guides that are suited for the engineering practice? The situation was complicated by the fact that the consortium consisted of a multidisciplinary team the members of which had varying degrees of experience in handling topics of research ethics. It was agreed that two experts with backgrounds in bioethics, ethics and technology research and development, and ageing, would be invited to draft an overall concept for the project’s approach to ethics. This concept for ethical peer review and guidance was then implemented for the entire duration of the project. In what follows, the approach taken and the main observations and lessons learned during the course of the ethical peer review in the FRR project will be described.

2. Three Observations to Consider: Continuity, Taboo Effect, Potential Vulnerability

In drafting the approach for ethical peer review in the FRR project, the peer reviewers took three central observations as their starting point. First of all, it was likely that predicting emerging ethical issues for the entire trajectory of the project would be difficult. Hence, the ethical peer review and guidance should be continuous and geared toward identifying and addressing ethical issues as they surfaced during the project’s lifetime. Second of all, the topic of personal hygiene and toileting can be considered a sensitive area of research. The research participants could feel embarrassed or uncomfortable when confronted with questionnaires and interviews in which they were asked to disclose any challenges experienced in toileting and personal hygiene. Not only the risk of embarrassment but also physical risks, such as the risk of falling and being injured, would need to be addressed in the prototype trials of the friendly rest room unit. Given the taboo subject it was hypothesized that the approach adopted for preparing the users for their participation and the process of informed consent would have a decisive role in guaranteeing users’ well-being. In other words, the goal of the preparation would be to help participants become open and confident in providing their ideas, concerns, and feedback to the research teams. Special attention would need to be paid to building trust between the users and researchers. M. Rauhala / The Shaping of Ethical Peer Review and Guidance in the FRR Project 51

Third of all, the user groups whose contribution and commitment to the project was perceived essential were considered potentially frail or vulnerable.2 As a user- driven project, the FRR intended to rely on a close and continuous cooperation with older persons and persons with disabilities from the very beginning (see for example [3]). Hence, various risks and safety issues had to be taken into account and addressed in the project’s approach to ethics and ethical review. Furthermore, it was agreed that despite many differences, a number of similarities could be identified between research participation in the contexts of technology development and clinical research [4]. This fact had implications to the shaping of the normative framework and the process of informed consent. In sum, the ethical reviewers felt that the user-driven approach in the FRR project, its user group, and the sensitive area of research placed much responsibility in the project’s research teams. Thus the FRR ethical review and guidance should attempt to achieve more than merely providing the project’s researchers a predefined set of principles and action guides from existing frameworks for ethical review.3 Ideally, the FRR concept of ethical peer review and ethical guidance could provide the research teams with tools to reflect on, and in case necessary, improve their work practices with regard to ethics. In this way, the approach was in agreement with Flaskerud and Winslow [5], according to whom “Issues of providing informed consent, maintaining confidentiality and privacy, weighing the risks and benefits of a study and paying attention to issues of fairness are all especially important when working with groups who are vulnerable.” The approach also took some elements of action research as the project workers were engaged in a new inquiry which, in the words of Martin [6], meant an invitation “to challenge prior beliefs and understandings and reframe what they know.” In what follows, the background commitments and assumptions that contributed to the shaping of the ethical peer review in the FRR project will be described.

3. Constructing a Framework: Sources for Guidance for a Normative and Empirical Approach

In drafting the approach for the ethical peer review, the tenets of participatory systems design (PD) (see for example [7]) were relied on. Additionally, a number of commonly accepted international ethical guidance documents from other related fields of research involving people, mainly those from the medical and health care research, were investigated and adapted for the FRR context. It is the core philosophy of PD to offer the stakeholders and target groups to take part in the development of a system or application that has direct relevance to their work or personal life. In PD projects users are considered co-designers with a voice, meaning that their ideas and preferences are taken seriously by integrating them in the

2 For a very useful and informative account on vulnerability and research, see the Social Science Research Ethics web-resource of the University of Lancaster [2]. The website provides a range of resources designed to help social science researchers increase their knowledge and understanding of the processes and practices involved in undertaking ethically sound research. 3 Frameworks for ethical review have been formulated to address ethical issues in various disciplines that rely on research participation of human subjects. See for example [8]. The kind of formal review described in this document, for example, was not available for the research teams at the three sites of user trials in the FRR project. 52 M. Rauhala / The Shaping of Ethical Peer Review and Guidance in the FRR Project emerging design. A commitment to participatory design had two interrelated implications for the ethical guidance and the user involvement in the FRR project: First of all, serious effort had to be invested in making users feel safe, open, and confident as providers of feedback. Second of all, the design of user trials and user needs elicitation had to allocate the users an active role in the process making use of techniques that allow ways for lay participants to influence design without being technical experts themselves. Such techniques include prototyping, storytelling, and observing the users' at work or in everyday situations of technology use. The essential principles and norms that guide appropriate research with all human beings are anchored in widely accepted international declarations of human rights, research guidelines, and opinions and recommendations of high level working groups. These include the Helsinki Declaration of the World Medical Association (WMA) [9], which spells out the Ethical Principles for Medical Research Involving Human Subjects; the International Ethical Guidelines for Biomedical Research Involving Human Subjects by the Council for International Organizations of Medical Sciences (CIOMS) and the World Health Organization (WHO) [10], and the relevant opinions issued by the European Group on Ethics in Science and New Technologies (EGE) (see for example [11]). The role of ethical principles is important in formulating the foundation of the research participants’ rights and the researchers’ responsibilities toward the participants for the duration of a given research endeavour (and beyond). In the FRR project, the principles of autonomy, dignity, and privacy formed the core principles that shaped the framework for ethics and they were incorporated in the process of informed consent, which was tailored for the project from established guidelines in clinical research [9, 10]. Facing the lack of specific guidelines addressing ethical dimensions of research participation in technology R&D settings, the ethical reviewers considered adapting already established frameworks for ensuring participants’ safety and well-being the best solution, even if it meant coming up with a do-it-yourself approach for the FRR context. Drawing on the above-mentioned documents, the ethical framework then focused on the following aspects of the FRR project’s user participation:

Safety; Well-being and comfort (psychological and physical); Sensitive area of research, or, a potentially taboo subject; Voluntariness; The process of informed consent; Privacy; and, Avoiding raising unfounded expectations.

Whereas the research teams appreciated the normative dimensions related to their work at hand, they needed support in translating more abstract principles into practicable action guides with relevance to their tasks. It was therefore proposed that in addition to a normative approach to user participation some empirical work, in forms of participant observation of user tests and interviews with participants and research teams, would be performed within the ethical review. The reasons for proposing an empirical rather than a strictly normative approach to practicing ethics in the FRR project were the facts that the technologies to be designed were highly complex, the intended user groups were heterogeneous (and potentially vulnerable), and systems M. Rauhala / The Shaping of Ethical Peer Review and Guidance in the FRR Project 53 designers had relatively limited experience in addressing ethical issues as part of their technical work in a substantiated, grounded way.4 The empirical approach allowed studying the ways in which the normative guidance was inscribed in the project’s documents and reports, design of user trials, and their implementation. Even more importantly, it was possible to observe in which ways ethical guidance was translated and integrated into the interaction between the research teams and the participants. Furthermore, the ethical reviewers gained valuable insight into the role of research ethics and ethical guidance in the settings of day-to-day research and development work, and, into the motivational bases and concerns of users who volunteered to share their intimate experiences with an unfamiliar team of researchers.5

4. Context and Case: Challenges for Ethical Review and User Participation

In a nutshell, the challenge for the user involvement and ethical review and guidance in the three research sites in Austria, the Netherlands, and Sweden can be summarized as follows. How can (potentially vulnerable) users be brought into a laboratory setting to openly talk about their difficulties related to personal hygiene and demonstrate their preferred ways of being seated on a prototype toilet unit and cleansing themselves while a research team is recording their every move?

4.1. Research Setting: Out of Place

The research setting where the toilet prototype was to be tested posed additional challenges. The first prototype consisted of an ordinary toilet seat embedded in exposed machinery that controlled the movements of the toilet bowl and the unit’s grab bars. At the test site in Austria, the trials of which are the main source of information for this article, no actual toilet facility was available for setting up the prototype. Instead the unit stood in the office of two of the project’s researchers, obviously displaced amongst desks and computers. The test design required the trial participants to talk through and demonstrate their preferred toileting routines, including, ways of transferring to and from the toilet seat (in many cases from a wheel chair), being seated, cleaning themselves, and finally getting up off the unit. Participants were asked to repeatedly try out different heights and tilts of the toilet bowl in order to find comfortable positions for transferring, sitting down, being seated, and getting up. The entire test situation would be videotaped and take up to 1,5 hours. Including a test leader, 4-5 researchers would be present, asking questions, taking notes, and taking up space in the small room. Obviously, for the researchers to obtain useful data, the users would need to feel comfortable and safe during the trials. Although the research team who had assembled the prototype and whose work space it occupied soon began to treat the toilet bowl as an additional seating arrangement in their office, the (female) social scientists and the

4 The FRR consortium consisted of a multidisciplinary and multinational team of researchers and developers with varying degrees of experience in systematically reflecting on the ethical dimensions of their work. The process of translating the normative recommendations into the engineering and design practice contributed to a shared view on ethics in the project. The empirical work, the findings of which were fed back to the partners and researchers, served to evaluate how the project’s commitment to ethics had been implemented in the practice. 5 Some of the lessons learned and the possibilities and limitations of ethical review have been discussed elsewhere, see [12]. 54 M. Rauhala / The Shaping of Ethical Peer Review and Guidance in the FRR Project ethical reviewer who were visitors to the site, could not be persuaded to ‘take a seat’ in the presence of their (male) colleagues. Only gradually did the team members overcome the strangeness of the situation. Despite the fact that no clothes were supposed to be removed for the test, it became obvious that the users would be likely to experience the same unease at the user trials as the project’s social scientists and the ethical reviewer. The question then turned on how to remove the unease and taboo effect and replace them – as much as possible – with comfort and confidence. The trials of the FRR prototypes had to be constructed to meet the criteria of:

Safety for participants, bearing in mind some users were mobility impaired, relying on wheel chairs and other walking aids, and faced an increased risk of falling at every transfer to the toilet seat; Respect for autonomy, voluntariness, and non-coercion, bearing in mind that some users lived in institutional care settings with limited chances to leave the premises; Well-being and dignity of participants while being exposed to a potentially embarrassing research situation; and, Privacy while participants’ intimate data was collected and interviews and trials were audio and video recorded; and Sensitivity toward users’ specific needs as visitors to a research site.

After careful and relatively time-consuming planning, the above-listed criteria became inscribed in the trial plans. A detailed script was prepared, rehearsed, piloted, and revised.

4.2. Step-By-Step Informed Consent: Peeling Away the Taboo

Although not all risks of injury could be eliminated, the user trials were physically as safe as regular daily toilet use. Whether it would be equally safe from the psychological point of view was thought to depend on how well the research team would succeed in preparing the users for confronting the prototype and their potentially embarrassing tasks. Because increased familiarity with the prototype appeared to have changed the way the members of the research team treated the prototype, it was thought that a similar development could take place in the users. An extensive process of informed consent was devised with the goal of removing the taboo effect of the research situation and making the participants feel confident, open, and safe. Different media were used to convey information about the project, the depth of the information increased with time. The initial recruitment took place through a peer, a kind of expert user in the project, who used a self-help group meeting of the target group to informally tell potential users about the project and its aims. Those who showed interest in participating in the project received more extensive written material with photographs about the prototype, including one with a researcher seated on the unit. Users were provided detailed information regarding expectations on time to be spent, a schedule of events, descriptions of tasks, and the setting itself. In an informed consent form, the main information was summarized, and the usual rights of research participants were repeated. M. Rauhala / The Shaping of Ethical Peer Review and Guidance in the FRR Project 55

Included in the informed consent document were then, for example, the participant's right to interrupt the participation at any time, right to refuse to answer questions, as well as a reminder that the development project is a long-term one, that may not result in a short-term solution for the participant's situation. To provide users with a chance to exercise their rights, the research teams were trained to continuously refresh the participants’ informed consent, even in-between the tasks, through questions such as: “Are you all right? Would you like to have a break?” Finally, when the users arrived at the site, they were first greeted and showed a video of the functions of the prototype demonstrated by a researcher in the team. Only after asked if they were willing to proceed to seeing the prototype, did they enter the laboratory. Before the testing itself started, one of the social scientists would demonstrate how he/she would operate the prototype while seated. By this time, users were usually very curious to get started themselves. In this way, gradually peeling away the taboo effect through information and familiarity with the project that increased step-by-step seemed to have worked well. Awareness of the risk that users could be intimidated by the prototype and test situation contributed to carefully planned user trials and to an informed consent process that helped neutralize the research context and empowered the participants. It could be observed that the participants knew what they were confronted with and that they felt their effort and feedback was valued. Furthermore, users showed much courage in telling their personal stories indicating trust had been built in the project’s research teams. In addition to a careful process of informed consent, a strict data protection policy was implemented in the project. For example, users were assigned codes, any data collected was stored on secured servers, pictures and video materials were only used internally within the project and limited educational purposes if users had explicitly agreed to it.

5. Description of the Empirical Work

In order to investigate the implementation of the normative approach to the user trials and the process of informed consent the ethical reviewers performed some empirical work in the project. They collected data through participant observation of trials, interviews with trial participants, project researchers, and test leaders, and analysed available project materials and reports. Participants were interviewed in three settings: at the end of each trial, in their homes, or in a focus group at the end of the project. The material was recorded in field notes and to some extent on audiotape. One of the ethical reviewers was in close and continuous contact with the developers at one of the research sites. One cycle of the user tests was observed at the Swedish test site where interviews with users were also conducted. The findings were fed back to the researchers at the respective test sites and the consortium and reported in the project’s deliverables.

5.1. Observations: Dealing With Unexpected Reactions and Incidents

Three cycles of user tests were completed without incidents. In the fourth cycle, when organizing the tests had become somewhat of a routine, some problems emerged. In what follows, the incidents will be described. 56 M. Rauhala / The Shaping of Ethical Peer Review and Guidance in the FRR Project

One test user broke into tears during the coffee break, possibly as a reaction to having failed in a task he had been asked to perform. The task required a capacity in the participant, namely, raising his voice which had been affected as a result of his recent stroke. A successful rehabilitation made the man physically appear a healthy volunteer to the research team. What the team could not foresee was how the man’s failure to activate an alarm with his voice meant would mean a sad reminder of the loss of health and control in his life. The participant’s unexpected emotional response made the team members reflect on what they could have done differently to prevent the feeling of failure. There was – in hindsight – some indication of the user’s hesitance with regard to the task as he attempted to tell the test leader that the feature might not suit stroke patients. But it was not obvious for the research team that the user wanted to discontinue. An interview with a project’s secondary user, a nurse employed in a long-term care facility, revealed that the user trials were an exciting event for the participants from her unit. Many residents of retirement homes rarely have a chance to leave their facilities. One of the older participants in the project had never visited a university institute. The nurse reported the participants showing signs of being nervous and not sleeping well prior to the tests. Furthermore, the project’s participants included persons whose strength would vary on a daily basis, depending on external factors, such as room temperature, medication, intensive therapies, etc. One very committed participant was seemingly fatigued as a result of a recent period of therapy but he ensured the team he was fine. In transferring to the toilet seat, he could not hold back his bowel movement. Despite his discomfort and the team members’ explicit offers to discontinue, the participant wanted to try out all the new features of the prototype. Should the team have interrupted the test situation against the participant’s wishes? Because the team members personally knew the participant, they respected his judgment and allowed him to complete all the tasks. Wishing to help the project gain some publicity, a healthy volunteer in his 70s brought along a journalist to observe his own test and to report about the project in a local newspaper. As soon as the user was seated on the toilet unit, the journalist started to take pictures. Because users’ privacy and dignity had been an important consideration in planning the user participation, the ethical reviewer informed the journalist about the project’s approach to ethics and privacy. The project’s photo and video material was kept for internal use only. All users had been promised this would be the case. The user himself, a retired local politician, also expressed his wish not to be shown in the local newspaper seated on a toilet bowl. He would prefer being photographed standing next to the prototype together with researchers. Such pictures were indeed taken by the journalist. However, when the newspaper appeared, the user was depicted alone seated on the toilet prototype. In the accompanying story the user was identified by name.

5.2. Observations about Users’ Contribution

The users that participated in the test cycles can be described as very active, courageous, and willing to openly tell the project team about their personal experiences with existing toilets and their expectations of the FRR. Two observations can be made. On the one hand, it is possible that the recruited group was special with regard to their attitude toward toileting. One participant said there was nothing embarrassing for her in the topic of personal hygiene because through her long-standing illness she had become M. Rauhala / The Shaping of Ethical Peer Review and Guidance in the FRR Project 57 used to hospitals and research situations. On the other hand, it is also possible that the users were sufficiently prepared and therefore willing to communicate openly in the interview and test situations. One user explicitly mentioned that the information provided was “serious”. For this user respect for privacy and the fact that no pictures would be published were important. She admitted that toileting was a sensitive topic and that it had to be addressed accordingly. She found the university a trustworthy project partner. A healthy volunteer described her experience in the project in terms of “fun” and having felt “very safe”. For a secondary user caring for his wife the detailed information provided to participants was central. He compared the trial with a visit to a doctor; both cases required detailed information for decision making. Another user expressed her gratitude and relief that a research project would finally address a topic of such immense importance to her personal well-being. This participant had become increasingly home-bound because the only toilet she could safely and confidently use was the one in her home. This participant contributed information in a courageous, honest, and open way which communicated much trust in the researchers but also hope in the new technology. Looking back at this particular participant, it was important for the project team not to raise unfounded expectations. This meant communicating to the users from the start that the project could not guarantee improvement in their individual situations.

6. Lessons Learned – Concluding Thoughts

In the course of the ethical review in the FRR it became evident that the users appreciated the information materials provided for them prior to the beginning of each test cycle. The users interviewed in Sweden pointed to two main sources of trust and credibility: the fact that the project partner was a university and the quality of the written information that was provided to them before the test cycles. Another source of trust mentioned by users was being personally acquainted with someone associated with the project. In Austria, the project’s expert user helped recruit most of the participants making him a personal connection to the project. It appeared that the nature of the information, who provides it, and the institutions involved in the research play an important role in building trust in the users. These factors are then of central importance with regard to the maintenance of trust throughout the project and beyond. In the FRR project much attention was paid to easing of potential anxieties or embarrassment in users who were invited to test a toilet in a research context. However carefully the test situations were thought out ahead of time and however well they were rehearsed, not everything could be controlled or foreseen. Experiencing a failure in test situation can act as a sad reminder of the loss of personal control and trigger an emotional response. In such cases, the researchers can only apply their human and personal skills to offer comfort. Such unexpected reactions can also enhance sensitivity in researchers with regard to future cooperation with (potentially vulnerable) users. Even though the framework for ethical guidance could not prevent the particular incidents in the FRR project, they provided the research team with useful tools for discussing the issues. During the FRR project the partners who conducted user tests came to adopt a shared view of the ethical dimensions of user involvement, which became inscribed in the project’s approach to planning the user trials and the preparation of users. The shared view and understanding of appropriate and acceptable ways of confronting users 58 M. Rauhala / The Shaping of Ethical Peer Review and Guidance in the FRR Project with potentially embarrassing research situations can be called the practice or ethics of user involvement of the FRR project. Unfortunately there is no way to control how actors who are not committed to the normative frameworks that are shared in a project make use of the materials they have access to. In this way, a well-meaning user who intended to promote a good cause, ended up against his wishes in a newspaper article which depicted him sitting down on the toilet prototype. Despite the user’s protest and the ethical reviewer’s intervention the picture was published. This example serves to show that those who are external to a particular practice do not necessarily feel obligated to respect its rules. Nor do those who share the common view or practice necessary have any means, beyond kind words, to persuade others to follow their good example. In conclusion, the FRR project’s approach to ethical review and ethical guidance was successful in drawing the researchers’, in particular the engineers’ and developers’, attention to the ethical aspects of their day-to-day work. It also provided them with useful tools for addressing ethical issues in their future projects.6

Acknowledgements

The concept of ethical peer review for the FRR project is based on close cooperation between the author and Ina Wagner, professor for Multidisciplinary Systems Design and Computer-Supported Co-operative Work (CSCW) and Head of the Institute for Technology Assessment and Design, Vienna University of Technology.

References

[1] Council Decision of 25 January 1999 adopting a specific programme for research, technological development and demonstration on quality of life and management of living resources. [Internet] 1999 [cited 2010 Dec 30] Available from: http://eur- lex.europa.eu/Notice.do?mode=dbl&lang=en&ihmlang=en&lng1=en,de&lng2=da,de,el,en,es,fi,fr,it,nl, pt,sv,&val=329567:cs&page=#top. [2] Social Science Research Ethics [Internet] 2011 [cited 2011 Jan 27] Available from: http://www.lancs.ac.uk/researchethics/index.html. [3] Panek P, Alm N, Dayé C, Edelmayer G, Gentile N, Magnusson C, Mayer P, Molenbroek JFM, Neveryd H, Rauhala M, Rist A, Schlathau R, Zagler WL. Friendly Rest Room Project: A Toilet Prototype for Improving the Quality of Life of Old People and Persons with Disability. In: Pruski A, Knops H, editors. Assistive Technology: From Virtuality to Reality.Amsterdam: IOS Press;2005,pp. 8- 12. [4] Rauhala M, Topo P. Independent living, technology and ethics. Technology and Disability. 2003;15(3):205-214. [5] Flaskerud JH, Winslow BJ. Conceptualizing Vulnerable Populations in Health Related Research. Nursing Research. 1998;47(2):69-78. [6] Martin AW. Large-group Processes as Action Research. In: Reason P, Bradbury H, editors. Handbook of Action Research: Participatory Inquiry and Practice. London: SAGE; 2001, p200-208. [7] Computer Professionals for Social Responsibility (CPSR). What is participatory design? [Internet] 2005 May 6 [cited 2011 Jan 27] Available from: http://cpsr.org/issues/pd/introInfo/ [8] Finnish National Advisory Board for Research Ethics (TENK). Ethical principles of research in the humanities and social and behavioural sciences and proposals for ethical review. [Internet] 2009 [cited 2011 Mar 1] Available from: http://www.tenk.fi/ENG/publications.htm

6 Experiences of project workers’ with the continuous ethical review in the FRR project have been published elsewhere. Please, see [13]. M. Rauhala / The Shaping of Ethical Peer Review and Guidance in the FRR Project 59

[9] World Medical Association (WMA). The Declaration of Helsinki. Ethical Principles for Medical Research Involving Human Subjects. Adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964, and last amendment by the 59th WMA General Assembly, Seoul, October 2008. [10] The Council for International Organizations of Medical Sciences (CIOMS) in collaboration with the World Health Organization (WHO). International Ethical Guidelines for Biomedical Research Involving Human Subjects. CIOMS, Geneva, 2002. [11] European Group on Ethics in Science and New Technologies (EGE). Ethical issues of healthcare in the information society. Opinion n° 13 - 30/07/1999. [Internet] 2011 [cited 2011 27 Jan] Available from: http://ec.europa.eu/european_group_ethics/docs/avis13_en.pdf [12] Rauhala M. Ethical Counselling as a Working Method in Designing Technology for People with Dementia. In: Topo P, Östlund B, editors. Dementia, Design and Technology: Time to Get Involved. Amsterdam: IOS Press; 2009, pp. 97-110. [13] Rauhala M, Edelmayer G, Topo P, Zagler WL. Ethics and Assistive Technology Development - Project Workers' Experiences with Continuous Ethical Review. In: Eizmendi G, Azkoitia JM, Craddock GM, editors. Challenges for Assistive Technology. Proceedings of the 9th European Conference for the Advancement of Assistive Technology in Europe (AAATE). Amsterdam: IOS Press; 2007, Volume 20, pp. 610-614.

60 A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-60 User-Driven Research – How to Integrate Users’ Needs and Expectations in a Research Project

Christian DAYÉ1, Marianne EGGER DE CAMPO EURAG – European Federation of Older Persons, General Secretariat, Graz, Austria

Abstract. Within the FRR-project, user involvement was understood as a core task of researchers, designers and developers in the consortium, urging them strongly to justify their decisions with comments and expectations from potential users. What distinguishes our research structure from most other approaches to user involvement is the fact that, from the very beginning, primary and secondary users as well as representatives from the ethical review team had a say in structuring the research procedures and choosing the appropriate methods. Not only design decisions, but also research decisions were agreed with user representatives. In order to achieve that in an effective manner, we relied on a structure that combined continuous and specialized ways of collaboration with the user. This way of structuring user-driven research developed within the FRR-project constitutes an approach that could be used as a model for similar research projects, especially for those involving vulnerable users.

Keywords. Toilet, User Needs, User Involvement, Triangulation, Research Ethics, Assistive Technology, User-driven Research

1. Introduction

From the very beginning the FRR project claimed uniqueness in terms of considering users' expectations in research and development. For instance, in the part of the contract describing the work to be done within the FRR project, it is stated that users “are actively involved, as equal partners, and influence all research stages”. This chapter describes the approach to user involvement applied within the FRR project, and its implications. Reflecting both the professional background and the role of EURAG within the FRR-consortium, it is mainly concerned with the involvement of users into research activities. Actually, it focuses on how to integrate users in research about their own needs, expectations and preferences. The main task of researchers engaged in this kind of work is to assess users’ opinions and needs towards certain aspects of the area of interest, in this case toileting. It does so by collecting reactions towards given equipment or sketches of possible solutions, as well as by asking users to indicate problems with standard toilets. Toileting is in any case a multi-dimensional phenomenon, relating technology and design, aspects of health and hygiene, psychological, social and societal factors. From the beginning of the project, it was clear that a research design depicting this multi-dimensionality has to combine

1 Corresponding Author: Christian Dayé, University of Graz, Department of Sociology; Address: Universitaetsstrasse 15/G4, 8010 Graz, Austria; E-mail: [email protected] C. Dayé and M. Egger de Campo / User-Driven Research 61 quantitative and qualitative methods. Research, thus, requires a methodological setting that enables to cross-reference data from various sources, implementing the principles of triangulation. Denzin describes four basic types of triangulation: data triangulation, investigator triangulation, theory triangulation and methodological triangulation [1]. Within the setting of FRR, the most important type was methodological triangulation, i.e. the use of multiple methods to study a phenomenon, which consequently called for data triangulation, the cross-referencing of various kind of data. Data originated from various methodological settings, thus located on different positions on dimension like e.g. quantitative vs. qualitative data, sociological vs. technological data, questionnaire vs. log file data. Also, investigator triangulation, i.e. the use of several different researchers was applied. However, one very decisive type has been added to this fourfold scheme by Janesick [2]. She called it interdisciplinary triangulation, urging the researcher to look beyond the usual frontiers of his/her discipline in order to come to a picture of the studied phenomenon that is more likely to depict the reality of this phenomenon than it could be achieved within the mere artificial boundaries of disciplines. Though depending on the research context, triangulation can enhance the probability that the research results are valid, i.e. that they depict what they are said to depict. If one achieves to create a research design that links all these aspects it is very likely to produce results that enable designers and developers to come up with usable, useful, and ‘useworth’ technology [3]. This can be understood as the second task of researchers: to communicate and sometimes advocate the results of their research activities towards the other partners, thus allowing for interdisciplinary triangulation activities within the project consortium. Nevertheless, it is necessary to make clear that it does not lie within the responsibility of the researchers whether the results of their activities are appropriately implemented in the design. The emphasis that is put here on research activities is not neglecting the importance of other activities within RTD-projects (Research & Technological Development); at least in the realm of assistive technology development, the first purpose of research is to provide input for design and development activities. Thus, provides a starting point, from which the consortium sets out to find its way towards a realization of useful and innovative technology. Research, nevertheless, has more to offer than just a starting point. Under certain conditions, continuous interaction between design and research partners allows for continuous refinement at several stages of the design and development process. Researchers thereby form a link between the users and the design and development partners. After some general considerations on user involvement (paragraph 1), the paper focuses on the question how to integrate users' needs and expectations in an RTD- project like FRR. The definition of various user categories is described (paragraph 2), and continued by reflecting on some principles of user-driven research. Further, the approach of considering users' comments both in design and research decisions is promoted and a combination of both continuous and specific forms of collaboration between users and project partners (paragraph 3 & 4) is proposed. Finally, four decisive stages of user-driven research are defined (paragraph 5), and followed by a conclusion.

2. User Involvement

User involvement, in its basic understanding, refers to the notion of an interaction between the actor responsible for a product or service (either being the producer or the 62 C. Dayé and M. Egger de Campo / User-Driven Research provider) and the consumer of the respective product or service. In this general definition, user involvement has particularly economic relevance. The decision whether a product or a service fails or succeeds in the market is finally taken by the consumer. This also applies to assistive technology (AT) products. The risk of launching or offering an AT-product of low usability remains high as long as the preferences, needs, objections and suggestions of the consumer are not taken into account. At all stages in the lifetime of a product, from its development to its distribution and finally to its use by the consumer, users can and should be involved. Thus, at least three levels of user involvement can be distinguished: The first level is the area of development. User involvement in this context is a research and development strategy. Potential users shall steer, or at least guide the development process, thereby trying to ensure a higher acceptability of the later product. Examples for strategies of user involvement efforts at this level are user- driven research, when the focus is on research, and user-centered design, when the focus is on design. The following paragraphs focus on user-driven research, though some of the considerations presented show intersections with other levels of user involvement. The process of choosing an AT-device can be understood as the second level of user involvement. It deals with the decision which device is best for which person. It was found that the less the consumer is involved in this process of selection and delivery, the more likely s/he is to refuse to use this device, a phenomenon called abandonment [4]. Scientific effort in this area on the one hand aims at raising the awareness of the experts towards the social and psychological importance of user involvement, for example as stated in [5] “The delivery of technology is not an end in and of itself; the processes involved in ensuring adequate attention to the finer points of technology integration include a unique understanding of the person with a disability. Professional efforts to deliver the targeted technology can be successful only if attention is given to the needs of the individual”. And, on the other hand, on developing didactic routines for the user that deliver the knowledge requested to actively participate in the selection process [ 6]. The third level, the area of support services and evaluation after the delivery of the AT-device, has raised growing awareness throughout the past decade. Developed initially for justification purpose towards the (mostly public) investors [7], research activities in this area repeatedly showed that a continuous personal interaction with the user of a certain AT-device has presumably the same impact on the success of the delivered AT-device as the delivery of the ‘right’ customized technology [8]. Considering this, the practice of user involvement transcends its mere economic relevance. Within AT-development efforts funded by public sources, it relates to societal and political normative concepts like democracy, equality, legitimacy, active citizenship, participation and transparency [9]. Considering this as a normative basis, we defined the basic principle of user involvement as follows: “The development of the FRR should be primarily based on values of needs instead of market.” [10] The development should be guided by the needs, wishes, expectations and constraints of the target population instead of the interests of stakeholders that will not use the FRR themselves. C. Dayé and M. Egger de Campo / User-Driven Research 63

3. User Categories

In order to define the target group of the FRR-project, the following rough categories of users were distinguished:

− Primary users: This category comprises older persons and persons with (physical) disability. − Secondary users: This term refers to persons assisting primary users. Here, above all, we find family carers or relatives; further, this category contains caregivers, nurses, therapists, practitioners and the like, but also cleaning staff should be considered to assess questions of hygiene. − Tertiary users: Within this group, we find decision-makers and stakeholders from local and national authorities, insurance companies, hospital managers, organizations that provide AT-devices etc.

Due to the basic principle of user involvement mentioned above, users from the first two categories were involved in the research and development activities. As tertiary users are assumed to represent a market perspective, their contribution is mostly valuable for the levels of AT provision and service delivery as described in the previous paragraph, but it can be regarded as less essential at the level of the initial design and development phases.

4. User-Driven Research

Development work is oriented towards potential consumers – this notion can admittedly not be treated as epoch-making novelty. For many decades now, market researchers investigate needs, preferences, objections and suggestions of consumers, prefiguring trends of a continuously evolving entity they called market. The results of their studies traditionally are translated into guidelines that serve as basic grid for the subsequent development efforts. Consequently, in the end of development, consumers are usually called in a second time to evaluate the potential product or, in more general terms, the outcome of the development phase. Nevertheless, over the years, a growing number of failures and problems seemed to indicate that this two-phased scheme of user involvement (in the beginning and in the end) could not guarantee the success of a product. It was noticed that the reason for these failures was that the potential users were only sporadically involved in the design and the development process. Needs and wishes of consumers have been collected to set a starting point for development work and define the aims it should reach, but the consumers themselves were not actively integrated in the design and development process. Especially, in the area of assistive technology, this was more than just a problem of marketing. Users were not enabled to contribute to the development of products that they finally should benefit from. Their experiences from daily life were not acknowledged as expertise with a great potential to enhance the quality of development process. Step by step, it was understood both by researchers and stakeholders from various backgrounds that most of the advantages of user involvement can only be assessed via the narrow pass of continuous collaboration with users. It is understood that this approach is complicating the development process, prolonging it in terms of time and making it more expensive. Though it was found that 64 C. Dayé and M. Egger de Campo / User-Driven Research

AT-companies are rather interested in the development strategy of user involvement and are also aware of the opportunities it can bring to their development work, most companies do not follow this strategy for the reasons mentioned in [11]. Metaphorically spoken, they still prefer to use the highway, avoiding the narrow passes, even if the risk of driving past the place they want to reach is relatively high. They see the advantages user-driven research and user-centered design can to offer, but the effort necessary to apply these strategies properly, i.e. soundly, thoroughly and continuously, surmounts what they are willing (or able) to invest. It can be assumed that this is partly a problem of interdisciplinarity. Depicting a phenomenon in its multi-dimensionality requires experts from many different fields. However, it can be assumed that another significant problem in this context arises when dealing with the question how continuous collaboration can be carried out in a way that is at the same time efficient in terms of budget (both for the users, and for the researchers) and effective in terms of valuable results assuring a high quality development process.

5. User Board & User Club

A possibility to solve the dilemma between time and budget restrictions and high validity of users' response is to combine continuous and specific forms of interaction and collaboration with the user. Within the FRR-project, we structured the collaboration with users along two principle lines. The first line was built up by users who have professional experience with the situation of specific user groups. Represented in the user board, they continuously followed, commented and sometimes criticized the project’s development activities, forming thus a kind of continuous monitoring board. This user board involved specialists from various backgrounds: primary users experienced in representing the interests of specific user groups, a general practitioner, nurses and therapists with different areas of expertise. All together, the user board consisted of seven persons that agreed to accompany the project and to be available for the researchers in case of questions during the process of development. The second line, called user club, was understood as a form of specific collaboration. Some of the users in this club, in total about 50-60 persons, were invited at strategic points of the development process in order to evaluate the current status of technological features and provide ideas for further development activities. Usually, this collaboration took place in the framework of laboratory tests that were carried out regularly within the project’s development. Within the FRR-project, five test cycles were carried out, thus forming a cyclic sequence of development phases oriented at a continuous enhancement of the developed features [16]. The test participants were selected together with members of the user board according to the principles of theoretical sampling [12]. In the context of FRR research activities, theoretical sampling means the conscious selection of test users according to their experience and knowledge, given the area the research is concerned with. The test participants were chosen according to the assumed contribution they could bring to the project. E.g. when testing a toilet is adjustable in height and tilt which addresses people with restricted mobility, the theoretical sampling suggests to choose people with mobility problems. This, on the one hand, reduced unnecessary effort on the part of primary users and thereby counteracted the possibility of disappointment which forms a massive though often not considered ethical problem. On the other hand, it helped to focus on certain aspects of the users’ interaction with the given equipment, thus C. Dayé and M. Egger de Campo / User-Driven Research 65 enhancing the efficiency of our research. Theoretical sampling thus provides a rather powerful strategy for user driven research, above all as it avoids the narrow logic of random sampling that, at least in our opinion, proved to be rather misleading in contexts similar to ours. The main characteristics of the two forms of collaboration are summed up in Table 1. By helping us with choosing the test participants, the user board acted as a kind of mediator between the user club and the FRR-research and development team. Most of the members of the user board were professionally related to members of the user club. The combination of these two lines of collaboration allows for a development process steered by the primary and secondary users, whereas the involvement is structured soundly, thoroughly and continuously and the data gathered by this involvement show high degrees of systematization and complexity.

Table 1. Continuous collaboration versus specific collaboration

Continuous collaboration Specific collaboration User board User club

Members of the user board continuously accompany Members of the user club were involved in the the project and are available for the research and project at defined strategic points to evaluate the development team, optimally throughout the project’s progress and provide input for further lifetime of the project. development. They participated in all central decisions of Nevertheless, they were kept up to date by regular development as well as of research activities. news Further, they participated in the tests as pilot testers. This way of collaboration is very intensive in terms The reason for that was to achieve a continuity of of time. It requires a lot of flexibility, commitment test participants, thereby broadening the quality of and commitment of the users. the data.

Within the FRR-project, user involvement in research and design activities was carried out in five places, the so called User Research Bases (URBs). These URBs were located at the premises of project partners in Athens, Delft, Lund, Milan, and Vienna. In total, more than 250 documented tests were carried out within three years of project lifetime [16].

6. Four Phases of User-Driven Research

Based on these two forms of collaboration, one is enabled to tackle all the tasks research implies in a way that really merits the term „user-driven“. Referring to the FRR project, these tasks can be assigned to four decisive phases.

6.1. Phase 1: Setting Up the User Board

In the first phase, the user board has to be set up, possibly taking into account the challenges of the coming years and thus inviting persons that themselves can contribute and are also willing to contribute to the project’s activities. It is further wise to consider the opportunities secondary users could bring in terms of selecting test participants 66 C. Dayé and M. Egger de Campo / User-Driven Research from their professional scope. URB Vienna acted as prototypical unit, delivering inputs to the other URB’s of the FRR-project.

6.2. Phase 2: Structuring the Collaboration

Together with the members of the user board, the basic grid for the collaboration within the coming years is being planned. It should be made clear to all persons involved how many resources (mainly in terms of time) are available both from the user board members and the project partners involved. That is of central importance, above all when the collaboration of the user board happens on a voluntary basis. Though the user board members get reimbursed their travel expenses, there were no funds available to pay them equally as project employees as it once was suggested by the FORTUNE- consortium [13]. It is clear that this second phase cannot be clearly separated from the first phase, because the general conditions of collaboration of course have to be made transparent to potential members of the user board.

6.3. Phase 3: Planning of Joint Activities

It was a crucial point for the implementation of user-driven research that the user board members as well as the ethical review team were involved in planning the research activities. Together, it was decided which topics were most promising and should be addressed, and which methods (tests, focus groups, etc.) were best suited to study these topics. Further, the test populations were chosen by the user board – according to the principles of theoretical sampling as shortly described above. Jointly a so called „FRR Information Kit“ was developed, a collection of information material on the background of the project, the purpose of the specific test round, and the technological equipment the participants were invited to test. Further, it contained a confidentiality agreement needed for reasons of patent application and, most important, information on the informed consent the users were asked to give. Thus, this information kit was part of the informed consent procedure. As Fischman puts it, „Obtaining consent is more than simply having a potential research participant sign a consent form; it is a process by which necessary information is communicated to the participant by the researcher.“ [14] The conception of informed consent as a process understands the signing of the consent form as the last step of an intensive communication process between the researcher and the participant that started some weeks before the actual test, and thus the signing, takes place [15]. Also, a test script (see Table 2) was developed that provided the base for every testing activity. The total duration of the test, thereby, was about two hours. After each point the voluntary users were asked whether they were willing to continue the test. As this kind of planning was repeatedly done (i.e. prior to every test round), we ensured that every step in the research process could be taken in a cooperative atmosphere and, most importantly, in an ethically safe way.

6.4. Phase 4: Evaluation of the Project’s Outcome – Validation

Finally, user involvement must be considered in the end of a project when evaluating whether the project has reached its objectives. This final decision whether or not the project was successful is up to the users, thus finalizing the process of user involvement in a sound way. This does not have to be a simply binary decision relying exclusively on the categories of Yes or No. As the chapters on the validation phase in this volume C. Dayé and M. Egger de Campo / User-Driven Research 67 shows, validation activities can contribute to a more thorough understanding of problems with the proposed design [17]. Experiencing design in daily life might lead to other attitudes towards the given device, its functionality and its design, thus possibly requiring re-design.

Table 2. Test script

(1) Welcoming: First, the project partners introduced themselves. They made clear that any questions the test user might have would be answered at any time. To ensure that test participants can at any time address the representatives of the FRR-project, we were wearing name tags during the whole test run. (2) Introduction: The participant was introduced to the FRR-project and its aims. Optionally, a video-tape was presented showing the current prototype. The purpose of this video was to introduce the functions of this prototype. (3) Confidentiality agreement: The confidentiality agreement was signed. (4) Demonstration: After this, the voluntary participants were asked to go into the room where the tests were carried out. Here, once again, a project employee demonstrated on the spot the features of the prototype and how to handle them. (5) Instructions: The next step was that each point of the informed consent form was read out and explained. After the instructions the persons were explicitly asked whether they wanted to participate in the tests. (6) Informed Consent: If all questions were completely clarified and after it was made sure that the test user participated voluntarily, s/he was asked to confirm the consent with a signature. (7) Test: The participants were asked whether they wanted to do the test on their own or with support of the (nursing) staff present. Then, the test was carried out. (8) Interview: After the test the participants were asked to give feedback in a semi structured interview about how they have experienced the test, whether something was unpleasant, whether they find the technical possibilities of this prototype helpful or not. (9) Thank you: Finally, all the persons involved in the testing procedure came together to explicitly thank the participant for his/her time and effort.

7. Conclusions

User involvement in the user driven research design is twofold: firstly it integrates users in decision-making processes concerning the collection of data (i.e. sampling, methodology). Secondly users' responses at various stages of development of the FRR were analyzed (by content analysis) and complemented by findings from literature. This knowledge (documented in deliverables and reports to the consortium) enhanced and guided the design and engineering decisions by setting goals and priorities and by feeding back creative new ideas from practice.

68 C. Dayé and M. Egger de Campo / User-Driven Research

Acknowledgements

We are very grateful for continuous support from our user board members Robert Schlathau, representative of the Austrian Multiple Sclerosis (MS) Society, Vienna (AT); Ramona Rosenthal, manager of a day care center for MS patients, Vienna (AT); Christine Pauli, nurse at a center for neurological long-term care, Vienna (AT); Niki Stefanakis, voluntary coworker at project partner fortec, Research Group on Rehabilitation Technology, Vienna (AT); Eduard Riha, secretary-general of the Austrian National Council of Disabled Persons, Vienna (AT); Karin Schliefsteiner MD, practitioner in Graz (AT); and Silvia Dvorak, nurse at the Geriatric Center Wienerwald, Vienna (AT).

References

[1] Denzin NK. The research act: A theoretical introduction to sociological methods. New York: McGraw- Hill; 1978. [2] Janesick VJ. The Dance of Qualitative Research. Metaphor, Methodolatry, and Meaning. In: Denzin NK, Lincoln YS, editors. Handbook of Qualitative Research. London-New Delhi: Sage Publications, Thousand Oaks; 1994, p.209-219. [3] Eftring H. The Useworthiness of Robots for People with Physical Disabilities [Doctoral Dissertation]. Certec, Division of Rehabilitation Engineering Research, Lund University; 1999. Available from: http://www.english.certec.lth.se/doc/useworthiness [4] Phillips B, Zhao H. Predictors of Assistive Technology Abandonment. Assistive Technology. 1993;5:36-45. [5] Brown-Triolo DL. Understanding the Person Behind the Technology. In: M.J. Scherer MJ, editor. Assistive Technology. Matching Device and Consumer for Successful Rehabilitation. Washington D.C.: American Psychological Association; 2002, p.31-46. [6] Andrich R, Besio S. Assistive Technology education for end-users: the Eustat perspective. In: Placencia-Porrero I, Ballabio E, editors. Improving the Quality of Life for the European Citizen. Technology for Inclusive Design and Equality. Amsterdam: IOS Press; 1998, p.152-155. [7] Gelderblom GJ, De Witte LP. The Assessment of Assistive Technology Outcomes, Effects and Costs. Technology and Disability. 2002;14:91-94. [8] Wessels RD, De Witte LP, Weiss-Lambrou R, et al. A Dutch Version of QUEST (D-QUEST) applied as a routine follow-up within the service delivery process. In: Placencia-Porrero I, Ballabio E, editors. Improving the Quality of Life for the European Citizen. Technology for Inclusive Design and Equality. Amsterdam: IOS Press; 1998, p.420-424. [9] Dayé, G. Meeting the Challenges of Demographic Change. This volume. [10] EURAG. Guidelines for User Involvement. Internal document FRR project; 2001 Jan. [11] Baldursdottir R, Flo R, Hurnasti T, et al. User Involvement in the Development of Assistive Technologies in the Nordic Countries (USDAT). In: Marincek C, Bühler C, Knops H, et al, editors. Assistive Technology – Added Value to the Quality of Life. Proceedings of the AAATE 2001. Amsterdam: IOS Press; 2001, p.95-98. [12] Glaser BG, Strauss AL. The Discovery of Grounded Theory. Strategies for Qualitative Research. New York: Aldine de Gruyter; 1967. [13] Bühler C. Guidelines for Participation of Users with Disabilities in R&D Projects. In: Marincek C, Bühler C, Knops H, et al, editors. Assistive Technology – Added Value to the Quality of Life. Proceedings of the AAATE 2001. Amsterdam: IOS Press; 2001, p.104-109. [14] Fischman MW. Informed Consent. In: Sales BD, Folkman S, editors. Ethics in Research with Human Subjects. Washington D.C.: American Psychological Association; 2000, p.35-48. [15] Ethical Review Team. On informed consent procedures for testing the FRR. Internal document FRR project; 2001 May. [16] Panek P, Edelmayer G, Mayer P, Zagler WL. Laboratory Tests of an Adjustable Toilet System with Integrated Sensors for Enhancing Autonomy and Safety. This volume. [17] Gentile N, Dayé C, Edelmayer G, Egger de Campo M, Mayer P, Panek P, Schlathau R. Concept, Setting up and First Results from a Real Life Installation of an Improved Toilet System at a Care Institution in Austria. This volume. A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People 69 J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-69 The FRR-Questionnaire – Assessing Who Needs What Where

Christian DAYÉ1 EURAG – European Federation of Older Persons, General Secretariat, Graz, Austria

Abstract. A questionnaire measuring difficulties with toileting and users preferred solutions was developed as part of the User Needs Research Design. It was disseminated in five European countries. This questionnaire was conceived as building a bridge between technological and non-technological aspects of toileting. In this paper, the most relevant outcomes of this questionnaire will be reported. In the beginning the general characteristics of the sample will be described, thus providing background knowledge for the interpretation of results. The purpose of using this questionnaire was threefold. First, it delivered quantified insights into the need for new technology in this area by assessing the extent to which the lack of usable toilets de facto reduces the quality of life of elderly and disabled persons, therefore justifying the effort spent in the development of innovative solutions. Second, it assessed the frequency of various difficulties with toileting and the acceptance of proposed solutions and assisting devices, thus guaranteeing a development process steered by users towards an AT (assistive technology) device that allows for an improved quality of life. And third, the questionnaire gave an insight into cultural differences with toileting throughout Europe, thus ensuring that AT products developed in this area in the future can offer tailored solutions.

Keywords. Toilet, User Needs, Quantitative Research, International Survey, Assistive Technology, User Driven Research

1. Introduction

Since the early nineties of the last century, studies repeatedly show the importance of non-technical aspects in the area of Assistive Technology (AT). The success of an AT- device, defined by complete or partial physical rehabilitation or, if not possible, the enhancement of the user’s quality of life, can not be guaranteed solely by the functionality of the device. It is strongly depending on social and psychological factors [1, 2]. To consider psychological and mental factors as well as factors of the social and societal environment of the individual is thus an essential demand towards Research & Technological Development (RTD) efforts in this area. The questions that shall be raised in the beginning of such a project must not be reduced to a functional or technological perspective. Questions like: ‘What functions should an innovative toilet include?’, should be seen in combination and interrelation with socio-psychological dimensions, as e.g. simplified by the question: ‘Which non-technological requests must such a toilet meet in order to be helpful?’ The more sophisticated this linkage is, i.e. the

1 Contact Information: Christian Dayé, University of Graz, Department of Sociology; Address: Universitaetsstrasse 15/G4, A-8010 Graz, Austria; E-mail: [email protected] 70 C. Dayé / The FRR-Questionnaire – Assessing Who Needs What Where better these different dimensions are combined into a holistic picture, the lower the risk of developing a product that in the end does not provide any significant improvement for the users it is designed for. The questionnaire of which the results are presented here is understood as a bridge between technological and non-technological aspects of toileting, capturing thus the problem of toileting as a multidimensional phenomenon interrelated with concepts like personality, technology, societal environment, culture [3, 4, 9]. Its items were developed based on the outcomes of an exploratory research phase carried out in the beginning of the FRR-project, in which twelve in-depth interviews were carried out with care workers in Austria, trying to assess the most important problems when using standard toilets. The resulting questionnaire contained 61 items on four pages. It was distributed in the German speaking area of Central Europe (Austria, Germany and Switzerland), translated and disseminated in Greece and in Italy, as well. The questionnaire was used as an anonymous paper and pencil questionnaire to ensure confidentiality of a rather sensitive matter in every day life. So far, no comparable study has been conducted. This questionnaire therefore represents a unique data source, combining technological and non-technological perspectives to a multifaceted picture of toileting. After describing the general characteristics of the national sub-samples (paragraph 1), insights are reported into the need for new technology in this area gained by the questionnaire by assessing the extent to which the lack of usable toilets de facto reduces the quality of life of elderly and disabled persons. It is argued that every effort spent in the development of innovative solutions is justified by the massive restrictions caused by the lack of adequate toilet solutions (paragraph 2). Further, the questionnaire assessed the prevalence of difficulties with toileting and the acceptance of proposed solutions and assisting devices, thus guaranteeing a development process steered by users towards an AT device that allows for an improved quality of life (paragraph 3). Finally, the questionnaire's potential to study cultural differences with toileting throughout Europe is demonstrated and the main arguments of users against an installation of such a toilet are reported, thus ensuring that AT products developed in this area in the future will be tailored to users – and consequently customers (paragraph 4).

2. The Samples

2.1. Description of the Samples

The data analysis of which the results are presented here is based on four sub-samples that represent a total of 345 respondents. These four sub-samples are distinguished according to the recruitment process and are named as follows: Older People from Central Europe (1), Members of Austrian MS Society (2), Greek respondents (3), and Italian respondents (4). For better readability, onwards they will be referred to via the numbers. The recruitment of the sub-samples was carried out by FRR-partner organisations in several phases and by different means. Sub-sample (1) was recruited by contacting member organisations of EURAG in the German speaking area of Central Europe, sending them a certain amount of questionnaires. Sub-sample (2) was established by including the questionnaire in the bi-monthly journal of the Austrian MS Society, asking the readers to complete the questionnaire and send it back. Further, the C. Dayé / The FRR-Questionnaire – Assessing Who Needs What Where 71 questionnaire was disseminated by project partner HAGG (Hellenic Association of Gerontology and Geriatrics, Athens), thus building up sub-sample (3). In Italy, the questionnaire was disseminated both by project partner SIVA in Milan (Servizio Informazioni Valutazione Ausili) and by SSSUP (Scuola Superiore Sant’Anna) in the region of Pisa among older persons living both in their homes and in care institutions; the respondents are comprised in sub-sample (4). In Table 1 the age of the respondents is described by minimum, maximum, median and mean. The variable gender is described by its distribution (in %, see Table 1). In general, it can be said that the samples concentrate on persons aged 50+, thus ensuring that the persons contributing to the project via the questionnaire represent the main target user group, i.e. the older population of several European countries. Further, it is obvious that women dominate all the samples with a proportion of about 2:1. This high proportion of females in the study on the one hand reflects the demographic situation, i.e. women outnumbering men in the elderly [5]. On the other hand, it can be argued that the way of disseminating the questionnaire via institutions in the social and health care sector (where there are more female clients) resulted in a higher participation of women. However, as Figure 1 shows, this proportion is nearly the same in all age groups, thus decreasing the risk of unintended bias when comparing the sub-samples. The age cohort that finds itself represented best is the one reaching from 61 to 70 years of age. About a third of the interviewees are in this cohort. As the first cohort is characterized by a very unsophisticated “up to 40”, it becomes clear that the focus of the questionnaire lies upon people in the second half of their lives. As 63 questionnaires were completed by people aged 81 or above, almost 20% of the respondents are aged 81+, making this database a relatively unique source of information. Understood as different groups (and thus assuming, to some extent, homogeneity within these groups), these four samples enable us to investigate cultural dimensions that otherwise could not be investigated. Figure 2 shows the distribution of the variable frequency of assistance2 for the four samples (in %).

Table 1. General characteristics of the samples

Sample name Age Gender (in %) Min. Max. Median Mean Female Male (1) Older People from Central 38 91 73 69,9 72.5 27.5 Europe (N = 93) (2) Members of Austrian MS 29 81 54 51,5 66.2 33.8 Society, (N = 77) (3) Greek respondents, (N = 126) 21 96 73 70,7 65.9 34.1 (4) Italian respondents, (N = 27) 24 93 78 72,5 66.7 33.3

2 The respective item reads: “Please also indicate how often the persons assisting you come to you: daily – at least once a week – less frequently – never.” 72 C. Dayé / The FRR-Questionnaire – Assessing Who Needs What Where

35 30 25 20 female 15 male Percent % 10 5 0 up to 40 41 to 50 51 to 60 61 to 70 71 to 80 81 to 90 90 and mor e

Figure 1. Age-gender distribution (n = 345)

"Please indicate how often the persons assisting you come to you"

80 Elderly A-CH-D 60 Austrian MS Society 40 Greek To 65 Greek Over 65

Percent (%) Percent 20 Italian resp 0 Daily Weekly Less Never

Figure 2: Frequency of assistance (n = 345)

The frequency of assistance the respondents get is reported as an indicator of the dimension of health or dependency on assistance. Existing differences between the various samples like those that can be read from this graph, e.g. that an overwhelming majority of the Italian respondents need care on a daily basis, must be taken into account when interpreting the national results. Further, it is suggested that dividing the Greek sample into two subsamples along the variable age allows for leveling out an internal heterogeneity and thus allows for a more elaborated analysis. However, it should be noticed that there is neither a significant relation between age and the frequency of assistance nor between age and the degree of dependency (measured by ADL scores [6]). Thus, in this sample, age is not a valid predictor with regard to the question how frail or healthy a person is.3

3 This presumably is a speciality of our sample, but nevertheless underpins the notion that we achieved to depict the population we wanted to depict. C. Dayé / The FRR-Questionnaire – Assessing Who Needs What Where 73

2.2. Sampling for FRR-Questionnaire

The rationale behind samples is, in general, that they enable the researcher to draw conclusions valuable for larger population that is represented by the relatively smaller sample. Usually, when dealing with questionnaires, random sampling methods are applied. Randomness in this context is defined each case of the studied population having a fixed or calculable chance of being selected, i.e. of being part of the sample. Probability statistics then measure quantitatively the risk of drawing wrong conclusions about the population [7]. This sampling method, however, requires some knowledge about the prevalence of the studied property, as an estimate of this prevalence is a basic term in the formula that is used to calculate the optimal sample size at given validity parameters [8]. As this background estimation of the prevalence was not available, it was decided to give up the idea of random sampling and choose the pragmatic solution of using available contacts of the partner organisations to distribute the questionnaire. By these means, the sample was built up as depicting not a whole population (e.g. of a country), but the target population the FRR shall be developed for. From this perspective, the chosen approach seems to be more effective, though generalizations can only be drawn about a part of the whole population.

3. The Need for Solutions

As mentioned above, the questionnaire was not restricted to a technology-oriented perspective but comprised various kinds of questions and dimensions of interest. The results reported in this chapter relate to a set of items that measures the extent to which the quality of life is affected by the lack of useable solutions in the everyday toilet. It investigated social and psychological considerations of the respondents, asking them to judge to what extent a series of statements is true for them. A quarter of the respondents stated that when using a toilet they are always afraid something could happen to them (e.g. falling or fainting; see Figure 3). In addition to the actual costs of accidents possibly caused by inadequate technology, the emotional costs of fear provide a massive argument for efforts to be spent in the development of better technical solutions in the toilet area. Further, this implies that, in congruence with the philosophy applied in the FRR-project, problems typically encountered when using a toilet are problems that can be solved only by designing a whole room concept. More than 50% (accumulated) of the respondents agreed that it applies at least to some extent that they avoid going out longer in order not to need to use a toilet (see Figure 4). This finding underpins the assumption that the lack of adequate toilet facilities manifests itself as an inescapable restriction in the lives of older people or people with physical disabilities. It affects their quality of life because it excludes them from participating in social life to the extent they would like to. Even from these short blank figures it becomes obvious that people from our target population feel inhibited in their daily life by the lack of adequate solutions in the area of toileting. This lack sets limits to their mobility that they cannot overcome, a fact which heavily impacts their quality of life. Consequently, the approval towards new solutions is rather high: About 60% stated that having user-friendly toilets installed in public areas would very much improve their every day life.

74 C. Dayé / The FRR-Questionnaire – Assessing Who Needs What Where

"When using the toilet I am afraid something could happen to me"

40 applies completely 30 applies to some extent 20 does not really apply

10 does not apply at all don't know 0 in %

Figure 3. Experienced fear on the toilet (n = 323)

"I try to avoid going out in order not to need to use a toilet"

40 applies completely

30 applies to some extent 20 does not really apply

10 does not apply at all

0 don't know in %

Figure 4. Avoidance of going out (n =337)

"Do you think that the installation of such user friendly public rest rooms would improve your every day life?"

60 yes, very much 50 40 a bit 30 hardly 20 no, not at all 10 don't know 0 in %

Figure 5. Opinions on improvement of every day life (n = 298) C. Dayé / The FRR-Questionnaire – Assessing Who Needs What Where 75

4. Challenging Technology – What to Improve?

To develop innovative toilet concepts is, as shown, an urgent request. But where to begin? To ensure that the direction for design and development work is given by the users, the questionnaire included an item block that asked the user to evaluate several parts of a standard toilet. By specifying how often they experience difficulties when using standard technology, they provided us with valuable information on how to improve the current situation. The respective items assessed how often the respondents experience difficulties with certain features of standard toilets.4 Within the frame of this analysis, two main measures are used to describe the importance of a problem: the rank and the score. The score is a measure that is calculated for each problem using the data of the questionnaire and then standardized in order to be comparable with scores from other samples. It multiplies the count of the “always”-answers with 10, adds the count of the “sometimes”-answers multiplied with 5, and divides it through the number of valid answers. The higher this score, the

Overall ranking of problems

7,0 1. no place to store 2. grips 6,0 3. room size 1 4. door 5,0 2 5. toilet seat 3 6. toilet bow l height 4,0 4 7. floor 5 8. mirror 6 Scores 3,0 7 9. light sw itch 8 9 10 10. toilet paper not in reach 12 14 11. w ash bow l height 2,0 11 13 15 12. w ash bow l size 13. toilet bow l size 1,0 14. flush 15. cannot use toilet paper 0,0

Problems

Figure 6. Ranking of Problems

4 The header of this first item block read: “Please try to imagine an ordinary toilet. What kind of difficulties do you experience when using an ordinary toilet? (If you have adapted the toilet in your private home please try to imagine a public toilet!)”, giving the following options: “always – often – sometimes – never – don’t know”. 76 C. Dayé / The FRR-Questionnaire – Assessing Who Needs What Where more important a problem was rated by the respondents. By ranking the problems based on their score, the urgency of various problems can be shown by sample. Thus, we obtain a Ranking of Problems that describes the internal relations between the problems in a simple dichotomous way (higher/lower). As displayed in Figure 6, the most pressing problem is the missing “place to put a walking stick or other personal belongings”, followed by “missing or inadequately- mounted grips” and the fact that the room size is not satisfying. The same analysis routine was applied with a second item block suggesting technological solutions. 5 This item block was thus investigating the acceptance of several ideas that were proposed in the very beginning of the project. The results are displayed in Figure 7. Considering that the maximum score one item can reach is ten, it can be said that the acceptance of the proposed solutions is very high, especially for the first five items reaching from 8.69 to 7.82 points. An alarm device that is mounted in a well reachable position is regarded as most important, followed by “a place to put a walking stick or other personal belongings”, and by grips “mounted on each side of the toilet and at

Overall ranking of improvements

10,0 1.alarm device 9,0 1 2 2.place to store 3 4 8,0 5 3.grip 6 7,0 7 4.light 5.flush 6,0 8 9 10 11 12 6.doors 5,0 13

Scores 7.toilet bow l height 4,0 8.bidet function 3,0 9.w ash bow l heigt 2,0 10.mirror

1,0 11.toilet seat

0,0 12.chip card Improvements 13.voice control device

Figure 7. Ranking of Improvements

5 Here, the header read: “Currently engineers and technicians are developing a user friendly toilet. It should consider the needs of aged and impaired users. Please indicate whether the following adaptations would be an improvement for you!”, giving the following options: “That would be a: significant improvement – some improvement – hardly any improvement – no improvement at all – don’t know.” C. Dayé / The FRR-Questionnaire – Assessing Who Needs What Where 77 adjustable height”. It can further be said that there is congruence between the experienced problems and the accepted solutions, indicating the validity of the results and reinforcing the request for better technological solutions in the respective areas.

5. Further Considerations – What to Take into Account When Reinventing the Toilet?

5.1. Cultural Differences

On grounds of the existing data base, it can be shown that there are cultural differences that manifest themselves in the evaluation of problems. It can be assumed that these differences are partly caused by differences in the physical abilities and partly by the fact that the term „standard toilet“ in different cultures refers to essentially different technical environments. Considering for example that older persons from Central Europe encounter more often the problem of toilet paper out of reach than the other respondents might partly be explained by different physical abilities. However, it remains unclear why the Greek older persons do not encounter the same problems. The most striking difference is that the Greek respondents have much more troubles with the toilet seat than other respondents; while it is ranked on 11th and 14th place by the samples from Central Europe (1) and (2), the Greek respondents (3) rank it 1st, regardless of their age. Here, it is rather likely that this is caused by different technical environments. Cultural differences of this kind should be taken into account when trying to come up with technical solutions that meet the needs of the users. A scientific explanation of these phenomena would however require further in-depth research, while a quantitative questionnaire can only indicate possible areas of differences.

5.2. Gender Differences

Further, it can be assumed that within the different cultures, there are gender differences in response to the questionnaire. A respective analysis revealed that when evaluating problems, gender does not play a major role. Only within the Greek respondents, one item showed a significant gender correlation, saying that Greek women are more likely to assess the height of the toilet bowl as a problem than their male compatriots (Spearman-Rho = -0.201*6) which may indicate that the interviewed men use the standard toilets in a different position. According to a personal communication with the Greek researchers the gender difference in sitting comfort is not a result of the squatting type toilets which would cause female users more strain when physically impaired. Most private homes as well as most public buildings are equipped with Central European standard toilets. Still, though, some respondents might have considered the existence of squatting type toilets when filling in the questionnaire. In general, the problems older persons and persons with physical disabilities have to face when using standard toilets can be treated as independent from gender.

6 Significant at the 0.05-level. 78 C. Dayé / The FRR-Questionnaire – Assessing Who Needs What Where

5.3. Counter-Arguments

The most decisive arguments against the installation of innovative toilet solutions as developed within the FRR-project were the following (see Figure 8).

insecurity

no need

size of room

money

0 10203040506070 in %

Figure 8. Arguments against installation of innovative toilet solutions (n = 345)

The most important conclusion to be drawn from this graph is that the developed toilet solution must be affordable: 64.7% stated that money was a decisive counter- argument. This is essentially underpinning the modular approach chosen by the FRR- consortium in the first year of the project. This modular approach enables users to choose which feature they need most urgently, thereby reducing the costs significantly. A second important conclusion is, as it also was suggested by the high acceptance of the proposed solutions, that a defensive attitude towards unknown technology (technophobia) is not as relevant as it was assumed, especially for older persons, in the beginning of the project. An overwhelming majority does not assess insecurity as a relevant argument against the installation of such a toilet. However, still a fifth anticipates insecurity, which leads to the conclusion that technophobia is a relevant issue for design and development, though there also is an explicit and known request for new technology in the toilet area.

6. Conclusions

It was demonstrated how valuable the input of a questionnaire can be for an RTD- project, especially when dealing with an area that is as unexplored as it is the case with toileting. Design links culture and technology. And if researchers achieve to transpose this linkage into their research instruments, it is likely that the final output of the development process will be a product that is of value for the persons it was designed for. Providing a bridge between technological and non-technological aspects, the questionnaire developed and disseminated as part of FRR User Needs Research succeeded to deliver valuable and, above all, new knowledge on toileting, thus being an instrument to advocate the needs of users and steer the development process. C. Dayé / The FRR-Questionnaire – Assessing Who Needs What Where 79

References

[1] Phillips B, Zhao H. Predictors of assistive technology abandonment. Assistive Technology. 1993;5:36- 45. [2] Brown-Triolo DL. Understanding the person behind the technology. In: Scherer MJ, editor. Assistive technology. Matching device and consumer for successful rehabilitation. Washington: American Psychological Association; 2002, p.31-46. [3] Scherer MJ. Living in the state of stuck. How assistive technologies impacts the lives of people with disabilities. Cambridge, MA: Brookline Books; 1993. [4] Scherer MJ, Craddock G. Matching Person & Technology (MPT) assessment process. Technology and Disability. 2002;14:125-131. [5] UN, Department of Economic and Social Affairs, Population Division. World Population Ageing 1950- 2050. New York: United Nations Publications; 2002. [6] Sonn U. Longitudinal Studies of Dependence in Daily Life Activities among Elderly Persons. Methodological development, use of assistive devices and relation to impairments and functional limitations. Scandinavian Journal of Rehabilitation Medicine. Oslo, Copenhagen, Stockholm & Boston: Scandinavian University Press; 1996; Supplement No.34. [7] Becker HS. Tricks of the trade. How to think about your research while you’re doing it. Chicago, London: The University of Chicago Press; 1998, p.67-108. [8] Bortz J. Statistik für Sozialwissenschafter. Berlin, Heidelberg, New York: Springer; 1999, p.103. [9] EURAG. Deliverable 4.1.4. FRR project document; 2004 Sep. 80 A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-80 Computer Based Information Gathering

Norman ALMa,1, Kenny MORRISONa, Peter GREGORa, Nick HINEa, Sian JOELa, Katrina HANDSa and Marja H. VAN WEERENb a School of Computing – University of Dundee, Dundee, UK b Landmark Design BV, Rotterdam, The Netherlands

Abstract. Toilets and toilet habits are perceived as a taboo subject that people may be reluctant or embarrassed to talk openly about. In the past, appropriately designed Computer Based Interviews have been shown to encourage more honest answers to sensitive questions than other forms of interview, and can be more interesting and engaging that filling out a paper questionnaire. This chapter presents Dundee University’s role within the Friendly Restroom project which was primarily to provide Computer Based Interviews and other computer-based requirements gathering tools to be used to elicit toileting requirements of elderly people. Dundee University also investigated the feasibility of using Virtual Reality technologies, such as 3D environments and 360 degree panoramas, to support this information and requirements gathering.

Keywords. Computer Based Interviews, Toilets, Virtual Reality, Information Gathering

1. Introduction

An important part of the Friendly Restroom (FRR) project was to ensure that the designs produced met the real needs of potential users, and that users were involved throughout the project in sharing their experiences, giving their views, and helping guide the design process. One novel method of gathering the views of users which was employed was the use of computer-based interviews (CBIs). The project developed a number of CBIs and other novel information gathering tools. The CBI has a 30 year history and has been shown to elicit revealing results. Due to its nature, the computer, unlike its human counterpart, is not judgmental, never bored, or impatient and does not become embarrassed. Because of this, people being interviewed about potentially embarrassing subjects often find a CBI to be pleasant, and easy to use. They often report they feel more empowered than in a face-to-face interview resulting in a greater number of answers and information of a higher quality [1,2,3,4,5]. The CBI team at Dundee University has many years experience in using this method as a tool for gathering information. Their experience includes interviewing primary school children, university students, scientists, people with alcohol problems,

1 Corresponding Authors: Applied Computing, University of Dundee, Dundee DD1 4HN, UK; E-mail: [nalm, kmorrison, pgregor, nhine, sjoel, khands]@computing.dundee.ac.uk

N. Alm et al. / Computer Based Information Gathering 81 patients and staff at a secure psychiatric institution and parents of children with behavioral problems [6,7,8,9,10].

2. Computer Based Interviews

Given the sensitive and possibly embarrassing nature of discussing toileting needs with strangers, it was decided to apply CBI to this task within the FRR Project. Using a computer-based approach also offered the advantage of easily including multimedia material into the interviews, and allowing for the possibility of delivering interviews remotely, over the internet. What was not clear at the outset of the project was how much cultural differences between the participating countries would affect the degree of embarrassment felt by participants in discussing toileting needs. In the event, we found that a stronger determining factor here was age, with older participants who we worked with being quite at ease discussing this subject, without the need for any account to be taken of sensitivities in this area. However the use of CBIs might still be of benefit, where the population of participants is more uneasy about discussing these subjects than the participants we worked with. The first CBI to be developed was web-based and consisted of two parts. Firstly an interview was developed which primary and secondary users could access directly. Secondly a translation tool was created which allowed the partners in the FRR project to translate an original English questionnaire version into their language, and which ultimately would allow users from other countries to complete the questionnaire in their own language directly.

2.1. CBI Interface

The system allowed the user to select their language of choice from a menu of flag symbols. The interface was designed so that the user’s attention was drawn to the centre of the screen, as the page was framed by a border. The interface also had a menu at the top of the page which allowed the user to see instructions on how to use the CBI as well as an option to return to the beginning of the questionnaire. The interview took a linear approach, with each screen showing one question at a time. Once the user selected their answer for that question from the page, another page was shown until the last question of the interview. At the end of each section in the interview, the user was shown a next section screen. This allowed the user to be informed of how far through the interview they were. In addition, by splitting the CBI into sections the questionnaire was in more manageable groups for allowing differing presentational choices e.g. the number of buttons could vary between one section and another or there could be multiple choices. At the end of the interview the user could see the answers they entered. The user could print a hard copy of these answers for their records. If the user had made an error in these answers, there was an option to add comments in a text box which could note the error, or the user could choose to go back to the page of the error and re-enter the correct answer, overriding the original. Once the user submitted their answers they were stored on a central database on the web server. 82 N. Alm et al. / Computer Based Information Gathering

2.2. Translation Tool

The Translation Tool had three options:

Allowing the user to translate the master questionnaire into the language of their choice Allowing that translation to have multimedia added to it Allowing the user to see the interview making use of that translation

The user had the ability to translate the master questionnaire from English into another language. The process of translation could be done in sections and did not need to be done all at once. The user had the ability to add images (jpeg or gif format) to the translation. The interface for this process showed the series of questions from the translated questionnaire and allowed the user to select an image from their own system which they could upload to the server. The image was then associated with the question or answer decided upon and was positioned, when shown, against it (Figure 1). The option to only allow jpeg and gif uploads was made in order to limit the size of the files which could be uploaded. However, the tool could be adapted so that more file types could be included e.g. higher resolution images, sound clips, or other multimedia files. The user was able to test and view the text they translated by using the User option of the Translation Tool. This User option of the tool acted very much as the user CBI does, with sections, one question per page and a view results page.

Figure 1. Interview with pictures. Questionnaire content and drawings from Landmark Design BV N. Alm et al. / Computer Based Information Gathering 83

3. User Trials and Focus Groups

Dundee University performed user-trials of the web-based CBI and two focus group discussions relating to the interviews and their graphics were also held. Data was produced on the attitudes of older people to a computer based interview on rest room requirements.

3.1. CBI User Trial: The CBI trial was performed in a cybercafé for older people in Airlie, a small village is Scotland. The participants’ age range was between 50 – 70, with one individual over 70. Eight persons participated in the trial and each completed 63 questions. The health problems that participants listed were back pain, pain in their fingers, hands and feet, and some eyesight problems. The main points gathered from the CBI included: most persons found that it was often, or sometimes, the case that the toilet was hard to flush, the wash bowl too high or too low or that there wasn’t anywhere to put a walking stick or personal belongings. The most popular toilet adaptations were grip bars, an emergency button and a place to put walking sticks or personal belongings. These findings were similar to those that were received using the paper questionnaire.

3.2. CBI Focus Group: The first CBI Focus Group was held at Dundee University. Five elderly people attended the group which consisted of a demonstration of the various types of CBIs available, a discussion about the CBI demonstrated, alternative CBIs that might be feasible and a discussion of issues about toilets and recommendations for improvements. The group members preferred the inclusion of photos in the interview rather than multimedia or simple text. This particular group commented that they liked to have an open discussion but understood that computer based interviewing could be useful for shyer people. Some felt uneasy about using a computer, the touch screen was preferred to the keyboard, “I’m no typist” was one response. A large font size was preferred The conclusions reached were that with this group of participants, the CBI was less essential than expected. The conversational discussion of the focus group allowed for more information to be elicited than could have been gained from the CBI. In the CBI trial the findings were in keeping with the results from the paper-based equivalent and very similar responses were given.

3.3. FRR Graphics Focus Group: A second focus group was held, also in the cybercafé in Airlie to discuss the graphics that were to be used in the CBI’s. The graphics were produced by Landmark Design, an FRR partner based in The Netherlands. For this focus group there were six participants, whose ages ranged from 60 to 75. Initially, there was a demonstration of the graphics and then a discussion on their acceptability. After this the group easily got into a discussion about their recommendations for improving toilet access and usability, making use of the picture as prompts occasionally. The consensus was that the pictures were acceptable, and helpful to the discussion, but they could be improved for more general acceptability by making the characters into humorous cartoon type figures (e.g. teddy bears). This would have the effect of making the material less personal. The use of humor was recommended as a way to 84 N. Alm et al. / Computer Based Information Gathering make possibly embarrassing material more comfortable to discuss. Some felt that the pictures could be a little less explicit but the overall opinion was that they had been well done and were very thorough. The point was made that the group knew each other very well, and so felt at ease discussing these matters in the group setting. A group of strangers might not do so well, and possibly individual interviews would be better.

4. Standalone Computer Based Interviews

Dundee University first designed and developed a predominantly text based computer based interview on rest room requirements which could be accessed from a website and which automatically stored results for subsequent analysis. An authoring and translation tool, which was accessible from a website, was also developed. This tool enabled partners to remotely construct interviews and produce translations of the interview in their own language. Field work with potential users identified the need for a version of the interview that could be run in a standalone format with no need for a good internet connection. This could be run from a laptop and taken to homes where internet access is not available. A version of the standalone interview incorporating illustrations was produced (Figure 2). It stored the results of the interview into a text file on the computer's hard disk. A dynamic version of the standalone interview was also completed which can retrieve the interviews constructed using the web-based authoring and translation tool. The standalone versions of the interview were developed using Macromedia Director.

Figure 2. An example question from the standalone CBI with pictures N. Alm et al. / Computer Based Information Gathering 85

5. Information Gathering and Virtual Reality

After completion of the web-based and standalone CBIs, an investigation was undertaken to determine the feasibility of using Virtual Reality (VR) technologies to support our information and requirements gathering. It was decided that these technologies should be web-based. The FRR project consortium consists of partners spread across Europe. Using the internet would make it easy to demonstrate, distribute and use the interviews. The VR software was designed to be easily accessible from any computer with an internet connection. The continuing increase in bandwidth size, broadband networks, desktop processing power and reduction of costs mean that the capabilities of the internet are rising and using 3D and VR based web-technologies over the internet will become more and more feasible.

5.1. 360 Degree Panoramic Views

Initial investigations focused on web-based 360 degree virtual reality representations of rest room environments (Figure 3). These enabled users to explore at will, and assisted in eliciting their views and comments on existing and proposed future provision. This software was designed to be used for requirements gathering and receiving user feedback about prototypes. It had a facility for recording the user's comments on an onscreen 'notepad' as they looked around the various parts of the rest room. The part of the room they were looking at was automatically noted. The user’s path through the tour was also automatically recorded. Navigation was by using the mouse to 'move' around the 360 degree environment. Red 'hotspots' could be clicked on to get a close up, or to go into another room (Figs. 3,4). Users’ comments were stored on a central server database. These 360 degree panoramas were created by ‘stitching’ together a sequence of digital photographs (Figure 5). Digital photography editing software was used to perform the ‘stitching’. The digital photographs were taken by a camera placed on a tripod that was positioned in the centre of the scene. There was about 25% overlap from each image to the next. To produce 360 degree panoramas where it is then possible to pan up/down through 360 degrees a camera with a fish-eye lens had to be used. The resultant stitched image was stored in jpeg format to keep download times down. The original 360 degree panorama software provided zoom in/out buttons. However, after initial evaluations, it was decided to remove this facility because the tour became more difficult to use, since the image became unfocused when zoomed.

86 N. Alm et al. / Computer Based Information Gathering

Figure 3. The 360 degree panorama – the star represents a ‘hotspot’

Figure 4. Close-up ‘hotspot’ of a sink

N. Alm et al. / Computer Based Information Gathering 87

Figure 5. Image ‘stitching’

5.2. 3D Virtual Reality Scenes

Following the 360 degree panoramic views, an investigation was carried out of other web-based VR technologies. This included 3D environments where the user can feel immersed within the scenes. A web-based 3D environment tool was developed. Using this tool, the user is presented with a 3D VR environment (Figure 6) and was free to move around within this scene. Navigation was by using the computer keyboard arrow keys. As well as being able to move freely, the user could also make comments and notes about the scene within the actual environment itself by writing/drawing on the walls or floor (Figs.7, 8, 9 and 10). To perform this action, the user first clicked with the mouse on the desired wall. Comments were then entered by keyboard typing or freehand writing using the mouse. Standard paint/drawing functions were also available e.g. shapes, line-drawing, erasing etc. Although the user could draw/paint within the environment, the layout of the environment itself could not be changed. This tool provided a novel way of obtaining user-feedback, although it was not clear what would be the possible advantages/disadvantages of such a system. Therefore a small pilot study was performed where the use of a more traditional paper-based interview was compared with the interactive environment. Scenarios using a virtual onscreen notepad were also included for comparison.

5.3 VR Pilot Study

There were twelve user evaluations performed. The twelve users rated their level of computer experience somewhere between intermediate and expert. Five users were between 18-25, five users between 26-35 and two users were between 36-60. There were six females and six males. The users participating in the task were presented with a small 3D VR environment consisting of a ‘living room’ scene and were asked to imagine they were browsing a 88 N. Alm et al. / Computer Based Information Gathering virtual catalogue. The users were then asked to select one item from the scene that they liked and one item that they didn’t like. They were instructed to record their selections and make some comments about what they liked/didn’t like about their selected items. There were four different methods for recording selections and comments and the users were asked to work through them in the order below. The expectation was that as they worked their way through the methods, the user was gradually becoming more immersed within the scene when recording their information.

Method 1 - Paper/pen (M1) - A traditional method of recording information Method 2 - Onscreen notepad (M2) (Figure 11) - An onscreen virtual notepad beside the 3D scene. The users could type onto the ‘notepad’ Method 3 - Notepad on the wall (M3) (Figure 12) - A virtual notepad on one of the walls within the scene itself. The user clicked on the notepad to begin typing onto the ‘notepad’ Method 4 - Drawing/writing on the floor/walls (M4) - The user could write/draw on the walls or the floor of the scene. The user selected a wall by clicking on it. Alternatively the user could click on the floor and view the scene from a top-down angle (Figure 10)

After completing the four methods the users were asked to complete a questionnaire. The user evaluations were split into four groups. The evaluations were performed individually:

Group 1 - The users were asked to work through the methods in the order above. Method 4 including an option to type using the computer keyboard as well as other paint/draw functions (four users) Group 2 - Again the users worked through the methods in the order above. Method 4 had the ability to type using the keyboard removed (four users) Group 3 - The same as the 2nd group, however the users were asked to work through the methods in reverse order to that listed above (2 users) Group 4 - The same as the second group, however the task was performed using a tablet PC, a notebook computers where it is possible to write on the screen display using a special-purpose stylus) (two users)

Using M2 and M3, the users are asked to type onto a virtual notepad, and upon reaching M4, Group 1 continued to type i.e. they immediately looked for a blank space on the wall and used the type function from the paint options and tended to ignore the option to draw within the scene. It was decided to remove the ability to type using the keyboard from M4 for Group 2. While not having been told this, Group 2 expressed the feeling that they missed being able to type after using M2 and M3. For Group 3 the methods were used in reverse order i.e. the users had not been asked to do keyboard typing when they first arrive at M4. No comment was made by Group 3 about typing until they reached the notepad methods when they commented on how much easier it was to type than to write freehand. Group 4 used the tablet PC with stylus and seemed to find M4 much easier to record their feedback, however one user did comment that they ‘found it difficult to write fluently with the stylus’. N. Alm et al. / Computer Based Information Gathering 89

The users were asked which method they preferred overall. M2 was preferred by 9 users and 3 users preferred M4. All the users highlighted the fun aspect of M4. Although M2 was the overall preference there was a consensus that ideally some combination of M2 and M4 would be the desired option, the users could use the onscreen notepad and still be able to use the drawing capabilities of M4 if they desired.

5.3.1. Observations for Each Method Method 1 - ‘Paper/pen’ Nothing of any note. Method 2 - ‘Onscreen notepad’ Users had no problems with this method. One user who preferred M2 commented on the fact that they ‘liked being able to look around and type at the same time’. Method 3 - ‘Notepad on the wall’ Nearly all the users expressed a dislike of having to find the notepad on the wall in M3. Although, when they do find the notepad they intuitively know what to do, one user commented that ‘it looks obvious what it is, and what it’s for’. The majority of users comment that it is not apparent what the advantage of having a notepad on the wall as opposed to at the side of the scene. One user suggested more notepads spread throughout the virtual room but then suggested that this would make the scene seems messy. 3 users suggested a virtual post-it note system – where comments could be written and then ‘stuck’ to the selected items. A couple of users suggested signs to where the notepad is within the scene. Method 4 - ‘Paint/write on the walls’ A few users expressed confusion when they tried to draw on the furniture in the scene, or select objects by clicking on them. Most users have a play about first, they realize they can ‘start again’ with a blank canvas. However, during the study the male users were more likely to use the paint abilities freely, all the male users didn’t feel or worry that they were vandalizing the scene as they realized they were in a virtual environment. The 3 users who were reluctant to scribble or paint on the walls were all female. One female user said they ‘didn’t like writing on the wall’ as they felt they were vandalizing although they said they would use such a system for virtual decorating. Another female user said they enjoyed drawing and making patterns but would rather use typing to convey their thoughts. Although one of the male users who used the typing when beginning M4 mentioned that he noticed the painting functions, it just that he ‘doesn’t want to draw’. One user commented on how much they ‘enjoy writing all over the walls’.

When using M4, only one of the users referred to an object using the drawing features e.g. by circling them or drawing arrows – the other users tended to look for the biggest blank space on the wall and record their comments there. Initially some of the users had some confusion when coming out of the 3D scene to the static 2D view used for drawing/writing in M4. They initially thought they were still in a 3D environment, although they were soon able to adapt. 90 N. Alm et al. / Computer Based Information Gathering

5.3.2. User Suggestions/Comments About M4 Many users commented on the virtual graffiti aspect and suggested having a spray paint effect added to M4 to make the graffiti more realistic. A few users suggested that M4 may be most enjoyed by children and teenagers. There was a suggestion of a virtual classroom where there could be virtual chalk and a blackboard within the class. It could also be used as a shared environment or a virtual forum and could see previous users’ comments/artwork. Symbols such as ticks/crosses could be used or different ink colors e.g. green (positive) or red (negative)

5.3.3. Questionnaire Results There were three attitude style questions, within the questionnaire that was given after the task, where the users were asked to rate from 1(negative) to 7(positive).

Q1. How would you rate the usability of each method? Q2. How helpful would you rate each method as an effective tool used for information gathering? Q3. How would you rate each method as being enjoyable to use?

M1. Paper/pen M2. Onscreen notepad M3. Notepad on the wall M4. Drawing/writing on the floor/walls

Table 1. A table of averages for each question and each method

M1 M2 M3 M4 Q1 4.6 5.8 4.2 4.4 Q2 5.0 6.0 5.0 4.4 Q3 2.8 4.8 4.3 5.7 Total: 12.4 16.6 13.5 14.5

M2 scored the highest overall. M4 scored highly for enjoyment as opposed to M1 which scored very low.

5.4 Conclusions

The onscreen notepad was found to be the most usable and most helpful information gathering tool. The users can view the scene and record their feedback simultaneously and also view the scene and their comments side by side. The enjoyable aspect of drawing on the walls of the scene was clear from users' spontaneous comments. A combination of the onscreen notepad and scene-drawing ability might be a good choice. However, it was not clear whether the ability to draw within the scene would actually benefit information gathering. N. Alm et al. / Computer Based Information Gathering 91

Figure 6. The 3D ‘living room’ scene Figure 7. The paint/drawing screen

Figure 8. The paint/drawing screen Figure 9. The 3D scene after writing

Figure 10. The top-down view Figure 11. Onscreen notepad

92 N. Alm et al. / Computer Based Information Gathering

Figure 12. Notepad on the wall

6. Summary

In its work with older people the FRR project found that participants were generally unconcerned about talking about toilets and toilet-habits. In this respect, the CBI’s that were designed did not prove as necessary as first expected. However, it was shown that the CBI was still beneficial for gathering and storing data electronically, especially when dealing with large user-groups and sizable amounts of data. In group discussions and focus groups it was discovered that the elderly user group proved to be equally open and frank. The use of drawings within the CBI’s was discussed with such user groups and the addition of drawings was found to be an effective addition to the interviews. However, it was suggested that general acceptability could be increased by making the characters more humorous cartoon-type figures. This would have the effect of making the material less personal and the use of humor was recommended as a way to make possibly embarrassing material more comfortable to discuss. The feasibility of using web-based virtual reality tools to support information and requirements gathering was also explored throughout the project. This included 360 degree panoramic representations of rest room environments, produced by stitching together sequences of digital photographs. The users clicked on ‘hotspots’ within the scene to get a close-up of an object or to move to another room within the virtual tour. Virtual environments incorporating 3D models were also investigated where the user may feel more immersed within these scenes as they are able to move more freely within the scene. A novel idea was introduced where the user could make comments and notes about the scene within the actual environment itself by writing/drawing on the walls or floor. A pilot study was performed where the use of a more traditional paper-based interview is compared with the interactive environment as well as scenarios using a virtual onscreen notepad. From this pilot study it was determined that the onscreen notepad was the preferred choice of the participants as a tool for information gathering, however the participants highlighted the enjoyment aspect of being able to draw and write within a 3D environment. N. Alm et al. / Computer Based Information Gathering 93

References

[1] Dove GAW, Wigg P, Clarke JHC, Constantinidou M, Royappa BA, Evans CR, Milne J, Goss C, Gordon M, de Wardener HE. The therapeutic effect of taking a patient's history by computer. Journal of the Royal College of General Practitioners. 1977; 27:477- 481. [2] Duffy JC, Waterton JJ. Under-reporting of alcohol consumption in sample surveys: The effect of computer interviewing in fieldwork. British Journal of Addiction. 1984;79:303-308. [3] Holt S, Guram M, Smith M, Skinner HA. Computer assessment of life-style in a gastroenterology clinic. Digestive Diseases and Sciences. 1992;37:993-996. [4] Locke SE, Kowaloff HB, Hoff RG, Safran C, Popovsky MA, Cotton DJ, Kinkelstein DM, Page PL, Slack WP. Computer based interview for screening blood donors for risk of HIV transmission. Journal of the American Medical Association. 1992;268:1301-1305. [5] Skinner HA, Allen BA. Does the computer make a difference? Computerized versus face-to-face versus self-report assessment of alcohol, drug and tobacco use. Journal of Consulting and Clinical Psychology. 1983;51:267-275. [6] Morton HG, Alm N. Computer-aided interviewing of parents in a child psychiatric clinic. Journal of Microcomputer Applications. 1990;13:273-280. [7] Peiris D, Alm N, Gregor P. Computer interviews -- an initial investigation using free text responses in People and Computers. In: Kirby MAR, Dix AJ, Finlay JE, editors. Proceedings of HCI'95 : People and Computers. Cambridge: Cambridge University Press; 1995, 281-288. [8] Alm N, Arnott, JL, Murray IR, Buchanan I. Virtual reality for putting people with disabilities in control. In: Proceedings of IEEE Systems Man and Cybernetics Conference. San Diego; 1998, 1174- 1179. [9] Peiris R, Gregor P, Alm N. The effects of simulating human conversational style in a computer-based interview. Interacting with Computers. 2000;12(6):635-650. [10] Williams B, Peiris DR, Gregor P, Alm N, Cumming S, Flockhart G, Groundwater M. Computer-based interventions for assisting people who have suffered disabling trauma.. New Technology in the Human Services. 1999;12:69-75.

94 A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-94 Knowledge Management

John MANTAS1, Joseph LIASKOS and Martha CHARALAMPIDOU Laboratory of Health Informatics – Faculty of Nursing, University of Athens, Athens, Greece

Abstract. The main target of this chapter is the presentation of the knowledge management approach in the Friendly Rest Room (FRR) European project. The intention was to organize the data collected during the project. The approach is twofold: the BSCW server and the FRR Knowledge Base. The BSCW server was used in order to develop a shared workspace for information exchange between the partners of the project. The gathered information in the BSCW environment was used to organize the FRR Knowledge Base, which consists of various elements. The first reactions for this knowledge management effort are also presented.

Keywords. Knowledge Management, Knowledge Base, Co-operative Work

1. Introduction

Across a wide variety of fields, data are being collected and accumulated at a great pace. The information extraction process from rapidly growing volumes of data requires analysis and organization of the information content which is a huge amount of work. The World Wide Web (WWW) has drastically changed the availability of electronically accessible information. Since textual format is a very flexible way to describe and disseminate various types of information, large amounts of information are stored as text. This amount of data has made it increasingly difficult to find, access, present, and maintain the information required by a wide variety of users. There is a growing need for a new generation of computational techniques and tools to assist humans in extracting and managing useful information (knowledge) from the rapidly growing volumes of data. Knowledge management refers to the methods and tools for capturing, storing, organizing, and making accessible knowledge and expertise within and across communities [1]. In this chapter the approach is presented for knowledge management and information dissemination within the Friendly Rest Room (FRR) project, using the World Wide Web.

1 Corresponding Author: John Mantas, Laboratory of Health Informatics, Faculty of Nursing, University of Athens, Papadiamantopoulou 123, 115 27, Athens, Greece; Email: [email protected]

J. Mantas et al. / Knowledge Management 95

Finding the right piece of information is a very crucial task for the implementation of the FRR scopes. The aim of our effort was to develop a system, which supports information extraction and content categorization.

2. The FRR Project

Friendly Rest Room (FRR) is an EU project within the ‘Quality of life program’, which aims at making toilet facilities better suited for elderly and people with disabilities. It also involves research to define user parameters for design and development. All the elements of the FRR are individually adjustable to meet the needs of older persons with different functional limitations or disabilities, allowing them to gain greater autonomy, independence, self-esteem, dignity, safety, improved self-care and therefore enable them to enjoy a better quality of life. Among the project objectives lies ‘the generation of valuable knowledge and perceptions’ (not existing today) regarding toileting, personal hygiene, and falls prevention among the aging populations in Europe. The FRR knowledge base is used at the service of wide range of applications, innovations and solutions to improve the level of Quality of Life and of public health theory and practices among the aging populations. The measurable objective is the independent continuation of the "FRR- New Knowledge Base" after the ending of the FRR Project.

3. FRR and Knowledge Management

The knowledge gathering, organization and management in FRR project is two fold:

Within the project consortium a shared workspace is used and A FRR Knowledge Base was developed.

3.1. BSCW Server

Our initial intention was to find a way of dynamic information exchange between the participating individuals in the project, offering them a possibility of proposing new ideas and enriching the existing ones. Normally, the information is presented in the format of documents of various formats e.g. .doc, .xls, .pdf, etc. All these should be organized in a non-static way: a partner adds a new document with new ideas, collected data, research outcomes, etc. and the others enrich this document by adding their own knowledge. This was the original idea of building new knowledge. The BSCW (Basic Support for Cooperative Work) server is the environment that was used for the implementation of these purposes (Figure 1). BSCW supports asynchronous and synchronous cooperation with the partners in the project, over Internet [2, 3]. For asynchronous cooperation, BSCW offers shared workspaces that are used to store, manage, jointly edit and share documents. There is the possibility of sharing documents (of all 96 J. Mantas et al. / Knowledge Management formats) by using any standard web browser and independently of the specific computer system that the partners use, moreover the system keeps all informed of any relevant events in a shared workspace. For synchronous cooperation, BSCW provides tools for planning and organizing meetings, for starting ‘virtual’ meetings on the basis of conferencing programs or by telephone, for communicating with partners who are currently logged in to a shared workspace and therefore are likely to be working on a common task.

Figure 1. BSCW Server

3.2. FRR Knowledge Base

After the collection of new knowledge, the next step was the development of an environment for the knowledge management. A website composed of various elements was developed. This environment was named the ‘FRR Knowledge Base’ (Figure 2). The ‘FAQ’ link offers some key Questions-Answers to basic topics regarding the project and the knowledge management in it. The ‘LEXICON’ link opens a webpage where important concepts related to the basic aspects of the project, the disabled people, and to the technological issues, are included with their definition (Figure 3). Finally, the ‘SEARCH’ link opens a page (Figure 4) where the user is able to perform an advanced search in the library of FRR Knowledge Base. This library contains all the documents gathered in the BSCW server and was continually updated during the project.

J. Mantas et al. / Knowledge Management 97

Figure 2. FRR Knowledge Base

Figure 3. FRR Lexicon 98 J. Mantas et al. / Knowledge Management

Figure 4. Advanced Search in FRR Library

The SEARCH library is basically divided into four sub-libraries: the User_Needs, the Technical_Resources, the URBs (User-driven Research Bases) and the Evaluation sub- libraries. Each one contains all the relevant documents.. In the User_Needs sub-library all the information about the needs of the target population of the project (the disabled and elderly people) is included; the Technical Resources contains the technical achievements of FRR in a detailed way; the URBs sub-library refers to the collection and statistical analysis of data concerning the target population; finally, in the Evaluation sub-library, the validation, evaluation and other research findings about the innovations of the project are included. A brief description of the search and find procedure follows: All documents are indexed in four different catalogues. Every catalogue is defined according to the specifications of the four sub-libraries. Every catalogue encapsulates all the details needed to access and index the documents contained in corresponding sub- library. An enumeration mechanism identifies all the indexable files in the included directories and appends them to a queue. A document filter opens each queued file and emits properties and content of the document contained therein. The stream of text emitted by the filter is fed to a word breaker, which recognizes features such as words and numbers contained in the stream. Features that survive the stop list (noise word list) are eventually compiled into a master index that is used to resolve queries. The text extracted from a document is processed by a tool named: "word breaker", which identifies words from the stream of text. As soon as a document is filtered and J. Mantas et al. / Knowledge Management 99 processed by the "word breaker", the resulting words are stored in a word list. The master index is the final destination of all the word lists. Query formulation and result browsing can be accomplished using any standard web browser. The user can perform searches in multiple sub-libraries using Boolean and proximity operators. Also, the user can perform free text queries, which allow formulating a query based on the meaning of a phrase rather than the exact wording. The FRR Knowledge Base is considered as a quite dynamic environment that is continually updated according to the new information gained in the project. While developing it was tried to preserve its content and empower the gathered information. The basic concern was to develop a user-friendly knowledge management tool and make it available to all kinds of users. Finally, this tool was evaluated, in short periods, for its comprehensiveness, content, functionality and coherency.

4. Discussion and Conclusions

The goal of knowledge management at FRR is to use the knowledge that resides in the project in order to fulfil the FRR project mission which is to help the elderly people and people with special needs to overcome the difficulties in their everyday life when using rest rooms. The different categories of stakeholders, are primary users (people with different categories of special needs, elderly people), secondary users (people that help and assist the primary users to overcome the difficulties and restrictions of their physical problem in everyday life, such as nurses, social workers, physiotherapists, ergo-therapists, etc.), and designers and developers that will design and develop the friendly rest room. All stakeholders that are related to the project have contributed information into the knowledge base. The three discrete steps taken in order to tackle the whole process of managing knowledge in the project are [4]:

Capturing knowledge and processes that are being used in the different categories of stakeholders participating in the project. Consolidating these processes to provide an environment for cooperative problem solving in the design and development of the friendly rest room. Implementing an integrated system to enable collaborative knowledge-intensive processes.

The development and maintenance of a number of user guides, ‘FAQS’, documentation and technical papers, illustrations, questionnaires, reports, will serve the needs of managing FRR knowledge base. A short evaluation that was performed according to some guidelines provided us with quite accepted results. A group of experts that tested our facilities concluded that this kind of knowledge management could help us fulfil our purposes. They agreed that in the new era of health informatics, not only the knowledge extraction but also the knowledge organisations are very crucial issues. According to their suggestions some new features 100 J. Mantas et al. / Knowledge Management could be added; in this direction they proposed the automated summary extraction from the documents and the inclusions of interactive training systems. Finally, they advised that more documents should be added in the library and that the FRR Lexicon should be enriched with more terms. After experiencing several EU-projects we can conclude that an effective and user- friendly share workspace is essential for such a large project with so many partners. Such a system like the BSCW downsizes the email stream and makes the participant confident that the results from day to day are stored in a stable system that gives access 24 hours a day. Further it gives important feedback about the frequency of use by whom.

References

[1] Fayyad U, Shapiro G, Smyth P. Knowledge Discovery and Data Mining: Towards a Unifying Framework. In: KDD-96. Proceedings of the Second International Conference on Knowledge Discovery and Data Mining; 1996 Aug 2-4; Portland, Oregon. [2] Appelt W. What Groupware Functionality do Users Really Use? In: Proceedings of the 9th Euromicro Workshop on PDP 2001; 2001 Feb 7-9; Mantua, IEEE Computer Society, Los Alamitos. [3] Klöckner K. BSCW - Educational Servers and Services on the WWW. In: Proceedings of the International C4-ICDE Conf. on Distance Education and Open Learning "Competition, Collaboration, Continuity, Change"; 2000 Sep 9-14; Adelaide. [4] Tiwana A. The Knowledge Management Toolkit: Practical techniques for building a knowledge management system. Prentice Hall PTR; 2000. A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People 101 J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-101 Rapid Prototyping of Interface and Control Software for an Intelligent Toilet

Charlotte MAGNUSSONa,1, Norman ALMb, Georg EDELMAYERc, Peter MAYERc and Paul PANEKc a Certec – Rehabilitation Engineering – Lund University, Lund, Sweden b Applied Computing – University of Dundee, Dundee, UK c fortec – Research Group on Rehabilitation Technology – Vienna University of Technology, Vienna, Austria

Abstract. In the Friendly Rest Room (FRR) project a series of paper sketches and computer implemented prototypes were designed to obtain information about user preferences with regard to the user interface. The first stages in the process were performed with the help of the user group, while later prototypes were tested in end user tests. The results point to the importance of a combination of visual, audible and tactile information as well as underlining the importance of incorporating real end users in the design process. In parallel to the user interface software design also a control program to steer the FRR prototypes was implemented and successfully tested in laboratory settings and partly also in real life environment.

Keywords. Toilet, Assistive Technology, Rest Room, Human Computer Interface, Elderly

1. Introduction and Aim

As the Friendly Rest Room (FRR) system provides much more functionality than an ordinary toilet, a new type of user interface is needed to present information about what can be altered in a flexible, yet understandable way to the user. The following chapter describes the development and tests with this new type of user interface. As a second part, a brief overview on the overall FRR system software concept is given.

2. Development of the Human Computer Interface (HCI)

2.1. Early Stages of the Design Process

To obtain user feedback in the early stages of the design process both scenarios and paper sketches were used. Scenarios are stories that describe potential future use situations. They are extensively utilised throughout design processes for purposes such as user-requirements elicitation, interaction design, and usability testing (see e.g. [1]).

1 Corresponding Author: Charlotte Magnusson, Certec, Lund University, LTH, P.O. Box 118, S-221 00 Lund, Sweden; Tel: +46 46 222 40 97; Fax: +46 46 222 44 31; Email: [email protected]; Website: http://www.english.certec.lth.se/ 102 C. Magnusson et al. /Rapid Prototyping of Interface and Control Software for an Intelligent Toilet

Our reason for working with paper prototypes (so called “lo-fi” prototypes) was that they are known to allow the designer to focus on the design instead of technical issues [2]. The scenarios were designed to illustrate typical usages of different hypothetical usage situations. One scenario illustrating an interface where the user directly controls the FRR station is explained in the following: Ivan moves up to the FRR system. He logs in and the door opens. The toilet is changing so that Ivan’s initial settings are adopted. The voice says: “Welcome. You may lock the door by saying LOCK DOOR or move the handle. To open the door please say OPEN or press the handle. Please say INSTRUCTIONS to receive further voice instructions. Say HELP to call for help. Say INFORMATION to repeat this message”. Ivan moves the handle to lock the door. He then moves over to the toilet and gets on. He grabs the control interface and presses the toilet symbol. He then presses UP to move the toilet seat up. He presses the handles symbol and then OUT to move the handles out a bit. He does not want to change the initial settings, so he does not press SAVE. When he is ready he presses TOILET and then FLUSH. While having TOILET active he also presses UP to move the seat further up. He leaves the toilet and moves to the sink to wash his hands. He unlocks and the door opens. He leaves.

Figure 1. Display arrows by the objects. The arrows indicate the possible changes that can be made.

Figure 2. Select object in the image but select actions from buttons shown separately. C. Magnusson et al. /Rapid Prototyping of Interface and Control Software for an Intelligent Toilet 103

The scenarios illustrated fully automatic, sequence based and direct control type of interfaces. The fully automatic interface assumes the system knows what the user does and automatically controls all the devices in the room. The sequence based interface assumes that there is a sequence of actions a user may want to perform and the user initiates changes between these different states. In the direct control type interface the user controls everything directly (although there is a pre-programmed initial state which is saved for each user). The users were also shown a set of preliminary interface sketches which illustrated different principles for organising the interface. Figure 1, 2 and 3 show three such sketches.

Figure 3. Make selection of objects from a range of images or icons. Then a new screen is shown indicating object, available actions and a return button (note that the screens above are shown after each other, not simultaneously).

The feedback from the user board showed that the users preferred the direct control type of usage, where the system has a set of saved settings, but where all changes are initiated and controlled by the user (including saving of new preferred settings). Comments on the images and on the icons led to a first interface design which made use of the fact that actions were easier to interpret if you saw them related to the object as in the tilt forwards icon in Figure 4.

Figure 4. A tilt forwards icon which shows both the action and the object. 104 C. Magnusson et al. /Rapid Prototyping of Interface and Control Software for an Intelligent Toilet

Since the users did not want to see too many icons at the same time, the interface was organized hierarchically (Figure 5). This first implemented version of the interface was tested at a second user board meeting, and since the results from this first test were promising it was decided to continue developing this interface for the first round of full user tests.

Figure 5. Overview mode. Main menu (left), toilet sub menu (middle) and light sub menu (right).

Figure 6. A screen shot from a sub menu in the large mode interface.

2.2. First Round of User Tests

For testing purposes a hand held computer on base of a PDA (Personal Digital Assistant) was used as an input device, as it has the size of a hand held device and C. Magnusson et al. /Rapid Prototyping of Interface and Control Software for an Intelligent Toilet 105 allows for touch input as well as both visual and auditory output. The user interface was developed through a sequence of paper prototypes into two basic versions:

Overview mode (giving overview, but showing fairly small icons, Figure 5) Large mode (showing only few icons, but allowing for the use of big icons, see Figure 6)

Both modes allowed for the use of a scanning function, where the PDA changed images automatically after a pre-defined interval. Pressing a button generated auditory (speech) feedback, and in the large mode every time a new icon was shown on the screen it was accompanied by the corresponding speech feedback. The PDA devices were positioned in the FRR room to allow for the testing of suitable locations of this type of device. Two positions (by the door and by the toilet) were used, and at each location the users were asked to perform relevant tasks. At the door the users were asked to change the level of light and turn off the sound feedback, and at the toilet the users were asked to change toilet position and tilt as well as change the distance between the grab bars and then finally to flush the toilet (Figure 7).

Figure 7. The two iPAQ locations. One by the door and one by the toilet.

Figure 8. Discussing the interface in more detail. 106 C. Magnusson et al. /Rapid Prototyping of Interface and Control Software for an Intelligent Toilet

The interface was also discussed in more detail on a table outside the FRR station (Figure 8). Users with severe visual impairments performed the whole test at this location to make it easier for them to bring the device close to the eyes with full intensity on the screen (the iPAQ reduces the light of the screen when it is removed from the cradle). This first round of user tests performed with eleven users showed in general that the users that could see the interface could also use it (success rate 8 or more of 11 for 15 out of 22 tasks). Unfortunately the loudspeaker in the iPAQ generated only quite low sounds, and most of the visually impaired users could not hear the voice feedback. The one visually impaired user that could hear this feedback could also operate the interface in the scanning mode. The menu navigation caused some initial problems for several users, but it appeared to be quite easy to learn how to operate it as most users could navigate from the grab bar menu to the toilet menu in the final task. The icons appeared in general to be clear and easy to understand. The exceptions were the main menu or back button, the save button, the left/right buttons and the sound on/off button. It was also interesting to note that the black ring around the flush icon which was intended to make this icon more visible instead appeared to make it harder to find for some users. The size of the device was commented on by a few users. If possible a somewhat larger screen may be chosen for the final system. This would also make it easier to provide tactile information about the button locations, as it would be possible to show both the main menu and the sub menu on the same screen.

Figure 9. The iPAQ hand held Figure 10. The toilet and sound sub menus in the ‘normal’ mode. computer showing the main menu The feedback icon in the top left corner is replaced by a restore in the ‘normal’ mode. The save button. In the sound menu two different buttons indicate on and off button has a new icon, and a restore (instead of the previous toggle type button). The main menu button is button is added (the icons are also changed to work better with the large version on the interface. intended to indicate saving/retrieving data from the Radio Frequency Identification - RFID card) C. Magnusson et al. /Rapid Prototyping of Interface and Control Software for an Intelligent Toilet 107

This way it would be easier to keep fixed button locations (although the content of a button may change depending on the sub menu) and with fixed button locations it would be possible to use transparent plastic with relief to indicate a button position. In the overview interface there was an image in the top left corner that provided feedback about which sub menu the user is in. Many users pressed this image when attempting to get to the main menu.

Figure 11. The large mode version of the interface. Buttons are always in the same position on the screen to make it possible to use a tactile overlay. The save and restore buttons can be found at the top, while the buttons for menu navigation are placed at the bottom of the screen.

2.3. Second Round of User Tests

The test results led to a re-design of the interface intended to allow for additional touch feedback for the large mode interface. The basic menu layout was the same as during the previous test. Some changes had been introduced however (Figures 9,10,11 and 12):

The feedback icon in the top left corner in the sub-menus was removed The save icon was changed and a restore button was added The main menu button was changed to work better with the large mode The on/off buttons showed both options (on and off) instead of the toggle type of button used previously. A tactile overlay was used for the large version of the interface to indicate button positions The large interface was reorganised so that buttons always were placed in the same locations to allow for the use of the tactile overlay Auditory feedback was programmed to synchronize better with the visual feedback in the large mode (there were some problems in the previous version) 108 C. Magnusson et al. /Rapid Prototyping of Interface and Control Software for an Intelligent Toilet

These new versions of the interface were tested during the second round of user tests performed in the autumn of 2004. This time external loudspeakers were used for the sound, which allowed all users to hear the sound. During the test three different versions of the tactile overlay (figure 12) were tested, and the users were asked for their preferences. The actual interface testing was then performed with the preferred tactile overlay. Ten users tested the interface. Four of these users failed to complete the whole test. One user was unable to use this type of small interface due to motorical problems (very limited reach and tremor that got worse the harder the person tried to use the device). Another could not see nor feel the buttons on the tactile overlay (higher relief needed). During another session the PDA hardware crashed and was impossible to repair during the time allocated for the test. Six users completed the full test. All users but one preferred the dotted version of the overlay (all ten users tested this). Two users that saw very well said it did not help, while four users commented on its usefulness. As was stated above the test indicates that it would be better with higher relief. The sound on/off button was now easier to use since it showed both possibilities

Figure 12. The three different versions of the tactile overlay. C. Magnusson et al. /Rapid Prototyping of Interface and Control Software for an Intelligent Toilet 109

(sound on and sound off) compared to the previous version of the interface that used a toggle type button where you only saw the current state (on OR off). The save icon in the previous version had gotten comments for being hard to understand, but the new version was not appreciated as well.

2.4. Conclusion

In general though, both tests show that this type of interface is possible to use with this user group. As always, care needs to be taken with interface design, and it is clear that for many of these users a larger interface (allowing the use of the overview mode type design) would have been better. The tests also show the importance of making information available through more than one sensory channel. Not only vision, but also hearing and touch should be used. A simple way of achieving touch feedback by using transparent tactile overlays was suggested, and the test showed this approach to be useful.

3. Development of the Control and System Software

3.1. Software Concept

The control software is part of the general software concept that was developed for the FRR system. The system software consists of several modules that work together (partly via a defined XML message structure) to provide all necessary functionality. The software also provides the interface structure to connect to dedicated hardware (Figure 13). Within the project the FRR control and system software was realized partly. It was only used for those five iterative prototypes which were evaluated at the user test site in Vienna [4]. A modified version of the FRR control software was used for the real life test [3] in Vienna.

Figure 13. FRR Software Components and Sub-Components including external hardware, third party software, control unit hardware, Interface software and control software (bottom to top rows). 110 C. Magnusson et al. /Rapid Prototyping of Interface and Control Software for an Intelligent Toilet

Figure 14. FRR system software v2.1c with integrated remote access via http (laboratory stage, to be used only by engineers), September 2003.

The system software modules were tested implicitly during user tests, as the FRR system software provides the internal interfaces to those parts of the whole system that actually are the interface to the user (like the HCI described above). Thus the system software was tested implicitly while not being directly visible for the test participants. During life time of the FRR project (2002-2005) several iterative versions of the system software were developed and tested according to the test set up of the different tested toilet hardware modules. In general the control software provides the following functionality:

Measuring position including scaling to units of cm Moving toilet to certain positions Storing / recalling user profiles Semi-automatic calibration of system Continuous logging of sensor data Compensation algorithm (height/tilt) Graphical User Interface (GUI) for technician Semi autonomous control via ultra sonic seat sensor Acoustic prompting Basic safety routines Environmental control: switching on/off room light, spots, occupied indicator, alarm indicator Interface to user recognition unit (RFID reader) Remote maintenance service Emergency call (only simulation) C. Magnusson et al. /Rapid Prototyping of Interface and Control Software for an Intelligent Toilet 111

3.2. Human Computer Interface for Control Software

The HCI of the control software is implemented as graphical user interface (GUI) and is only used by the technician to adjust the FRR system for the different tests. It also is used for administrating a very basic user database where predefined settings are stored. A screenshot of the GUI used by the technician during the laboratory tests in Vienna is shown in Figure 14. For the real life tests in Vienna [3] the control software was modified to provide remote accessibility via the internet using a specific technological approach described in [5] and an enhanced continuous logging functionality for 24/7 data logging. Further to this, it is to note that the possibility to steer the FRR system actively (i.e. drive the motors as in the laboratory tests [4]) was not used for the real life tests [3] for safety reasons.

3.3. Conclusion

The software concept, although not realized in full, forms guidelines for an open and extendable system so that future development can be easily supported. The used control modules proved to work reliable in both laboratory and real life situations. Some parts of the system are currently (June 2009) still in laboratory use for demonstration and education purpose.

4. Summary

Prototypes of multimodal interfaces for end users were designed and tested in laboratory environment. Multimodality of the interface (using vision, hearing and touch) was judged as useful, while the used hardware device could be larger. A basic implementation of the main control software was done which provides a framework open for future extension. The software was used to steer the toilet prototype system during end user tests in laboratory environment and part of it was used successfully during real life evaluation in a day care centre.

References

[1] Carroll JM. Making use: scenario-based design of human-computer interactions. Cambridge, Massachusetts: MIT Press; 2000. [2] Rettig M. Prototyping for tiny fingers. Communications of the ACM. 1994 Apr;37(4):21-27. [3] Gentile N, Dayé C, Edelmayer G, Egger de Campo M, Mayer P, Panek P, Schlathau R. Concept, Setting up and First Results from a Real Life Installation of an Improved Toilet System at a Care Institution in Austria. This volume. [4] Panek P, Edelmayer G, Mayer P, Zagler WL. Laboratory Tests of an Adjustable Toilet System with Integrated Sensors for Enhancing Autonomy and Safety. This volume. [5] Panek P, Beck C, Zagler WL. Giving Wings to the Service Delivery Process - New Possibilities by the RESORT Tele-Service Approach. In: Craddock G, McCormack L, Reilly R, Knops H, editors. Assistive Technology - Shaping the Future. Amsterdam: IOS Press; 2003, p. 405-409.

112 A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-112 The Final FRR Components

Theo J.J. GROOTHUIZENa,1, Atilla RISTb, Marja H. VAN WEERENa, Dries DEKKERc, Renate DE BRUINc and Johan F.M. MOLENBROEKc a Groothuizen Beheer bv, Rotterdam, The Netherlands b Clean Solutions, Debrecen, Hungary c Faculty of Industrial Design Engineering – Delft University of Technology, Delft, The Netherlands

Abstract. The design challenge within the Friendly Rest Room project has been to anticipate the needs of individual users, in particular older persons and people with disabilities, and to combine this with serving the needs of a far less specific audience, of secondary users (e.g. caretakers, cleaning personnel) and even tertiary users (e.g. facility managers). From start it was clear that the participating project partners did not all share the same view and expectations about how to approach the big design challenge to and about the exact process to follow. The first exploration of the use of a rest room by older or disabled users and additional statistics on accidents showed that many problems occur while entering the rest room, moving through the rest room and while preparing for toileting. The design team focused strongly on finding feasible solutions aimed to improve physical safety and the perception of safety. Ergonomic variables related to the use of a rest room played a central role. For that, the design team explored the use of a rest room by the target user groups and analysed the relation between functions in the rest room and potential user problems and risks. Based on those findings, it was proposed to distinguish three functional areas in a rest room: the access, the transfer and the toilet area. In 3 and later in 5 countries prototypes were built and tested. Finally the integrated version was user tested in a nursing home in Vienna during 3 months. The resulted knowledge was disseminated in a conference, in this book and several conference papers and a in a commercial version produced by Clear Solution, Debrecen Hungary.

Keywords. Smart Toilet, Smart Home, Design, Assistive Technology

1. Introduction

The design challenge within the Friendly Rest Room project has been to anticipate the needs of individual users, in particular older persons and people with disabilities, and to combine this with serving the needs of a far less specific audience, of secondary users (e.g. caretakers, cleaning personnel) and even tertiary users (e.g. facility managers). Even the unanticipated ‘healthy’ visitor of our Friendly Rest Room should not feel ‘handicapped’ when he or she enters, a feeling which is easily called upon by the stigmatizing ‘robust’ design of most assistive aids for elderly and disabled. For the latter group the final Friendly Rest Room (FRR) should contribute to a greater individual autonomy and independence, hopefully adding to improved dignity and self- esteem. In brief, it‘s goal is “an improvement of quality of lives for many” [1].

1 Corresponding Author: Theo Groothuizen, Design Consultant, Groothuizen Beheer bv, Rotterdam, the Netherlands; E-mail: [email protected] T.J.J. Groothuizen et al. / The Final FRR Components 113

It is clear that even for experienced industrial designers, product developers, engineers and researchers it is hard to imagine the possible outcome of such a project. This chapter will show how the industrial designers, product developers, engineers and researchers involved in the FRR project have mutually worked together to develop a prototype and to test it with the help of representative users, in order to learn, adapt and re-develop. To illustrate this learning path, this chapter will describe the consecutive steps in the development and industrial design process. The results and some critical considerations during the development process will be presented along the way.

2. Integrated Design Process

It all started with a rough beginning. From start it was clear that the participating project partners did not all share the same view and expectations about how to approach the big design challenge to and about the exact process to follow. How to achieve a greater independence and autonomy for elderly? How to develop a rest room for European elderly, with so many different cultures? Where to start? The initial problem description and research was focused on the adjustability of the toilet, arm supports etc. and did not include the rest room environment. Upon advice from the involved industrial designers and excerpting from a proven design methodology [2], it was decided to study all variables related to using a rest room and to broaden the problem description accordingly. The first exploration of the use of a rest room by older or disabled users and additional statistics on accidents showed that many problems occur while entering the rest room, moving through the rest room and while preparing for toileting [3, 4 and 5]. To avoid these problems users need assistance. This is in conflict with the wish to be independent and with their dignity. How to get all participating disciplines, engineers, industrial designers, sociologists, ethical specialists and business oriented partners, on the same track? Agreement was reached on trying to find solutions for those people who could move independently of others, also including persons using a walker or wheelchair, and to find safe and reliable solutions based on the principles of "Design for All". This means trying not to exclude people from using the FRR. An integrated development and user-centred process was followed, assuring that all disciplines and end-users were involved in all stages of the development process.

3. Design Approach

The design team focused strongly on finding feasible solutions aimed to improve physical safety and the perception of safety. Ergonomic variables related to the use of a rest room played a central role. For that, the design team explored the use of a rest room by the target user groups and analysed the relation between functions in the rest room and potential user problems and risks. Based on those findings, it was proposed to distinguish three functional areas in a rest room: the access, the transfer and the toilet area (see Figure 1). These areas all represent a specific group of usability problems, risks and complexity. Further findings of user involved research in the URBs (User Research Bases) and by the design team resulted in a list of problems to be solved and recommendations for 114 T.J.J. Groothuizen et al. / The Final FRR Components additional research [6]. It was in fact this ‘list of problems to be solved’ that focused the design activities:

Difficult to locate toilet and to see whether toilet is in use Difficult to open door and difficult to manoeuvre through door opening Difficult to lock the door Difficult to store personal belongings (bag, coat) Distinction (white) sanitary from (white) environment, or distinction floor from wall difficult, due to diminished sight Difficult to move to the toilet; either too little manoeuvring space or too much space without any support Difficult to undress, turn around and sit down, due to balance problems or in case of wheelchair-users difficult to undress and transfer to toilet Difficult to sit stable on toilet and difficult to clean intimate body parts (balance problems) Difficult to stand up and dress (balance problems)

Figure 1. Three functional areas in the toilet environment

T.J.J. Groothuizen et al. / The Final FRR Components 115

Figure 2. Top view of the cantilever door and its movement

4. Access Area

4.1. The Door

Standard doors cause serious problems for many elderly or people with disabilities. In particular, in case of lack of force in arm or hands, of using a walker or wheelchair, doors can be frustrating barriers. A cantilever door (see Figure 2) was tested at project partners CERTEC in Lund and at the Delft University of Technology. A cantilever door rotates in such a way that only a part of the door moves towards the user and the other part away from the user. This removes the need for the user to "step back", because of the limited space the door needs. The door hardly requires force to open and close. The cantilever door improves the accessibility substantially, particularly for users with a wheelchair or walking aids. For them, this type of door makes it possible to close the door without extremely rotating their body or grabbing for the door handle behind them. The door, manufactured by project partner Clean Solution (CSO), proved to satisfy the needs of the users, in particular in combination with the newly designed door handles. The door is prepared for an electronic lock mechanism and an unlocking option in case of emergency.

4.2. The Door Handles

Traditional door handles often are problematic for elderly and disabled persons, mainly because of the force needed to rotate them. Based on user tests new door handles were designed by project partner Landmark. Larger and smaller versions of the door handle, both mounted on a cantilever door, were successfully tested in Lund and Delft. The handles, (see Figure 3) are considerably larger than standard and have a triangular shape. The shape offers users the possibility to use a hand, arm or elbow, a high or low grip or even a vertical grip. The large dimensions mean that a very low force is needed. 116 T.J.J. Groothuizen et al. / The Final FRR Components

Figure 3. Door handle with lock indicator in locked and open position

Figure 4. The door with communication unit

T.J.J. Groothuizen et al. / The Final FRR Components 117

The handle was designed to accommodate people with less strength, in case hands cannot be used and for manipulation from a low or sitting position. The door handle was rated very satisfactory for many subjects in the test groups. The door handle is prepared for an automatic lock/unlock sign which is also visible from the outside. This makes it possible for users to recognise whether the toilet is available or occupied from larger distances. The design is prepared to activate a light switch as soon as the door handle is used.

4.3. The Communication Unit

The Communication Unit is the central module of the FRR. The core function of this multifunctional component is to identify a specific user and to adapt the rest room to the specific, individual needs of that user. The unit is mounted on the outside vertical post of the doorframe, at the side of the door handle (see Figure 4). The following functions are integrated in this unit: 1. A contactless card reader which can identify the FRR user by Radio Frequency Identification (RFID) technology 2. An intercom-function in order to communicate from outside the rest room with somebody inside in case of emergency 3. An (optional) numeric keypad (digits 0-9), including an indication for acceptance or rejection of a code 4. An alarm indicator, which can double as an indication for an occupied toilet 5. A sensor for indicating whether persons enter or leave the room steers the light switch. 6. A sensor for a closed-door position to lock the door and activate the lock/unlock signs 7. An activator to unlock the door in case of alarm/emergency Only in case of alarm a two-way communication is made available. By pushing the "speaker button", authorised assistive personnel can talk with the person inside and check the situation before entering the restroom. The person inside does not need to activate a button. Inside the rest room a speaker and microphone are mounted. The keypad offers tactile, visual and aural feedback. The lock mechanism can be unlocked from the outside by helpers after receiving an electrical signal from the alarm system. The unlock indicator on the inside of the door will then change from red to green.

4.4. The Alarm Indicator

An alarm indicator is positioned at the top of the communication unit and is visible in a 180º angle. The alarm indicator has a double function. It can present a blinking red light in case of emergency/alarm as well as a continuous red light to indicate an occupied rest room, or green when available.

4.5. The Accessibility Sign

Different designs for an accessibility sign to indicate that the rest room is a "Friendly Rest Room" were made (see Figure 5). The first design concepts were rejected by some of the expert users, because there was no recognisable relation with known and accepted signs for accessibility. A new design was made which was tested and approved by the project partners in Athens. 118 T.J.J. Groothuizen et al. / The Final FRR Components

Figure 5. Final design of the accessibility indicator tested in Athens

5. Transfer Area

5.1. The Wall Mounted Grab Bars

Observational studies of elderly users in rest rooms [7] clearly showed, that particularly people with mobility problems grab anything in order to maintain balance or to feel more secure. This is not only the case when close to the toilet itself, but also during the transfer from entrance to toilet area. This made clear that many target users fear losing balance when they move or stand in a rest room. Besides having grab bars in the toilet area, it was concluded that they are needed along all walls in the rest room. Standard grab bars offered in the market are limited in size and expensive. In order to make it feasible, and affordable for users, to apply them along all walls, a design is needed which can be mass-produced, reducing the costs for consumers (see Figure 6). The wall grab bars mainly function as a "balance" providing support. The bars will combine continuous support availability, an integrated mounting functionality, optimum cleaning and an integrated, non-stigmatising look. The continuous rounded inside shape (without sharp, dirt-holding corners) and the lack of external mounting points, makes it very easy to clean the inside in almost one stroke. Corners are open for ease of removal of dirt or moist. The design proposal is based on extruded aluminium profiles and offers several integrated added values, such as fraction strips or retro reflective lines. Handmade prototypes of the grab bars were used for testing in the FRR project. T.J.J. Groothuizen et al. / The Final FRR Components 119

Figure 6. Main part of the wall mounted support bar, manufacturable by extrusion

6. Toilet Area

6.1. Body Support Bars: Horizontal and Vertical

In the Netherlands, horizontal body support bars at the left and right of the toilet are very common in rest rooms for persons with mobility problems, both in private as well as public areas. The design team concluded from observations and research that vertical supports however might be a better alternative, mainly because they offer a better support for users when standing in front of the toilet bowl, or for sitting down and getting up. Besides testing the horizontal bars extensively in the URBs, this project also focused on comparing, via testing in Delft, of horizontal and vertical oriented body supports [8]. From the results of this study, it was concluded that elderly test users tend to prefer using vertical bars. A design oriented study [9] pointed out that a combination of both horizontal and vertical supports can be visually attractive. Of course care was given to avoid a stigmatising image of the overall interior, which is opposite to what the design team wanted to achieve. Engineering models of vertical grab bars were produced and tested. These prototypes aimed to offer the user help to find balance while sitting down or standing up. In order to prevent obstructing the user, in case they do not need vertical supports, the bars can be rotated in a horizontal direction to the sidewalls of the rest room. The distance between the vertical supports can be adjusted to the needs of the user (see 120 T.J.J. Groothuizen et al. / The Final FRR Components

Figure 7). By pushing a button the bars can be moved, and when released the position will be locked. The grab bars move up and down with the height of the toilet seat. A complete redesign was realised for the horizontal grab bars, which were originally developed and manufactured by partner Clean Solutions (CSO). The redesign engineering models offer a friction function in any bar position (to prevent the bar from falling down), a release button, an additional grip (at right angles with bar) and an improved side grip (see Figure 7).

Figure 7. The toilet with the vertical bars in two positions and the horizontal supports by CSO

6.2. The Lift Toilet

The CSO Lift WC, which was the basis for this project, offers height adjustment from 46 cm above the floor to 81 cm, in order to accommodate a large variety of users. In combination with a tilted position, it can assist users to sit down or get up and can function as a urinal in its highest position. Ergonomic research at the Delft University of Technology indicated that standard toilet bowls and seats do not satisfy the needs of the target users of this project. Dissatisfaction not only concerns comfort, but aspects related to personal hygiene as well, particularly in (semi) public spaces. It is strongly recommended to initiate a research project to study this subject, aiming to develop and design a better and affordable toilet bowl for older users or people with disabilities, as this subject lies outside the scope of the FRR project.

6.3. The Toilet Seat

User involved studies indicated that many elderly users and people with disabilities complain about the lack of space offered by a standard toilet seat and even experience serious discomfort. Assistive solutions as offered in the market, such as an "add on" to increase the height of the seat, do not offer an integrated solution and have a poor visual quality, thus contributing to a stigmatising image. T.J.J. Groothuizen et al. / The Final FRR Components 121

The design team has put much effort in studying the usage problems and proposed three new concepts for seats. Different principles were developed resulting in three functional models of seats, which were tested in several URBs [10]. The users almost unanimously preferred the functionality of the so-called Transfer Seat. This seat consists of two parts: on the one hand a "normal" toilet seat and on the other hand a transfer surface, on the left and/or right side of the seat (see Figure 7). The transfer surfaces are meant to offer wheelchair users a large and flat surface for transfer. The surface is smooth and allows easy sliding. The design also offers user the possibility to use the surface to put aside some personal belongings needed during toileting (for example a catheter or incontinence diapers) or to give support when sitting down, adjusting body position or standing up. The initial design included an adjustment of the width of the toilet seat. This was left out in the new designs, because the risk of physical injury could not be excluded. The toilet seat itself was redesigned in a later stage into a so-called comfort seat, in order to offer more support and stability to the user, as result of additional ergonomic research and user tests. The seat and transfer surface are connected with the height adjustment and tilting mechanism of the toilet bowl. The width of the transfer seat will be based on the available width of the rest room but is limited to a maximum of 40 cm left and right of the toilet seat.

6.4. The Comfort Washbasin

During the exploratory phase of the FRR project, many target users mentioned the necessity of being able to cleanse themselves during toileting, in particular in case of a reduced physical mobility and in case of particular hygiene operations (i.e. changing diapers or catheter). A washbasin out of reach does not offer a comfortable solution. Therefore, it was suggested to develop a small washbasin, which offers the possibility to cleanse hands and or body parts while seated on the toilet (see Figure 8). The basin is mounted close to the toilet area on the wall or floor. The basin can be pulled close to the person while seated. By pulling the handle at the front the basin releases the brake function and allows movement in all directions in the vertical and horizontal plane. After releasing the handle, the basin is locked in its position. The washbasin can thus be moved in all directions into a most comfortable position close to the user: "comfort washbasin". The washbasin is equipped with a faucet with two integrated functions: water and soap. The water sensor is located underneath the faucet outlet and the one for soap above. Users will be instructed by pictograms. Additionally, a hand shower can be mounted for comfortable cleansing of intimate body parts. Underneath the basin, an additional light source is foreseen in order to improve visibility while cleansing the intimate body parts. The design was granted a patent [11] and additional R&D activities will be planned.

122 T.J.J. Groothuizen et al. / The Final FRR Components

Figure 8. View of total FRR toilet environment including comfort washbasin

7. Conclusions

After prototyping this design in 3 and later 5 countries, the integrated version was built together with the company Clean Solution and tested 3 months in a nursing home in Vienna. This evaluation was organised by fortec, a research group on rehabilitation technology of the Vienna University of Technology, Austria. The recommendations followed from these tests were announced in the final conference in Vienna and written down in this book, in several conference papers [12] and in a commercial version of the toilet produced by Clean Solution in Debrecen, Hungary.

T.J.J. Groothuizen et al. / The Final FRR Components 123

References

[1] Technical Annex, Project QLRT-2001-00458, Friendly Rest Room for Elderly People. Quality of Life and Management of Living Resources, Key-Action 6: the Ageing Population and Disabilities. FRR Project document; 2003. [2] Roozenburg NFM, Eekels J. Product design: fundamentals and methods. Chichester: John Wiley & Sons Inc; 1995. [3] Buzink S, de Bruin R, Groothuizen TJJ, Haagsman EM, Molenbroek JFM. Fall Prevention in the Toilet Environment. This volume. [4] Buzink SN, Molenbroek JFM, Haagsman EM, de Bruin R, Groothuizen TJJ. Falls in the toilet environment: a study on influential factors. Gerontechnology. 2005;4:15-26. [5] Kira, A. The bathroom. New York: Viking Press; 1976. [6] Molenbroek JFM, de Bruin R. Overview of the FRR Project; Designing the Toilet of the Future. This volume. [7] Plante, R.A. Toilet customs of the elderly; an exploration to find problems caused by the symptoms of old age and injury into the problems that exist when using the raised toilet seat [Student research report, in Dutch]. Delft: Delft University of Technology, Faculty of Industrial Design Engineering; 2002. [8] Dekker D, Buzink SN, Molenbroek JFM. User Preferences Regarding Body Support and Personal Hygiene in the Toilet Environment. This volume. [9] Buzink SN. De ontwikkeling van een product ter preventie van valongevallen in toiletruimten [Master thesis, in Dutch]. Delft: Delft University of Technology, Faculty of Industrial Design Engineering; 2004. [10] Gentile N, Dayé C, Edelmayer G, Egger de Campo M, Mayer P, Panek P, Schlathau R. Concept, Setting up and First Results from a Real Life Installation of an Improved Toilet System at a Care Institution in Austria. This volume. [11] Groothuizen TJJ, inventor; Delft University of Technology. Wasbak. NL patent NL1027416. 2006 May 8. [12] Fortec homepage. FRR - Friendly Rest Rooms for Elderly People / Intelligent Toilet. [Internet] 2011 [cited 2011 Mar 15]. Available from: http://www.is.tuwien.ac.at/fortec/reha.e/projects/frr/frr.html This page intentionally left blank

Section 3 FRR Case Studies and User Tests

This page intentionally left blank A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People 127 J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-127 Elderly and People with Disabilities - Limitations in their Everyday Life

Panayota SOURTZIa,1 and Terezinha MENEZELLOb a Hellenic Association of Gerontology and Geriatrics and Faculty of Nursing – University of Athens, Athens, Greece b Physiotherapist – Centro di Bioingegneria, Fondazione Don Gnocchi Onlus.Milano, Milano, Italy

Abstract: The proportion of older people (65+) in the population is increasing steadily worldwide due to longer life expectancy and decreasing birth rates. The ageing population often presents with chronic diseases that result into limitations in the activities of daily living. People with disabilities, either congenital or acquired, also face various degrees of limitations and need some form of assistance. Disabilities in general and limitations that are common in old age, including epidemiological data, are discussed. Indubitably, the need for adapting the living environment of this population becomes apparent. Three case studies with older people and people with disabilities in different situations are presented as examples of adaptation of the bathroom area. Concrete solutions that have been proposed with respect to their limitations and the way they successfully solved their problems by means of home adaptations using mostly low-tech solutions are described. Overall, these three cases encompass typical situations encountered by aging and disabled persons.

Keywords: Elderly, Disabilities, ADL, Toilet, Observational Studies

1. Introduction

It is a fact that the demography of our world changes rapidly following the Second World War. The synthesis of the population in the developed countries, but increasingly in developing countries, too, has been altered in such a way that the most common comment in the news today is the ageing of the world’s population. In the European Union (EU) almost all countries show a decrease in birth rates, with the average been 1.5 children per woman, while there should be 2.2 children per woman for natural growth of the population. At the same time life expectancy of the populations grows steadily. The average life expectancy of men in EU has reached 76 years and of women 82. Therefore, it is expected that the natural growth rate for most European countries will diminish and it is predicted to become negative by 2010, although in some countries it already is. The result of this development is that the ratio of older people in the total population is expected to increase from 17% that is the average today for the age group 65+ to 30% by 2060. Similarly, the proportion of the

1 Corresponding Author: P. Sourtzi; Address: 123 Papadiamantopoulou street, 11527 Athens Greece; Email: [email protected]

128 P. Sourtzi and T. Menezello / Elderly and People with Disabilities very old people, aged 80 or more, is expected to rise from 5% today to 12% in 2060 [1,2]. The ageing of the population is a phenomenon that comes with many problems for the society, the family and the health and welfare systems. Although ageing is a natural biological fact, it is also strongly correlated with increased morbidity, especially of chronic diseases, which very often cause various disabilities. Similarly people with disabilities carried on from younger ages will have even greater limitations as they become older. Dependency rates therefore, are expected to increase greatly and will impact on health care systems as well as on the social and economic structure. The prevalence of chronic disease and disability is an important factor for any population’s health and quality of life. However, not all EU countries collect such data and existing statistical reports are based on different sources, therefore cross-country comparisons are difficult to find. In most countries relevant data are based on health surveys, but in others they are estimated from the list of people receiving social insurance disability pensions [3]. It is estimated that 10% of the EU population are disabled, while 40% have reduced mobility [4]. Cross-cultural variation was noted in self-reported disability adjusted for performance score. These differences may be due to sociocultural and physical environmental factors [5].

1.1. Definitions

Old age is widely accepted today – at least in the developed countries of our world - that starts at 65 years of age, while very old age refers to persons of 80 years old or older. Disability is defined by WHO as a “loss or abnormality of body structure or of a physiological or psychological function”. Dependency is measured by the need for assistance in the activities of daily life (ADL) [6] and instrumental activities of daily life (IADL) [7] as reported by the individuals themselves (Table 1).

Table 1. Definitions of self reported activities of daily living.

Basic ADLs Instrumental ADLs Bathing Using telephone Dressing Grooming Transferring (moving from chair to bed or toilet Laundry and vice versa) Shopping Toileting Housework Feeding self Taking medicine as directed Ambulating Managing one’s own money

P. Sourtzi and T. Menezello / Elderly and People with Disabilities 129

2. Older People with Limitations in Every Day Life

People, in the vast majority, remain independent until their old age. People aged 65 or older that are able to perform the essential activities that help them remain independent, are considered healthy and they do not need any form of assistance, although they may have developed some chronic health problem, such as high blood pressure or diabetes type II. Therefore, old age does not mean disability and consequently limitation in any ADL or IADL. However, as old age advances the possibility for impairments emerges and increasing deterioration is a common pattern. This is even more common for the persons older than 80 years old, who are also in their majority women, a result of longer life expectancy in comparison to men. Strauss et al [8] have found that women have more limitations, according to basic ADLs, than men as age advances. According to the report “The social situation in Europe” [9], the old age dependency ratio has increased from 21.6% in 1990 in the 15 EU countries to 24.3% in 2001 and it is expected to rise to 27.3% in 2010. In 2000 in the EU-15 the average ratio of people receiving disability benefits was 8.1%, while the older people accounted for 46.4% of the total number of people receiving any kind of benefits [9].

2.1. Most Common Problems That Lead to Limitations in Everyday Life

The main causes of death in older ages are diseases of the circulatory system, cancer, diseases of the respiratory system and external causes such as injury (including car accidents) and poisoning. Morbidity however, presents a different picture in older ages.

Neuro-degenerative diseases such as dementias are becoming a severe problem that increases with age and results into increasing dependency until the individual becomes invalid and die. It is estimated that 4% of people between 65 and 74 will develop some form of dementia, while this proportion rises to 20% for persons 75 or more [10]. Cardiovascular diseases are also a severe problem, with high incidence in almost all EU countries and has been found to lead to various degrees of disability [11]. Musculoskeletal disorders lead into limitation in movement and are one of the main causes of dependency in that age group. The most common age related health problems that contribute to both musculoskeletal disorders and accidents are osteoporosis and arthritis. Injuries, caused by a pathological condition, either in the home or in the external environment are becoming more frequent and result into disability. Visual impairments among adults in the US account for 0.78% blindness and 1.98% of low vision, with the most common causes being macular degeneration, cataract and glaucoma [12]. Similar prevalence and causes have been found in Denmark [13]. Hearing impairments are also a largely age-related problem and although it is not disabling as such, when it coincides with other conditions, then limitations are becoming even more severe.

130 P. Sourtzi and T. Menezello / Elderly and People with Disabilities

2.2. People with Disabilities

A disability can affect any person regardless of sex, age, race, ethnic group or social class. A disability is defined as any limitation in physical, mental or intellectual health and result in different levels of need of care or assistance. A disability could be congenital or established later in life following an accident or a chronic disease. According to a recent report disability is defined in different ways in different countries especially in terms of socioeconomic status [14]. In the characterization of disability one refers, very often, to persons younger than 65, which is the average age of retirement in Europe. However, once a person is characterized with a permanent disability, this classification usually remains for the rest of his/her life. In 1996, when the total EU-population was 300 Million, 40 million persons or 13% had some sort of disability and of those 50% were of working age [15]. According to the report compiled by EIM Business and Policy Research [3] the percentage of persons aged 16- 54 years with self-reported disability was 14.3% in the 15 EU countries. Disability is much more prevalent as age advances, because the health condition that is responsible for it usually deteriorates with age. Disabilities that start early in life, are lifespan and not likely to be cured, are often due to:

Congenital and chromosomal defects, Learning disabilities, Injuries at birth or other perinatal complications, Accidents at work, traffic accidents, Acquired disabilities related to chronic diseases such as asthma, juvenile rheumatoid arthritis, cystic fibrosis, cancer, Neuro and muscle degeneration diseases, with more prevalent multiple sclerosis, are also becoming more prevalent with age, as well as more disabling.

Statistical data from the USA show that injuries cause 13.4% of all disabling conditions, while orthopaedic impairments account for half of all disabling conditions. According to ICD classification, diseases of the musculoskeletal system and connecting tissue account for 17.2%, while circulatory system diseases for another 16.7% [16]. From the same data set it is also shown that the rate of people with at least one ADL limitation was 14.4% in 1994. Older people experience disability at roughly twice the rate of those in the older working ages (45-64) and four times the rate of the younger working-age group (18-44). A still smaller fraction of children have disabilities.

2.3. Conclusion

It is clear from the above that dependency rates in the general population from both ageing and disability are increasing in the EU countries. Because of this trend more services will be required in the future in order to respond to the needs of older people and persons with disabilities. These services include mainly traditional health and social care. Assistive technology that will increase accessibility, equity and independence, however, could play an important role and could additionally free the services from some of the costs induced by the need for traditional care. Therefore, the study -

P. Sourtzi and T. Menezello / Elderly and People with Disabilities 131 according to the needs that emerge from users, their family and health care professionals -, of products innovation looking for new solutions, in terms of technique and use, is essential. For existing products, the aim is to assess and optimize the application of new components. It is also important to improve the functionality of the devices and their comfort, by developing new designs, applying new materials to increase safety, autonomy and dignity in the restroom. [19,20,21]. Therefore the need for adaptation of the home environment is indispensable, if there is a possibility for older people or persons with a disability to stay at home independently or with some assistance for as long as possible.

3. Three Case Studies

The following case studies2 illustrate how the bathroom, one of the most important rooms in the house, can be adapted with the amenities and assistive technology that are currently available in the market, in order to contribute to the aim of helping people to stay at home, and to provide them with an acceptable quality of life. In addition, these case studies show how important it is to study new ways of making the life of old and/or disabled persons easier and better.

3.1. Luigi and His Wife

The actors: Luigi (96 years old) and his wife (82 years old) live on their own in an apartment on the 4th floor, in a big city. Luigi has slowness in his movements, it is difficult for him to get up from his seating, he feels back pain and also has oedema in his legs. In spite of their advanced age, the couple lives alone without needing any help in the activities of daily living. Luigi and his wife have a lucid mind and they are looking for assistive devices to support the independent living for them. The main purpose of the intervention described here, was to find out facilitation in the bathroom, to make it possible for Luigi and his wife to carry out their every day’s sanitation activities without additional help.

3.1.1. The Bathroom The room is 160cm wide and 350cm long (see Figure 1). The door entrance is 70cm wide and all elements are localized on the left side, in the following order: Bathtub (170x70x90cm), washing machine (60x60x85cm), sink (70x50x85cm), bidet and toilet bowl (height 42cm). The distance between toilet bowl and bidet is 40cm. Near the toilet bowl there is a window and on the right side, along the wall there are two pieces of furniture that contain their personal things.

2 Although the case studies are based on real life problems, actors’ names are fictional.

132 P. Sourtzi and T. Menezello / Elderly and People with Disabilities

Figure 1. The Rest Room

3.1.2. The Every Day Activities in the Bathroom Luigi moves independently inside his home. He uses a walker to support shifting. When he comes near the bathroom door, he leaves the walker outside and uses different support points (the door handle, the washing machine, the sink, the drawer handle) to move to the toilet bowl. The height of toilet is lower than standard; it is –including the toilet seat- only 42 cm high. As the problems related to growing old increase, like sitting down and getting up from the toilet, Luigi becomes more dependent on his wife; she is pulling him with both hands, with the consequence of forcing her back and risking to fall down together. Following a discussion with the couple about possible solutions for these problems, it was decided to install a raised toilet seat, fixed on the toilet bowl and with support bars alongside. When Luigi gets up from the toilet bowl, holding on the radiator or supported by his wife, he moves towards the sink, in order to continue his personal hygiene activities. He sits down on the commode chair, equipped with a cushion, because the hard surface causes pain and leads to skin problems in the sciatic region. The long support bars of the chair allow for autonomy to get up alone. Luigi adopted this solution about two years ago, when standing up became difficult for him. When taking a bath, Luigi used to sit on the edge of the washtub, with his wife sitting in front of him in a small chair; she took off his shoes, and helped him turn inside the wash tub; he then turned himself hanging on to the water tap and she helped him to lift his legs one by one and put them inside the washtub. On the bottom of the

P. Sourtzi and T. Menezello / Elderly and People with Disabilities 133 washtub an anti slippery carpet had been placed. Supported by his wife, Luigi used to get up and sit down on a fixed stool placed 15 cm below the edges of the washtub. When finished bathing, they used the same procedures to get Luigi out of bathtub. For the last six months Luigi has not used the washtub anymore, because he does not feel safe due to the increased difficulties for him to move.

3.1.3. Adopted Solutions The solutions that were discussed with Luigi and his wife and eventually installed in their bathroom were:

1. Raised toilet seat with fixed support bars (Figure 2) to allow for stability and safe sitting down and getting up. 2. Swivel washtub chair (Figure 3), suitable to overcome difficulties of positioning inside of washtub. Characteristics:

Seat width 46 cm. Swivel 360° with blocking option each 90° Support bars Maximum weight 130 Kg.

Figure 2. Raised toilet seat Figure 3. Swivel chair

3.1.4. Expert’s Evaluation At the first meeting, the couple was looking forward to find solutions to support their daily activities in the bathroom, so it was necessary to understand their way of doing in order to solve their problems. Therefore, the solutions that were proposed were based on their expressed needs. It was very important for Luigi and his wife not to make structural changes in the bathroom. The solutions should fit in the actual restroom for instance by using innovative products or assistive technology. Specifics: The toilet: Luigi considers the choice of a raised toilet seat 10 cm higher to be perfect; it allows for maintaining the foot contact with the floor, but is easier to get up from. The side handles, made of anti-slippery material and appropriately

134 P. Sourtzi and T. Menezello / Elderly and People with Disabilities designed, provide sufficient support for independent transfer to and from the toilet bowl. He does not use the urinal anymore and his overall mobility has improved. The sink: By using a commode chair placed near the sink, Luigi sits down to carry out the daily morning activities of personal hygiene; he washes his face, brushes his teeth, combs his hair and shaves without help. The use of the sink is considered satisfactory by the couple. The washtub: By using a swivel chair mounted on the washtub, Luigi is able to wash himself with minimal assistance from his wife. They now feel safe and are satisfied with this solution.

3.2. Silvia’s Bathroom

The actor: Silvia is a 59 years old woman. In July 2002 she has had a hemorrhagic aneurysm resulting into compression of the brain with consequenting hemiplegia. Following discharge from a Rehabilitation Center, she lives at home with her family. The bathroom is for her currently the main problem to be addressed in order to take control of the hygiene activities independently and without assistance. Silvia is not able to walk and uses a wheel chair to move inside her home. She is able however, to make transfers with a minimum of help (she needs somebody aside to feel safe). The apartment has two bathrooms; a small one, with a not accessible shower box (Figure 4), and a larger one with a wash tub (Figure 5). After a thorough study Silvia and her family decided to change the main bathroom to create an accessible room for her and her needs.

3.2.1. Description of the Bathrooms The following photographs show the components inside the two bathrooms; the small bathroom (Figure 4), the main rest room (Figure 5) and the main rest room after adaptations for Silvia (Figure 6 and 7).

3.2.2. Adopted Solutions The toilet has a double function; as a normal toilet and as a bidet. It is about 50 cm. high and it is provided with a front opening in order to allow for the washing operations through the use of an external shower. The baked clay washbasin is provided with rests for the elbows, splashboard borders and it has a particular hollow shape which allows an easier approach for people on wheel chair. The washbasin has a mixer with clinical lever. The box shower has a shower tray floor edge and a folding seat with back and arms. An adjustable tilting mirror is fixed on the wall above the sink. The room is spacious enough to move around inside it for a wheelchair user and an assistant. Silvia now is able to use the bathroom safely and comfortably.

P. Sourtzi and T. Menezello / Elderly and People with Disabilities 135

Figure 4. The small bathroom

Figure 5. The main bathroom

136 P. Sourtzi and T. Menezello / Elderly and People with Disabilities

Figure 6. The adapted shower

Figure 7. The adapted toilet and washbasin

P. Sourtzi and T. Menezello / Elderly and People with Disabilities 137

3.3. Tina’s Bathroom

Tina is a young woman of 46 years old. In 1985 she suffered a surgical complication following an operation to a severe scoliosis that led her to stay in bed for l0 years. In 1999 she became able to sit; she could then use a wheelchair and began to seek more autonomy. The first changes she has made were in the kitchen, which for her had priority in her new way of life. Then, she tried to become more independent at home. After three years not being able to use the bathroom, she decided that it was time to return to a more autonomous life, and feel the pleasure of a shower after so many years. The bathroom as it was, was however not accessible, so she decided to change the whole room and she asked for help.

3.3.1. Description of the New Bathroom. The restroom is 225 cm. long and has a central door 60 cm. wide, sliding on rails. The room width is 180 cm. There are no windows and an appropriate fan provides the ventilation. The changes made and the results are presented in Table 2 and Figures 8 and 9. Actions that were suggested by the expert are also presented in this table.

Figure 8. The sink and toilet bowl

138 P. Sourtzi and T. Menezello / Elderly and People with Disabilities

Table 2. Tina’s bathroom

Part Success Failure Action Suggested Sink Tina considers the No further action suggested. accessibility, the size, and height adequate. The mixer tap is easy to handle and safe. Light point It is located too high (150 cm) and Transfer the light point and and it is not accessible. To turn on the electrical outlet at 100 cm high electrical light she uses a walking stick but and at the left side of the sink outlet the electrical outlet is not usable. because access is easier. Toilet bowl The access is impaired on the left The wheelchair should be side by the sink and on the right positioned transversally to the side by the shower box. There is no WC to make it possible to slide place to install support to the up to e from the WC. The height transfers and it is too high for the of WC should be the same as the user. The bowl has an opening at wheelchair. It is important the the front side, designed to help support of handles during the with cleaning, however, it creates transfers. WC without the front instability. Tina has spastic legs opening. The bidet system and the transfer can produce would be functional with a contractions and she does not feel handle shower. safe; she fears the empty space in front of her while attempting transfer. The back hole for the delivery of cleaning water (the bidet system) is not functional. Shower Inability to enter the shower box The user decided to eliminate box with the wheelchair because the the upsetting chair; alternatively, floor of the shower box is lower 2,5 she’s trying out a shower chair cm. than the bathroom floor and with the big wheels to be able to connected to the latter by means of manoeuvre on her own. By this a short ramp. It was initially way, the transfer will be done in designed to accommodate a plastic the bedroom (bed to shower or a wooden carpet, but it has been chair and shower chair to bed). not yet installed (when Tina’s tries On the floor a plastic carpet will to get in the wheelchair she tends be installed. to tilt forward with the front wheels pivoting side wards thus creating instability). Tina feels like falling and cannot make it without help. Basket It is situated at the right side of the There should be 2 baskets sink and the access is difficult (it is installed at both sides of the sink too near to the corner). at the same high (100cm) but not too far as it is now. Door It is too narrow (60 cm.). It should be 10 cm. wider to make the entrance and the exit in the restroom easier. Floor The user is happy No further action suggested. with the non- slippery tiled floor

P. Sourtzi and T. Menezello / Elderly and People with Disabilities 139

Figure 9. Reaching for the light point and electrical outlet

4. Conclusions

From the viewpoint of 'adding life to years', studying socioeconomic inequalities can give us clues about how much 'life' can still be added to the 'years' of elderly people and persons with disabilities that are in a socioeconomically disadvantaged position [22]. To finally conclude, the following part from an EC report [9] illustrates current needs and future developments:

“It is a feature of human life that the number of functional disabilities of all kinds tends to increase with age. Sickness, risky lifestyles, accidents and socio-economic factors all combine to create a 'disabling' process, which accumulates overtime. It is not surprising, therefore, that young people make up 5% of the people with disabilities, while people of working age constitute 46% and the remaining 49% of the people declaring disability are over 60 years of age (ECHP Data). With increasing life expectancy, prevalence of visual and hearing impairments also increase, as well as neurological disorders such as Alzheimer’s disease and dementia. However, future trends in age-specific risks of becoming hampered will be a key factor in the number of elderly people that will be in need of assistance and care”.

140 P. Sourtzi and T. Menezello / Elderly and People with Disabilities

References

[1] World Health Organisation. Atlas of health in Europe. WHO Europe; 2003. [2] European Commission. The 2009 Ageing Report. Underlying assumption and Projection Methodologies. European Communities; 2008. [3] EIM Business and Policy Research. The employment situation of people with disabilities in the European Union. EC Employment and Social Affairs; 2001. [4] European Disability Forum. Facts and figures about disability [Internet] 2009 [cited 2009 Jun 10]. Available from: http://www.edf-feph.org [5] Brink CL van den, Tijhuis M, Kalmijn S, Klazinga NS, Nissinen A, Giampaoli S, Kivinen P, Kromhout D, Bos GAM van den. Self-reported disability and its association with performance-based limitation in elderly men: A comparison of three European countries. Journal of the American Geriatrics Society. 2003;51:782-788. [6] Katz S, Downs TD, Cash HR, Grotz RC. Progress in development of the index of ADL. Gerontologist. 1970;10:20-30. [7] Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9:179-86. [8] Strauss E von, Aguero-Torres H, Kareholt I, Windblad B, Fratiglioni L. Women are more disabled in basic activities of daily living that men only in very advanced ages: A study on disability, morbidity, and mortality from the Kungsholmen project. Journal of Clinical Epidemiology. 2003;56:669-677. [9] European Commission. The social situation in the European Union. European Communities; 2003. [10] Mougias A. Handbook on Alzheimer’s disease and other dementias [Greek]. Mendor Publications; 2003. [11] Kattainen A, Koskinen S, Reunanen A, Martelin T, Knekt P, Aromaa A. Impact of cardiovascular diseases on activity limitations and need for help among older persons. Journal of Clinical Epidemiology. 2002;57:82-88. [12] Congdon N, O’Colmain B, Klaver CC, Klein R, Munoz B, Friedman DS, Kemben J, Taylor HR, Mitchell P. Causes and prevalence of visual impairment among adults in the US. Archives of Ophthalmology. 2004;122:477-485. [13] Buch H, Vinding T, La Cour M, Appleyard M, Jensen GB, Nielsen NV. (2004). Prevalence and causes of visual impairment and blindness among 9980 Scandinavian adults: the Copenhagen City Eye Study. Ophthalmology. 2004;111:53-61. [14] Brunel University. Definitions of disability in Europe. A comparative analysis. Report. European Commission, Employment and Social Affairs; 2002. [15] European Commission. Employment-HORIZON; Better Employment Opportunities for People with Disabilities [Internet]. 1996 [updated 2010 Jun 30]. Available from: http://ec.europa.eu/comm/employment_social/equal/index.cfm [16] LaPlante MP. Health Conditions and Impairments Causing Disability. Disability Statistics Abstract. 1996; No 16. [17] Kaye HS, LaPlante MP, Carlson D, Wenger BL. Trends in Disability Rates in the US, 1970-1994. Disability Statistics Abstract. 1996; No 17. [18] Kennedy J, LaPlante MP, Kaye HS. Need for Assistance in the activities of daily living. Disability Statistics Abstract. 1997; No 18. [19] Jensen L, editor. Go for it! A user manual on assistive technology. Milano: Eustat Consortium, European Commission; 1999. [20] Andrich R, Besio S, editors. Assistive technology education for end-users - guidelines for trainers. Milano: Eustat Consortium, European Commission; 1999. [21] Andrich, R. Being informed, demanding and responsible consumers of assistive technology: an educational issue. Disability and Rehabilitation. 2002;24:152-159. [22] Huisman M, Kunst AE, Mackenbach JP. Socioeconomic inequalities in morbidity among the elderly; a European overview. Social Science and Medicine. 2003;57:861-873.

A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People 141 J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-141 Experience of Testing with Elderly Users

Gunilla KNALLa,1, Panayota SOURTZIb and Joseph LIASKOSc aCertec – University of Lund, Lund, Sweden bHellenic Association of Gerontology and Geriatrics and Faculty of Nursing – University of Athens, Athens, Greece cLaboratory of Health Informatics – Faculty of Nursing – University of Athens, Athens, Greece

Abstract: The experiences and knowledge gained from user tests with primary (elderly) and secondary (caretakers) users carried out at two of the five different User Research Bases (URBs) in the FRR Project, located in Lund and Athens, have been analyzed for commonalities and differences. Aim of the tests was to actively involve users in all the phases of development of the FRR, including needs assessment, actual measurements, reporting of requirements, and evaluation of designed components. Working with people with different abilities proved to be a challenging research experience in both URBs. In-depth understanding about what test persons need, think and feel about their difficulties in daily life was only possible through recognition of the importance of the role of test persons in this interaction. Valuable experience was gained about how to manage difficulties during interaction with test persons and prototypes as well as working in a multidisciplinary team and in collaboration with other URBs from different scientific and cultural backgrounds. It is concluded that rest rooms of today are often unnecessarily inaccessible and the test results of the FRR project have increased the knowledge on how to improve the design of toilets; and this, comparing the results from the different URBs, does not really seem to differ from culture to culture.

Keywords. Elderly, Toilet, Observational Study, Laboratory Testing

1. Introduction

The User Driven research model has been instrumental in the FRR project as in all projects funded by the EC Quality of Life Programme [1]. The primary end users in this project were older people and people with disabilities; secondary end users were health care professionals and caregivers. Experts were also asked to participate in the different stages of the research and development in order to enrich the data collected from users and the proposals made by the researchers. User Research Bases (URBs) were developed in order to actively involve users in the participating countries [2]. These bases included the research team and representatives of the users – primary, secondary and experts. The FRR prototypes, which were tested each time were the invaluable material part of each URB.

1 Corresponding Author: Gunilla Knall, Certec, LTH, P.O. Box 118, S-221 00 Lund, Sweden; Tel: +46 46 2220195; Fax: +46 46 2224431; Email: [email protected]; Website: http//www.english.certec.lth.se 142 G. Knall et al. / Experience of Testing with Elderly Users

Primary users in this project were older people with various limitations in activities of daily living and persons with disabilities [3]. Primary users were all volunteers, although recruitment followed different approaches in each URB. Secondary users were caregivers of older people and persons with disabilities, as well as professionals who provided direct care, such as nurses, physiotherapists, occupational and therapists. In most cases, secondary users came from the same institutions from where each URB recruited their primary users and very often they were instrumental in informing and supporting primary users. Users in this project were actively involved as equal partners and influenced the prototype design and development not only by presenting their needs and evaluating the components presented to them, but also by their insightful comments during all research stages. Special means and techniques with the intention of enhancing user participation and contribution were tested, developed and implemented, in the process and are described in other chapters [4, 5]. Ethical reviewers ensured that all steps recommended for recruitment and participation of users were seriously taken into account, especially because the issues involved in this project are of a very sensitive nature for the participants [6]. The aim of the tests was to actively involve users in all the phases of development of the FRR, including needs assessment, actual measurements, reporting of requirements, and evaluation of designed components. In this chapter the experiences gained from two of the URBs, one from the north of Europe and one from the south, are presented and discussed in order to give useful information for future similar efforts.

2. Experience of Testing with Elderly Users in Sweden

2.1. Why Testing?

You cannot know until you have tried! This is the truth in any project, so also in our FRR project aiming at an intelligent toilet specially designed for elderly and disabled people. See figures 1 and 2 for an impression of the test environment.

2.2. How Did We Choose the Test Persons?

One of the partners in the FRR project, EURAG, (European Federation of the Elderly) is an umbrella organisation for elderly people in Europe. They have a wide network of contacts in most European countries but not in Sweden. So we had to think of another way to find testers in our geographical neighbourhood. Our concerns were to find testers who represented a wide range of disabilities as well as different lengths, weight and gender. It was also important that they were not dependent on us in any way. Our test station in Lund, Sweden was the only one where the consortium was able to test different kinds of illumination; therefore we were particularly interested in people with visual impairments. At this stage we had created the User Board consisting of a group of people with both professional and personal experiences in the field of disabilities. We asked them to provide us with possible test persons. The criteria were: elderly with some kind of disability and preferably good verbal skills. When our User Board members found these people they asked them if they would be willing to participate in G. Knall et al. / Experience of Testing with Elderly Users 143 a research project like ours. If the answer was yes, we then contacted them and this is how we found our 12 test persons. All contacted persons answered that they were willing to participate in the trials. Some of them expressed their happiness that somebody wanted to take this issue about toileting seriously and carry out research on the topic, and thus they were pleased if they could contribute.

Figures 1 and 2. Pictures form the tests in Sweden

2.3. Information about the Project and the Tests

All five URB test stations used the same kind of information. It was sent out at least 2 weeks in advance and contained: Project presentation; images of the test station (in this case, Lund) The testing procedure A city map with directions Instructions for the test persons An informed consent form. The explicit purpose of the informed consent form was to ask the expected test person if they felt fully informed and if they agreed to participate in the research or not. Later, when the testers arrived for the first test trail, we also read through it together to make sure that they agreed to the contents. The information kit was highly appreciated by the test persons. The official FRR logo on the front page and the way the information was organized looked nice and gave a confident impression.

2.4. Preparations

To carry out these tests, we had to build the station and equip it with the test objects. We also had to prepare ourselves mentally for the procedure. To give ourselves the best 144 G. Knall et al. / Experience of Testing with Elderly Users chance of success we had to be very thorough when deciding how the testing should be done. Our test persons were generally old and frail and therefore the tests should not be too physically or mentally demanding.

2.5. Atmosphere

It was of paramount importance that the test persons felt at ease in the physical environment of the test area and with people around them, so their thoughts and reactions could be as natural as possible. To create the relaxed atmosphere we required, we met all the test persons at the main entrance and walked casually with them to where the lab is located enjoying some idle small talk along the way. To show that we were in no hurry we always had fruits and drinks available whilst they were in the laboratory and the test persons were encouraged to help themselves during their visit.

2.6. Security

In a test situation there is always a risk of component failure. To reduce that risk we were very careful when assembling our equipment and it was always double-checked before being put in use. During the tests the area used was kept free from unnecessary tools and equipment to avoid accidents. As en extra precaution we took out an insurance policy to cover our volunteers against injury. This covered the entire visit including time in transit.

2.7. Influence on the Testing

Carrying out tests like these requires objectivity from the test leader; on the one hand he/she must create a pleasant atmosphere and on the other he/she must not be so personally involved that the test person’s results are affected. We really think the risk that the test person’s eagerness to please by giving the “right” answers should not be underestimated and feel that we should emphasised this as a possible source of error.

2.8. Did They Come Back?

We were impressed by the effort made to attend our test sessions but were forced to increase the number of test persons by 4 to achieve the numbers we desired.

2.9. What Did We Learn?

We learned that our method for choosing test persons was very successful. It resulted in a fantastic mixture of testers who had a lot to tell us. They were unbiased and were capable of communicating their opinions on all the topics they were asked. We experienced that the two hours testing time was just right. We never had the feeling that they were stressed or that two hours was too much for them. The test persons seemed to be very engaged in the project and they also seemed to look upon their own contribution as important for the research, and they liked to be asked. G. Knall et al. / Experience of Testing with Elderly Users 145

We also learned that the way we carried out the testing, by not interrupting the testers but following their thoughts as they came during the session, gave us more input than the questioning afterwards. Sometimes the test persons had a need to concretise their opinions and they were then given paper and pens. It would have been much better if we had had small models of the test items that could be moved around. It would also have been much better if we in advance had thought of providing them with coloured images of the whole FRR station to take with them in order to facilitate their creative ideas when they were back home.

Without the test persons we would never have discovered that a divided toilet seat is very uncomfortable and even dangerous for paralysed people, because it was possible for their legs to fall into the gap. We thought it would be of interest for people who use a catheter for urinating to have a good spotlight above the toilet, but none of our testers really needed that. We thought that adjustable lighting was very important, and it was. However, we did not realised just how important. The very bright light was actually painful for one of our test persons, while others really appreciated it. Most of our test persons appreciated the adjustable toilet as expected. What we learned was that they did not understand that it could be used as a raising help if you have weakness in your legs. When we pointed this out to them it was greatly appreciated. Small things like a place to put your cane or your handbag are as important as the technically advanced aspects of the toilet. Support bars are essential and they must not be forgotten in a project like FRR. Spontaneous comments we heard from the testers when entering the test room were more often about the nice, clean appearance rather than the high tech utilities. There should be at least three persons from the research team present at each test session: one test leader guiding the test person through the procedure; one who is responsible for all technical equipment including documentation through photography and video recording and one expert observer.

3. Experience of Testing with Elderly Users in Greece

3.1. User-Driven Research Base in Athens

In the framework of the FRR project a user-driven research base [7,8] was established in Athens. Its aim was to recruit testers – potential users of the friendly rest room being developed – and organise for them the appropriate procedure for using and testing the components of the different FRR prototypes installed in the research base. The FRR prototypes, i.e. the models of the friendly rest room with the different components provided by the designer and manufacturing partners of the consortium, were installed in the building of the Faculty of Nursing of the National and Kapodistrian University of Athens [8,9] The decision to install the prototypes in that building was made mainly for two reasons. On the one hand, the Faculty of Nursing is an educational institution that educates and trains nurses, who are one of the major groups of the secondary users interested in this project, and an important link with the primary users of the FRR, 146 G. Knall et al. / Experience of Testing with Elderly Users which means that they can be easily informed, activated, and recruited for the aims and needs of the FRR research base. One the other hand, that building is the working environment of the researchers of two of the partners of the consortium, which means that the testing procedure for the users could be more efficiently prepared, organised and implemented. The tests carried out in the research base followed different phases, according to the different FRR prototypes installed. The testing station of the initial tests was different from that of the following ones. The first station was installed in a relatively small room with little space for the users, but with the installed prototype being fully functional, due to its connection to the water supply and drainage. On the contrary, the location of the second station, where the next prototypes were installed and tested, had dimensions large enough for the toileting needs of the users, but the water supply and drainage were absent. This meant that the tests conducted at the second station more resembled “laboratory” conditions [9,10,11]. See figures 3 and 4 for an impression of the test environment.

3.2. Recruitment of Users

One of the initial aims of the research base was the recruitment of primary and secondary users who would visit the FRR station, and test the different prototypes that were installed. A User Board was created in order to facilitate user recruitment. It consisted of a small group of people who were professionally engaged in the provision of care to elderly and people with disabilities, or they also experienced limitations as elderly or people with disabilities themselves. The User Board played an important role in advising the research team and counselling in aspects of the prototypes’ installation and the testing procedure followed. It also assisted in the recruitment of primary users, at least in the first phases of the tests. It was decided that the primary users were to be mainly elderly users, at least 65 years old and older, with limitations in mobility, either walking with aid or not. Moreover, the primary user group included younger people with visual limitations, mobility disabilities and use of a wheelchair. The test persons participate on a voluntary basis since they could not be paid for their contribution, apart from the expenses of their transfer to the test station and back home [9,10,11 12]. Most of the older people participating in the tests came from the KAPI network. KAPI is a centre where elderly people can assemble, socialise, work creatively, and be entertained. These centres are widespread in Greece, where a significant percentage of elderly people prefer to visit them and actively participate. All the users who were requested to participate in the tests responded positively and they were very willing to participate. Most of the users who participated in the first phase of the tests were asked to participate in the following ones as well. Thus, some of the users participated in all phases of the tests, some in two or three, and others in only one. Taking into account that four phases of tests were conducted in total, each of them tested different components of different FRR prototypes. In all testing phases around 40 different persons participated.

3.3. Informing Users about the Tests

A new primary user was requested to visit our station and participate in the test, usually through the nurse, physiotherapist, or occupational therapist that was taking care of him or through the administration staff of the KAPI. An information kit accompanied by a G. Knall et al. / Experience of Testing with Elderly Users 147 formal invitation letter to participate in the tests was sent to the user, and his/her visit was scheduled for the following one or two weeks. The information kit included brief information about the FRR project; information about the Athens FRR research base with an map of the area; a floor plan of the building and the place of the testing station; images from the installed prototype with a short description of its functions; description of the testing procedure, its steps and instruction for the test persons. The transfer of most of the test persons to the testing station and back to their residence was arranged for the scheduled day and time and a taxi or the car of one of the participating researchers was used. Before the user started the testing, a consent form was also signed, in order to ensure that the tester had been informed sufficiently about the project’s aims, the prototypes’ functions, the testing procedure, and that he fully accepted to participate in the test.

Figures 3 and 4. Pictures form the tests in Greece

3.4. Preparing and Conducting the Tests

Each test was conducted by the test person, with or without the attendance and or assistance of his physiotherapist or occupational therapist, while 2-3 members of the research team were giving the instructions, observing the test and interviewing the user. The new users also answered the two questionnaires developed in the project: the first one included questions about their personal health condition, and the common problems they had to face when using an ordinary toilet; the second one was about their personal hygiene habits while using the toilet [7,12,13,14]. Each test lasted around two hours in most cases. The researchers had to be prepared in such a way as to keep an objective attitude towards the user and the test, guide the user effectively throughout the testing procedure, make the appropriate questions and observations to the user, and help the user avoid difficult, insecure, or even dangerous situations (e.g. potential accidents during the test). In order to avoid such insecure situations the installed prototype had been thoroughly checked at its time of installation, and carefully inspected before each 148 G. Knall et al. / Experience of Testing with Elderly Users test conducted. Sharp surfaces were rounded, or additional soft materials were used to cover them. It was very important that the researchers create a friendly, warm and relaxing atmosphere for the participants. The users were given attention and time by the researchers to feel relaxed, express themselves and talk about their health conditions, while being offered refreshments during the test. The test persons appreciated the friendly manner, and hospitality of the researchers, the detailed instructions provided, and the well-organised process of the tests. Most of them agreed to be photographed or videotaped for research purposes as was planned in the different phases of the project.

3.5. Lessons Learned

We gained important knowledge about what the participating older people need, think, and feel about their difficulties in daily life and daily toilet usage. We developed and also helped the test persons to develop a positive attitude towards their problems and needs, and especially towards the private and sensitive matter such as using a toilet. This was mainly achieved through the discussions and interviews with the users, while trying to keep as open-minded as possible, objective, and unbiased towards the sensitive issues of toileting habits. In this issue, the advice and guidelines of the ethical team participating in the project played an important role. The elderly users were willing to participate in the testing process, and helped us to find ways and solutions for their needs. There were practically no refusals by any of the users to our invitation to participate in the tests; no reluctance at all by them to comply with any instructions, prompts and rules during the test; and a great willingness to answer to any question we asked. Most of the participants did not have any objections to answering the questionnaire about their personnel habits while using the toilet, even though some questions might be considered too private or might place the user in an uncomfortable situation. The users, who tested the different installed prototypes, had a great range of health problems and limitations, mainly in mobility but also in vision and hearing abilities. There was an effort to view each test person and each disability as a special case, which requires a different approach, care and provided solution by the prototype tested. The test persons helped us to realise uncomfortable, poor, insufficient, unnecessary, useless or unsafe situations and parts of the prototype’s components. This realisation led to specific efforts for the improvement or adjustment of these unsuitable conditions in the tests of the next phases. Most of the users found the testing procedure very interesting. In general, the prototype they tested seemed to be very interesting, with many features, very helpful, very innovative and up-to-date; but perhaps a bit complicated in some of its functions for the elderly people, since it would be necessary for them to be trained first. They also expressed their doubts with regard to the probable purchase and installation of such a prototype at their home due to the high price they thought it would cost. We learned to work with older users and persons with various disabilities in an environment where professionals from different specialties (nurses, physiotherapists, occupational therapists, sociologists, designers, engineers, manufacturers, etc.) were cooperating towards a common aim: to improve the toilet facilities according to the multifaceted needs of older people and persons with disabilities. Of course, in such an environment, where many people had to cooperate and the contribution of each of them was very important for the final result, obstacles, delays, or complaints were inevitable; G. Knall et al. / Experience of Testing with Elderly Users 149 moreover external elements or unpredictable situations also negatively influenced the scheduled work and tests. The most apparent example of such situations was bad weather on some scheduled testing days, which made it impossible for the users to be transferred to the testing station. Another example was unexpected cancellations of a specific test by users due to health problems, holidays, etc.; or a delay in the delivery or installation of specific elements of the prototype. However, in all these unplanned situations all participants displayed a positive attitude towards finding alternative ways to overcome them. Eventually, our cooperation with all participating people in the process of the prototypes’ testing was very effective, productive and successful. Moreover, our participation in this process was a great experience, indeed.

4. Conclusions

Working with people with different abilities was a great challenge within the FRR project for all participants, users and researchers alike. Researchers had the opportunity to gather a huge amount of information regarding users needs and expectations, which however, they needed to communicate efficiently to the other participants in order to use it constructively. Users on the other hand had to overcome any difficulties they faced in their every day life activities in order to participate in the tests, as well as to bear with the researcher’s very detailed questions. Researchers who do not always had much experience on how to respond to their specific needs, although they tried their best in all instances. What we have nevertheless arrived at is that the fundamental human needs are global or at least deeply human. The starting point for the project was that people need physically accessible toilets and when the body’s abilities diminish, this can to a certain extent be compensated for with advanced technology. However, it must be highlighted that the need to feel secure and safe, which can be achieved to a great extent with technical assistance as well, is equally important as that a rest room is hygienic, comfortable and pleasing in appearance. In a project such as this with participants from so many different countries and cultures, it is natural that there would also be different approaches and that disagreements would arise in how to manage a research project that deals with such a delicate topic as how people behave in a rest room. During the tests difficulties that arose from the prototypes themselves had to be managed in order that the tests be conducted according to the protocols decided inside the consortium. This was necessary to facilitate data collected to be comparable among different centres and the outcomes resulted from the collected data to be easily interpreted and used from researchers from different professional and scientific backgrounds. We have learned from our test persons that the rest rooms of today are often unnecessarily inaccessible and through the results of the FRR project we have increased the knowledge base for how to design as good a rest room as possible; and this, actually, does not really differ from culture to culture. Finally, the collaboration that was achieved through the FRR project, although it was very challenging it was fruitful and a valuable experience for future activities for all involved. 150 G. Knall et al. / Experience of Testing with Elderly Users

References

[1] Technical Annex, Project QLRT-2001-00458, Friendly Rest Room for Elderly People. Quality of Life and Management of Living Resources, Key-Action 6: the Ageing Population and Disabilities. FRR Project document; 2003. [2] Svensk A, Nordgren C, Magnusson C, et al. FRR Deliverable 4.2.1. and 4.2.2.: Report on critical design review – Engineering prototype and draft requirements and definition report. FRR Project document; 2005. [3] Sourtzi P, Menezello T. Elderly and People with Disabilities - Limitations in their Everyday Life. This Volume. [4] Daye C, Teissl G. FRR Deliverable 4.1.4.: Report on Module Approval. FRR Project document; 2005. [5] Alm N, Badon Ghijben N, Bruin R de, et al. FRR Deliverable 4.3.1. and 4.3.2.: Critical design review on the alpha prototype. FRR Project document; 2005. [6] Rauhala M, Wagner I. FRR Deliverable 4.1.2.: Guidelines and Report on Ethical Issues. FRR Project document; 2005. [7] Panek P, Neveryd H, Zagler WL. The FRR Project: Developing a More User Friendly Rest Room. In: Craddock G, McCormack L, Reilly R, Knops H, editors. AAATE ’03. Assistive Technology – Shaping the Future; 2003 Mar 8-9; Dublin, Ireland. Amsterdam: IOS Press; 2003. Vol. 11: p.678-682. [8] Neveryd H, Molenbroek JFM, Panek P. FRR – Friendly Rest Rooms for Elderly and Disabled Persons – A User Centered R&D Project. Gerontechnology 2002 – The International Society for Gerontechnology Conference. 2002 Nov 9-12; Miami Beach, Florida. Eindhoven: International Society for Gerontechnology; 2002 [Congress issue] [9] Sourtzi P, Panek P, Liaskos J, Mantas J. Friendly Rest Room (FRR): Developing the concept and the product. Proceedings of 13th Alzheimer Europe Conference - 3rd Hellenic National Alzheimer Disease and Related Disorders Conference. Sciences and Care. 2003 Jun 12-15; Thessaloniki, Greece. [10] Liaskos J, Tolika F, Sourtzi P, Mantas J. Designing friendly rest rooms for the elderly and for the people with special needs. Proceedings of the 5th Panhellenic Nursing Students Conference. 2003 Dec 12-14; Athens, Greece; 2003: p.42-43. [11] Liaskos J, Tolika F, Sourtzi P, Mantas J. FRR – Shaping rest rooms for older people and persons with disabilities. Proceedings of the 8th National Conference of Gerontology and Geriatrics. 2004 Jan 22-24; Athens, Greece. [12] Liaskos J, Tolika F, Sourtzi P, Mantas J. Developing and evaluating prototypes of a friendly rest room by elderly and persons with disabilities – the FRR project. Proceedings of the 5th Panhellenic Nursing Students Conference. 2004 Dec 10-12, 29. [13] Panek P, Edelmayer G, Magnusson C, Mayer P, Molenbroek JFM, Neveryd H, Schlathau R, Zagler WL. Investigations to develop a fully adjustable intelligent toilet for supporting old people and persons with disabilities – the Friendly Rest Room (FRR) Project. In: Miesenberger K, Klaus J, Zagler WL, Burger D, editors. Proceedings of the 9th ICCHP Conference. Computer Helping People with Special Needs. 2004 Jul 7-9; Paris, France. Berlin Heidelberg: Springer-Verlag; 2004, Lecture Notes in Computer Science Vol. 3118: p.392-399. [14] Joel S, Alm N, Egger de Campo M, Gregor P, Hands K, Hine N, Panek P. Eliciting sensitive information about toilet needs using a computer based interview [poster presentation]. Proceedings of the 7th European Conference for the Advancement of Assistive Technology. 2003 Aug 31 - Sep 3; Dublin, Ireland.

A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People 151 J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-151 Laboratory Tests of an Adjustable Toilet System with Integrated Sensors for Enhancing Autonomy and Safety

Paul PANEKa,1, Georg EDELMAYERa, Peter MAYERa, and Wolfgang L. ZAGLERa a fortec – Research Group on Rehabilitation Technology – Institute “integrated study”– Vienna University of Technology, Vienna, Austria

Abstract. This chapter describes the five different generations of toilet prototypes which have been installed and tested in a laboratory environment in Vienna during FRR (Friendly Rest Room) project. It outlines the data measured during tests with older and disabled persons and their care persons. The FRR prototypes have been equipped with a PC based control unit, voice input and output, contactless smart card technology and several sensors for estimating the user's intention and for recognizing potential falls of the user in the toilet area. The toilet components have shown to be very useful for disabled and older persons during extensive tests in a laboratory setting.

Keywords. Toilet, RFID, Older Persons, Assisted Transfer, Ambient Intelligence

1. Introduction

In the framework of the Friendly Rest Room (FRR) project the consortium has carried out various research, design, development and evaluation activities following a user centred approach [1,2,3]. Among these multidisciplinary tasks the user tests which were done on a regular base at up to 5 user test sites in Europe have played a decisive role. The test participants (older people, persons with a disability, carers) were asked to interact with new components of the FRR toilet system and to comment on them. Between September 2002 and February 2005 the FRR consortium has realised more than 200 test runs in laboratory environment (see Table 1). Additionally, a field test [4] in a day care centre with selected toilet components was carried out between December 2004 and February 2005. This chapter focuses on the FRR prototypes located in Vienna, while four other test sites were active in parallel to Vienna [5]. The objective of this chapter is to outline the iterative prototypes and to discuss the results gained from the user tests in Vienna. The test site in Vienna focused on user groups of persons with impairments in lower parts of the body. Thus, the selection of the FRR components to be tested in Vienna was done according to the specific needs of this user group. The overall aim was to develop and evaluate new methods and tools in order to

1 Corresponding Author: Paul Panek, fortec - Research Group on Rehabilitation Technology, Institute “integrated study”, Vienna University of Technology, Favoritenstrasse 11/029, A-1040 Vienna, Austria; Email: [email protected] or [email protected]. Web site: http://www.fortec.tuwien.ac.at/frr Tel: +43 1 58801 42913, Fax: +43 1 58801 42999 152 P. Panek et al. / Laboratory Tests of an Adjustable Toilet System with Integrated Sensors enhance the autonomy and safety of primary and secondary users at the toilet. For more details regarding the concept and the realisation of the user involvement please refer to [6].

Table 1. Number of Person Tests per prototype and per test site carried out by FRR consortium 2002-2005

Prototype AT SE GR IT NL total person tests Generation Vienna Lund Athens Milan Delft

1st 12 12 8 - - 32 2nd 19 14 9 - - 42 3rd 5 7 - - - 12 4th 12 11 10 8 15 56 5th + Real life test 412 10 33 10 19 113

Total Person Tests 89 54 60 18 34 255

2. Methods

The first prototype (PT1) was installed in a test booth which was set up in a laboratory room (see Figure 1). This setting has been extended when enhanced prototypes arrived for testing.

Figure 1. Left: First Prototype (PT1) tested in Sept 2002. Right: Third Prototype (PT3) tested in January 2004 in laboratory environment

2 Additionally to the laboratory test a field test with selected FRR components took place in Vienna. 29 primary users and 12 secondary users carried out 316 toilet sessions using a new toilet system in the daily life of a day care centre over a period of two months [4,20,25]. P. Panek et al. / Laboratory Tests of an Adjustable Toilet System with Integrated Sensors 153

As mechanical base of the first prototype an existing award winning product from commercial partner Clean Solution Kft. [7] was used. This base construction was extended iteratively during the different phases of the project (see Table 2). In 2004 it was replaced by a new construction which was tested as final research prototype by the consortium. After completion of the FRR project (March 2005) it was made final for production by Clean Solution Kft. A first basic commercial version [7] is on the market since January 2006. In the following sections the main features of the research prototypes (2002-2005) are being described.

Table 2. Adjustability of height and of tilt of bowl and of position of horizontal grab bars

Prototype seat seat seat seat bars min bars max bar bar Generation min max min. max horiz. horiz. min max height height tilt tilt distance distance height height [cm] [cm] [deg] [deg] [cm] [cm] [cm] [cm]

1st 47 76 0 +7,5 63 85 80 149 2nd 36,5 66,5 -12 +10 53 75 80 149 3rd 36,5 66,5 -12 +10 53 75 80 149 4th 44,5 77,5 -1,5 +9 69 77 78,5 111,5

5th 44,5 77,5 +2 +11,5 69 79 79,5 112,5

Table 3. Average velocity and duration for changing position of toilet seat and grab bars of PT1

Part Duration Average velocity Duration Average velocity (50kg (no load) load on part)

Bowl up 27 s 1,07 cm/s 28 s 1,03 cm/s Bowl down 26 s 1,12 cm/s 26 s 1,15 cm/s Bowl tilt forward 6 s 1,33 °/s 6 s 1,33 °/s Bowl tilt backwards 6 s 1,33 °/s 6,5 s 1,2 °/s Supporting bar up 52 s 1,35 cm/s 57 s 1,23 cm/s

Supporting bar down 49 s 1,43 cm/s 47 s 1,49 cm/s

2.1. Adjustable Position of Toilet Bowl and Grab Bars

Already the first prototype provided several degrees of freedom in adjusting the mechanical properties of the toilet. It was possible to change the height of the toilet bowl between 47 cm and 76 cm and to change the tilt between 0 and 7.5 degrees (see Table 2). Additionally, the horizontal bars left and right of the toilet seat could be moved up and down within the range of 80 to 149 cm independently from the position of the toilet bowl. This adjustability was realised via actuators (motors) even with load 154 P. Panek et al. / Laboratory Tests of an Adjustable Toilet System with Integrated Sensors on the toilet (e.g. a person is sitting on the toilet bowl while position is changed). Table 3 shows velocity of the movement with and without load on the toilet bowl and the average duration of the movement. Additionally, the horizontal distance between the two bars could be changed within a range of 63 to 85 cm manually. The later prototypes had some of the properties changed due to users' comments and due to mechanical adaptations and modifications of the construction (see Table 2). For PT2 and PT3 a mechanism for a manual tilt offset was used which extended the possible range of tilt and allowed also negative tilt up to minus 12 degrees. This mechanism was replaced in PT4 by a fully actuator driven mechanism with a range of minus 1.5 to plus 9 degree. PT1, PT2 and PT3 provided a mechanism for changing the horizontal distance between left and right bar manually. In PT4 the horizontal distance between the bars was fixed, but new types of bars were introduced providing a larger distance between the upper tubes of the bars and a shorter distance between bottom tubes of the bars. The first 3 prototypes had a possibility to change the vertical height of the bars via dedicated actuators independently from the height of the toilet bowl. These dedicated actuators were removed in PT4, the vertical height of the bars can only be changed synchronously with the height of the toilet bowl.

Figure 2. Three different types of seats of PT2 tested in June 2003, top view (top line), side view (bottom line). CP indicates the virtual “Central Point”.

2.2. Adjustable Grab Bars

Horizontal bars are an important means for assisting transfers and for increasing stability of one’s own body. Several iterative versions were provided and tested. The P. Panek et al. / Laboratory Tests of an Adjustable Toilet System with Integrated Sensors 155 horizontal bars can be folded up, are automatically locked in the horizontal position and are providing a friction hinge. Additionally, new types of vertical bars which can be moved around a fixed axe were introduced as part of PT5 (see Figure 7).

2.3. Toilet Seat

Several types of seats were tested as part of PT2 (see Figure 2). A seat with integrated transfer wings on both sides was developed further in PT4 (see Figure 4) and PT5 (see Figure 7). The overall dimensions of the transfer seat in PT5 are; width: 120 cm, depth: 39.5 cm. The purpose of this seat is threefold: (a) to provided place for storing personal belongings, (b) as means for transferring from / to wheelchair and (c) possibility to hold one self in order to increase body stability.

2.4. Control Unit and Control Software

A standard desktop PC with 512 MB RAM and AMD XP2000+ processor with Microsoft WindowsXP SP1 (later SP2) operating system serves as hardware for the control unit. On this PC the FRR control and interface software is running. It is equipped with special interface cards (counter card, ADC - analogue digital converter card, binary input/output card) for reading various sensor data and for steering the actuators. Additionally it interacts with other intelligent sub systems like the User Interface demonstrator [8] and the RFID reader / writer. It provides continuous logging functionality by saving all sensor data each 100 ms. This creates important data records for analysis. The logged data can be synchronised with the video recordings of the user tests in laboratory. Logged data also can be visualised as shown in Figure 3. Remote maintenance functionality via the internet is available. Software modules for speech input and speech output are included. For commercial product an embedded PC is planned to be used.

2.5. Sensors

The prototypes in Vienna were equipped with several types of sensors serving for different purposes. Firstly, it is necessary to measure the current position of the toilet system, e.g. the current height and tilt of the toilet bowl. Secondly, it is important to recognise potentially dangerous situations and thirdly it is interesting to recognise the user’s intention when interacting with the toilet system.

2.5.1. Sensors for Measuring Toilet’s Position The task of these sensors is to signal changes regarding actual height and actual tilt of the toilet to the control unit. For the first prototypes shaft encoders were used, later they were replaced by wire sensors. The sensors are connected to counter cards located inside the FRR control unit. It is important to note that the sensors are providing accurate relative information regarding height and tilt. This means that up to date information regarding absolute height and absolute tilt needs to be calculated by the control unit. The control unit also transfers the counter signals into units of cm and takes care for the calibration of the sensor system after power up of the whole system. 156 P. Panek et al. / Laboratory Tests of an Adjustable Toilet System with Integrated Sensors

Figure 3. Example of a visualisation of a log file showing the height and tilt during a user test run

2.5.2. Sensor for Measuring Distance to User’s Back An ultrasonic sensor measured the distance between the cover of the toilet system and the back of the user. The sensor was fixed in the middle of the toilet, 40 cm higher than the upper edge of the toilet seat. The motivation for introducing this sensor was to analyse the changes in the measured distance regarding an automatic recognition of the user’s intention to stand up. In this case, the toilet could optionally assist the user in getting up by moving into a higher position.

2.5.3. Sensors for Measuring Distribution of User’s Weight on Toilet Strain gauge sensors were provided to measure the forces in the construction of the toilet system due to the user’s weight. The purpose of these sensors is to gain more insight into the distribution of weights during a toilet session. Furthermore, the analysis of these data should allow deriving information of the user’s intention to stand up. In addition to the strain gauge sensors 2 load cells were integrated in order to compare data from load cells with the data from strain gauge sensors [9].

2.5.4. Sensor System for Fall Recognition Falls are an important issue in the area of toilet, especially for fragile older people. Therefore sensors which are able to recognise falls are of high interest, as such sensors could play an important role for triggering emergency calls even in those cases where the fallen person has lost consciousness or is not able to move herself / himself [10]. It goes without saying that prior to fall recognition the prevention of falls has to be done [11]. Unfortunately, falls can happen even if fall prevention has been implemented to the most reasonable or feasible extent. P. Panek et al. / Laboratory Tests of an Adjustable Toilet System with Integrated Sensors 157

The FRR prototype provides an optical sensor which is able to recognise falls which might have occurred. The fall recognition provides a binary output: a fall most likely has happened or a fall most likely has not happened. The sensor signal needs to be combined with the data from the FRR control unit which needs to know if somebody is in the room or not. In contrast to pressure sensitive mats this type of sensor can adapt itself autonomously to possible changes in the room.

2.5.5. Sensor for Triggering Alarm Calls A voice level controlled sensor allows the user to trigger an alarm / emergency call by shouting. This is language independent but requires a certain volume of speech which needs to be exceeded.

2.6. Voice Input

In addition to the conventional hand held remote control and in addition to the touch screen user interface demonstrator which is described in more details in [8,9] a voice control input module [12] was integrated (see Figure 4). It is speaker independent and was tested for German language. This feature allows controlling the toilet system via spoken commands in the user's or care person's native language. A set of pre-defined phrases is recognized and used to control functions of the toilet. Voice control is providing an additional way of controlling the toilet. It is expected to be useful in situations when the user does not have the possibility to press a button (e.g. when doing a transfer) but also for care personnel while helping the user doing a transfer. All voice commands to the toilet start with the word ‘computer’ in order to increase the length of the command which has a positive effect on the performance of the recognition. Then the actual phrase for the part of the toilet system one wants to change follows. It is necessary to make a small pause between the different command words to enhance Speech recognition. Commands that are usable (currently in German only):

Computer Licht Ein / Computer Licht Aus: This turns the light on and off. Computer Klo höher / Computer Klo tiefer: This moves toilet bowl up and down stepwise. Computer Neigung stärker / Computer Neigung schwächer: This changes the tilt of the bowl stepwise. ‘Neigung stärker’ means seat is tilted forward, ‘Neigung schwächer’ means tilt backwards. Computer Spülen / Computer Alarm: This triggers the flush function and the emergency call (nurse call). Computer Position 1 / Computer Position 2 / Computer Position 3: This moves the toilet to one of the three predefined positions. These positions could e.g. be a position for the transfer onto the toilet, one for transfer from the toilet and one that is especially suitable for using the toilet. Positions which can be recalled using speech recognition have to be stored in the control unit of the toilet. If no positions are stored, the commands are ignored. 158 P. Panek et al. / Laboratory Tests of an Adjustable Toilet System with Integrated Sensors

2.7. Voice Output

Pre-recorded personalised messages can be re-played optionally and pre-defined text messages can be spoken by the FRR control unit. This can be triggered by the system (e.g. when a pre-stored position has been reached, the system says: Position one has been reached) or by the user (e.g. when entering the room the FRR card of the user is being recognised and the user is being welcomed: Good morning Mr. X). Voice output can be seen as additional output channel for information of the user but also for guiding the user [13].

Figure 4. Fourth Prototype (PT4) tested in May 2004 in the laboratory in Vienna. Voice control was tested successfully. The microphone was mounted on the right top corner seen from the person sitting on the toilet.

2.8. Smart Cards

Integration of smart card technology based on RFID [14] allows recognising the users’ preferred toilet settings, which are stored on the FRR card (see Figure 5) in a contact less way, when the user is approaching the toilet. The system detects the user and can move the toilet automatically to the preferred height and tilt, can switch to the preferred language and activate / deactivate the optional features of the system. For the laboratory prototype the user profiles were actually saved on the control unit, using RFID only to get the unique ID of the FRR card. For application in daily life the user profiles are planned to also be stored on the RFID tag, which in future might be integrated part of one’s mobile phones, key, jewellery, etc.

P. Panek et al. / Laboratory Tests of an Adjustable Toilet System with Integrated Sensors 159

Figure 5. Smart Cards (RFID) used during laboratory tests of PT4 and PT5

2.9. Safety and Emergency Call

Manual triggering of the emergency call (nurse call) is possible via pressing the corresponding button on the conventional hand held control, via speech input and via loudness sensor.

3. Test Settings

The user tests of the different prototypes described here have been carried out in the laboratory. For details regarding used principles of user involvement including informed consent, information kit, and ethical remarks please refer to [6,15,16]. It is important to note that the tests have mainly been set up in order to gain qualitative rather than quantitative data. A booth-like structure was constructed with the geometric dimension (measured from inner side) of the booth: length: 265 cm, width: 99 cm, height: 215 cm. On the right side next to the booth a small control room was set up, where the FRR Control Unit (currently a standard PC-system) is located. The size of the control room is: length: 117 cm, width: 146 cm, height: 215 cm. During the tests the responsible technician is partly in this room to change parameters in the control software and for general supervision of the control system. The equipment was not connected to water neither to sewer. Two large emergency buttons were mounted on the booth for general safety reasons.

4. Results

Five prototype generations have been tested during a period of two and a half years. About 50 user tests have taken place in the laboratory in Vienna. More than 200 test sessions were carried out in all laboratories of the FRR consortium (see Table 1). Duration of each laboratory test was about 2 hours, whereas the hands-on time was about 1 hour [17]. Many of the tests have been recorded on video tape, additionally continuous logging data of all sensor signals are available and provide valuable data 160 P. Panek et al. / Laboratory Tests of an Adjustable Toilet System with Integrated Sensors sources in addition to the ADL (activity of daily living) scores of the individual users, the questionnaires and the interview data [6,18]. According to a user centred iterative design approach each cycle of specification, prototype building and testing led to a redesign of the specification following the comments received from the primary and secondary users. The manufacturing of the last FRR prototype is described in [19]. Below some qualitative and quantitative results from prototype testing are outlined, additional results from real life tests are documented in [4,20].

4.1. Adjustability of Toilet’s Height and Tilt

Being able to adjust the toilet to one’s own preferred position regarding height and tilt is one of the most important benefits from the users’ point of view. It brings benefits not only during sitting on the toilet but also during the transfer phases, e.g. moving from and to the wheelchair. Data measured regarding preferred sitting height from the user tests with PT2 were published in [21]. It was shown that the preferred sitting positions do not correspond much with the anthropometric data (like popliteal height or body height) of older adults [22]. Similar findings regarding the height of support bars were found in [23]. Nevertheless it is remarkable that most of the users were able to reproduce their preferred height of seat very well [21]. Another important and very plausible finding is that this adjustability does not only assist the primary but also the secondary users [24]. The range of adjustability was extended during the lifetime of the project (see Table 2). The range in height and tilt provided by the toilet is actually being used by users in daily life; this could be confirmed by the findings from the real life validation documented in [4]. The current minimum position (44.5 cm) should be lower.

Figure 6. Vertical Bars were seen to be useful add-ons, e.g. for assisting while dressing / undressing. Testing the PT5 prototype

P. Panek et al. / Laboratory Tests of an Adjustable Toilet System with Integrated Sensors 161

Figure 7. Fifth Prototype (PT5) tested in laboratory setting in Vienna in February 2005

4.2. Grab Bars and Seat

The improvements of the grab bars regarding fixation in the horizontal position in order to avoid unintended folding up during transfer were seen as benefit, as well as the introduction of the vertical bars as an additional support, e.g. for leaning against when dressing / undressing (see Figure 6 and Figure 7). The fixation mechanism which currently (May 2005) is implemented via a push button on the top of the vertical bar needs improvement. The new seat originally was introduced in order to facilitate transfer from / to wheelchair via moving step by step from wheelchair to toilet seat sliding over on the wings of the seat. Additional benefits are provided to the user by the fact that now one can grip left and right of the toilet seat in order to increase one’s own stability when sitting on the seat. The wings also provide place for storing personal belongings. The vertical bars need to be moved away far enough in order to allow access of wheelchair.

4.3. User Identification for Personalisation

According to the test persons one of the main advantages provided by the user identification is seen in the automatic adaptation of the toilet to the individual preferences. This saves times for the users, especially for those who, due to functional impairments, would need more time than others to adapt the system each time again. Additionally, the fact that the prototype toilet system offers many optional features demands a method for customisation to the individual preferences which does not put additional cognitive load on the user. It is evident that a user could forget to carry his/her FRR smart card around all the time. Therefore the RFID tags might not only be realised as smart cards in format of credit cards but might also be integrated in objects of daily life like mobile phones, keys, jewellery. Regarding privacy it might be reasonable to store personal preferences regarding settings of FRR toilet on the user’s own card, a centralised database server might be useful for backup but is not necessarily needed. 162 P. Panek et al. / Laboratory Tests of an Adjustable Toilet System with Integrated Sensors

4.4. Touch Screen User Interface Demonstrator, Speech Input and Speech Output

The speech control feature was rated to bring benefits by approximately half of the test participants. This is a much higher proportion than was expected before. The reliability of the speech recognition system also was higher than expected. Nevertheless it does not yet seem to be high enough to put it into a field test (see Table 4).

Table 4. Laboratory test of speech input system ASR 3200 (embedded system) from ScanSoft [12] with 3 subjects from research team. Entry marked with *) not 100% sure, details not known. Number of different speech commands: 7.

Correct No Wrong Correct No actions Wrong actions actions actions actions [%] [%] actions [%]

subject 1 83 15 1 *) 83,8 15,2 1,0 subject 2 85 10 0 89,5 10,5 0 subject 3 70 0 0 100 0 0

total 238 25 1 *) 90,2 9,5 0,4

Some problems exist regarding the minimum volume level which is necessary to be exceeded in order to trigger the recognition process. Some test participants actually were not in the position to speak loud enough to exceed this trigger threshold. It also needs to be considered that there is a cognitive load required to be carried by the user, as he / she needs to remember the exact command phrases. The speech input was said to be of great value also for secondary users when assisting a primary user manually during a transfer. In this situation both hands are used for assisting, the third hand for adjusting the toilet’s height is missing and could be replaced by the speech input functionality. Detailed results regarding the user interface demonstrator can be found in [8].

4.5. Sensors

The sensors for measuring the position of the toilet’s height and tilt were found to work stable and reliable. The sensitivity of these sensors is very high. Thus, even those changes in tilt caused not by technical actuators (motors) but just by the movements of the person sitting on the toilet, can be measured. Also the changes in tilt due to standing up or sitting down of the persons can be recognised clearly in the sensor data. When the person is sitting down, the load (seen from the toilet system) is increased by part of the persons own weight (assuming that there is contact form the person’s feet to the floor) and thus the tilt of the toilet is increased due to the mechanically flexible construction of the prototype. The increase of tilt can be measured by the sensors.

P. Panek et al. / Laboratory Tests of an Adjustable Toilet System with Integrated Sensors 163

height of toilet bowl

tilt force

height force

Figure 8. Exemplary visualisation of data from strain gauge sensors: A person of about 80kg weight sits on toilet. The toilet moves from lowest to highest height position and back to the lowest. While doing this, the feet of the person sitting on the toilet move from ground when the distance from toilet bowl to floor exceeds a certain value. Missing contact to floor increases the “tilt force” on the tilting mechanism and the “height force” on the height adjusting mechanism. Y-axis shows three curves: the “relative height of the toilet bowl”, the “height force” and the “tilt force”, x-axis shows time.

The ultra sonic sensor for measuring the distance from the cover of the toilet to the user’s back worked and could demonstrate the principle of deriving the user’s intention to standing up. Nevertheless the weight sensors described in the following seemed to be more promising. The data delivered by the strain gauge sensors on the tilting mechanism and the height adjusting mechanism showed compared with the data from the alternatively used load cells a lower but still a satisfying level of accuracy. Figure 8 shows one typical diagram which can be discussed as follows: The force on the tilting mechanism is increased when the toilet height is increased. This is plausible as the user’s feet will lose more and more contact to the floor which means that more force (due to user’s constant weight) will be led to the tilting mechanism (and the height adjusting mechanism). As soon as the feet leave the floor, tilt force and height force will deliver constant values. The toilet then reaches its highest position. As soon as the toilet moves down again, there is a step in the graph of the height force. This is assumed to be due to the mechanical construction of the height adjusting mechanism of the toilet. The tilt force is being reduced as the feet get more and more contact to floor and therefore take over more and more force. The fall recognition sensor was tested successfully in parallel to the laboratory tests. No real falls happened, so the sensor could only be tested with simulated falls. The alarm sensor triggered by shouting was tested successfully. It is multi lingual and speaker independent as it only monitors the volume level. Some test persons could not use it, as they were not able to exceed the loudness threshold. A better pre-amplifier for the microphone might help here to overcome this problem. 164 P. Panek et al. / Laboratory Tests of an Adjustable Toilet System with Integrated Sensors

5. Discussion

The tests of the prototypes described here were tests in a laboratory environment carried out in the framework of the FRR project. The toilet was connected to electricity but not to water and sewer. The users tested with clothes on, and only for approximately one hour. Several test cycles of iterative prototypes have been carried out and nearly all test persons have accompanied the tests through all the different cycles which can be interpreted as a high level of interest and engagement. Nevertheless the limitations of such tests in comparison to field tests cannot be overseen.

6. Conclusion

Running laboratory tests also brings advantages, e.g. it is possible to evaluate new concepts and ideas in an early stage of development. For example, hygienic needs are not so strict in a laboratory settings with clothes on, reliability and safety requirements can be fulfilled easier when a research team is participating in the test run and could interfere in case of occurrence of a risky situation. It also is to note that the design of the user tests followed the idea of exploring specific areas in detail by studying the interaction of users with the prototypes [6] rather than collecting statistical data of a large sample of randomly selected users. Some of the results from laboratory tests could be validated in a real life test which was carried out with some few selected components of the FRR project which were mature enough regarding safety, hygiene and expected usefulness to put them into a 2 months field test in a day care centre [4]. The results of this real life test underline and confirm some of the results gained in laboratory tests. This especially concerns increased autonomy and safety of users which was stated by the users themselves on their presentation [5] given during final conference of the FRR consortium held in Vienna March 17, 2005.

Acknowledgements

We want to thank all members of the Austrian User Board and all persons who have participated in the iterative prototype testing in our laboratory between 2002 and 2005 for your cooperation and for a huge amount of very valuable information. Our special thank goes to Ramona Rosenthal and Christine Pauli from Caritas Socialis Vienna and to Robert Schlathau from Austrian Multiple Sclerosis Society.

References

[1] Molenbroek JFM, Bruin R de. The Development of a Friendly Rest Room - A User Friendly Restroom for Elderly and Persons with Limited Abilities. Presentation during FRR final conference. Electronically available from [26,27] [2] Bruin R de, Molenbroek JFM, Groothuizen T, Weeren MH van. On the development of a friendly rest room. In: Coleman R, Myerson J, editors. Proceedings of the INCLUDE Conference 2003: Inclusive Design for Society and Business. London: Helen Hamlyn Research Centre; 2003: pp. 14: 570-14:576 [3] Neveryd H, Molenbroek JFM, Panek P. FRR - Friendly Rest Rooms for Elderly and Disabled Persons - A User Centered R&D Project. Presentation at Gerontechnology Conference; 2002 November 9-12; Miami Beach, Florida. Printed in Gerontechnology. 2002; 2(1): 94. P. Panek et al. / Laboratory Tests of an Adjustable Toilet System with Integrated Sensors 165

[4] Gentile N, Edelmayer G, Dayé C, Mayer P, Panek P. FRR field test - Real life test at a day care centre. Presentation during FRR final conference. Available from [26,27] [5] Panek P. Overview about Iterative Prototype Generations at the 5 test sites in Athens, Delft, Lund, Milan and Vienna. Presentation during FRR final conference. Available from [26,27] [6] Dayé C, Egger de Campo M. User-Driven Research - How to Integrate Users' Needs and Expectations in a Research Project. This volume. [7] Clean Solution Kft., Debrecen, Hungary [Internet]. 2005 [cited 2005 May 16]. Available from: http://www.cstechnologie.com/ and http://www.conplan.org [8] Magnusson C, Alm N, Edelmayer G, Mayer P, Panek P. Rapid Prototyping of Interface and Control Software for an Intelligent Toilet. This volume. [9] Panek P, Neveryd H, Edelmayer G, Eftring H, Knall G, Magnusson C, Mayer P. Design of a Flexible User Interface Demonstrator, Control Software and Sensors. Presentation during FRR final conference. Available from [26,27] [10] Sixsmith A, Johnson N. A Smart Sensor to Detect the Falls of the Elderly. IEEE Pervasive computing, 2004 April-June; 3(2):42-47 [11] Buzink SN, Bruin R de, Groothuizen TJJ, Haagsman EM, Molenbroek JFM. Fall prevention in the toilet environment. This volume. [12] Speech Pearl v8, ASR3200, Speech Control, embedded systems, ScanSoft [Internet]. 2005 [cited 2005 May 16]. Available from: http://www.scansoft.com/ [13] Mihailidis A, Barbenel JC, Fernie G. The efficacy of an intelligent cognitive orthosis to facilitate hand washing by persons with moderate-to-severe dementia. Neuropsychological Rehabilitation. 2004;14(1/2):135-171. [14] Radio Frequency Identification Systems, Texas Instruments Inc., USA [Internet] 2005 [cited 2005 May 16]. Available from: http://www.ti.com/tiris/ [15] Rauhala M, Wagner I. Ethical Review in the FRR Project – A Continuous Process. Presentation during FRR final conference. Electronically available from [26,27] [16] Rauhala M, Topo P. Independent living, technology and ethics. Technology and Disability. 2003; 15: 205-214. [17] Knall C, Sourtzi P, Liaskos J. Experiences of Testing with Elderly Users. This volume. [18] Dayé C. The FRR-questionnaire - Assessing Who Needs What Where. This volume. [19] Rist A. Engineering and Manufacturing of the final FRR Prototype According to the User Needs. Presentation during FRR final conference. Electronically available from [26,27] [20] Gentile N, Dayé C, Edelmayer G. Egger de Campo M, Mayer P, Panek P, Schlathau. Concept, Setting up and First Results from a Real Life Installation of an Improved Toilet System at a Care Institution in Austria. This volume. [21] Panek P, Edelmayer G, Magnusson C, Mayer P, Molenbroek JFM, Neveryd H, Schlathau R, Zagler WL. Investigations to develop a fully adjustable intelligent toilet for supporting old people and persons with disabilities - the Friendly Rest Room (FRR) Project. In: Klaus J, Miesenberger K, Burger D, Zagler W editors. Computers Helping People with Special Needs: 9th International Conference, ICCHP 2004; 2004 July 7-9; Paris, France. Proceedings (Lecture Notes in Computer Science), LCNS 3118. Berlin Heidelberg: Springer-Verlag; 2004: pp. 392-399. [22] Department of Trade and Industry, UK, publications@dti. Older adult data. The handbook of measurements and capabilities of the older adult: data for design safety, anthropometric and strength data on older people aged 60 and over. UK: Department of Trade and Industry; June 2000 [23] Dekker D, Buzink SN. User Preferences Regarding Body Support and Personal Hygiene in the Toilet Environment. This volume. [24] Knibbe JJ, Friele RD. Prevalence of back pain and characteristics of the physical workload of community nurses. Ergonomics. 1996 Feb;39(2):186-98 [25] Adolf S, Fink B, Freist A, Rosenthal R, Pauli C, Schlathau R. Voices of the Users. Presentation during FRR final conference. Available from [26,27] [26] Presentations Final Conference of Friendly Rest Room (FRR) project consortium, Caritas Socialis, Vienna, March 17th, 2005 [Internet]. 2005 [cited 2005 May 16]. Available from: http://www.fortec.tuwien.ac.at/frr [27] Web site of FRR consortium [Internet]. 2005 [cited 2005 May 16]. Available from: http://www.frr- consortium.org and http://www.fortec.tuwien.ac.at/frr

166 A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-166 Concept, Setting up and First Results from a Real Life Installation of an Improved Toilet System at a Care Institution in Austria

Nadia GENTILEa,b,1 , Christian DAYÉa, Georg EDELMAYERc, Marianne EGGER DE CAMPOa,b, Peter MAYERc , Paul PANEKc and Robert SCHLATHAUd a EURAG – European Federation of Older Persons, Graz, Austria b Compass – Institute for Social Research, Graz, Austria c fortec – Research Group on Rehabilitation Technology, Vienna University of Technology, Vienna, Austria d Austrian Multiple Sclerosis Society, Vienna, Austria

Abstract. The last phase of the Friendly Rest Room (FRR)-project was explicitly dedicated to the validation of the conceptual and technical solutions developed within the preceding years. Validation in this context means to assess whether the project has reached its objectives. As FRR is a project within the Quality of Life Programme, the main objective was to contribute to an enhancement of the quality of life of old people (and people with disabilities). In order to be able to investigate whether the quality of life of the target group could be improved by the toilet system developed within the FRR-project, a prototype must be set up in an adequate context, i.e., in an area where, in contrast to a laboratory situation, a ‘normal’ use is possible. This chapter describes the concept and the setting up of a real life installation of an improved toilet system which was carried out at a day care centre in Vienna, Austria. Furthermore, first results from this validation phase (29 primary users and 12 secondary users carried out 316 toilet sessions over a period of two months) are reported. It could be shown that the new toilet system increases safety and autonomy from point of view of primary and secondary users and that the toilet was more than well accepted in the day to day practice of the day care centre.

Keywords. Toilet, Older Persons, ADL, Multiple Sclerosis, Day Care, Autonomy, RFID

1. Introduction

Setting up the project, the Friendly Rest Room (FRR)-team decided that components of the new toilet system developed during the project should be tested in daily use at the Multiple Sclerosis (MS) day care centre of the Caritas Socialis (CS) in Vienna. Over a

1 Corresponding Author: Nadia Gentile, Compass - Institut für Sozialforschung; Adress: Flosslendstrasse 18, A 8020 Graz, Austria; Tel: +43 316 68 71 41- 0; Fax: +43 316 68 71 41- 41; Email: office@compass- org.at or [email protected] or [email protected]; Website: http://www.compass-org.at N. Gentile et al. / Concept, Setting Up and First Results from a Real Life Installation 167 longer period of time (2 months, from December 2004 to February 2005), clients and employees of this day care centre should be invited to use components of the FRR- system in order to evaluate them on the base of daily life experience. Only some selected parts of all the developed components and concepts [1-7] were used in order to ensure reliability, security and hygiene and also not to confront the clients of the day care centre with too many “new things". Contact to the Caritas Socialis was established through the MS-Society who intensively supported the development of the FRR system right from the beginning of the project. Before starting to plan the real life installation, some of the guests of the day care centre already tested previous FRR-Prototypes that have been built up in the laboratory of fortec at the Vienna University of Technology [1, 2]. Both the guests and their care personnel took part in expert discussions and delivered an important and valuable contribution for further development of the FRR system. The preparation phase of the real life installation was done in close cooperation with CS and the personnel there. The planning documents were updated and discussed on a regular basis and provided to all persons involved.

2. Setting the Scene

2.1. Description of Day to Day Life in the MS Day Care Centre

The opening hours of the MS-Day Care Centre are Monday to Friday from 8.00 a.m. to 4.30 p.m., except holidays and weekends. Its clients are people with MS syndrome and different physical/motoric and/or cognitive restrictions. The goals of the day care centre are to provide an ambulant management of a follow-up treatment instead of stationary rehabilitation, to provide preventive measures against social isolation and improving domiciliary treatment and extending it through specific relieve of relatives. The services offered to achieve these goals are manifold, e.g. rehabilitative neurological care, physiotherapy, MS-specific therapy, walking training, occupational therapy (self- help training, computer-assisted cognitive training, sensitisation training) music therapy, continuous specialized medical care, creative activity etc. The number of day guests is approximately 60 to 65, approximately 20 guests per day. They visit the centre twice a week on average but some guests visit the day care centre more often and make use of the whole weekly program. Nearly all visitors have a therapeutic indication. Many of the guests are using their visits to take a shower, because they need help with personal hygiene, or for medical treatment like changing bandages. The other time is spent in the lounge or in the dining room, after lunch some go to the cafeteria on the ground floor. The staff (nurses, nursing auxiliaries, civil servants, trainees) helps to support the guests if needed. For discussion rounds, games and other creative activities (e.g. painting) an animator/reactivation assistant is in charge. Apart from the therapy units another fixed time is lunch at noon. Concerning toilets, daily guests use those toilets suitable for them. For one it is the bigger space, for others the more suitable door handles, etc. Sometimes they just choose the one which is empty. What all guests have in common is that in their every day life toilets play really a crucial role. Thus many daily guests are experienced in developing strategies to avoid going to the toilet, which means not drinking enough or even taking tablets to dehydrate. 168 N. Gentile et al. / Concept, Setting Up and First Results from a Real Life Installation

2.2. The FRR System

The toilet system was built up in an already existing toilet room in the day care centre (Figure 1). The original toilet was dismantled and the test system was built up after some adaptations of the room. The personal computer (PC) running the FRR-software [1,2] for data gathering was hidden in a cavity in one of the side walls (Figure 2). The actual toilet system consisted of a LiftWC700 from 'Clean Solution Kft.' [4] with actuators for changing tilt and height, two horizontal support bars which can be folded up and a handheld remote control to steer the toilet and to activate the alarm call. Additionally a new type of a door handle developed within the project [3,5] was installed on the outside of the entrance door.

Figure 1. Toilet room in the day care centre before (left) and after (right) modifying and installing the FRR system. The traditional toilet bowl in the left corner was removed and the wall in the back was adapted to mount the adjustable toilet system. A 360 degrees view is available on [8].

For user detection an RFID mid range module (similar to what was used in laboratory environment, cf. [1]) was installed and the antenna of the module was hidden behind the toilet back cover (Figure 2). 'Smart Cards' with unique identification numbers were given to each test participant so that identification of persons using the system was possible. A box-like cavity was built into one of the walls to provide space for keeping a PC running the FRR control software and doing data logging. The necessary electronics was put next to the PC. For data collection position sensors for height and tilt were installed. Binary sensors were used to read the status of the six different buttons (pressed/released by user) on the hand held remote control (height N. Gentile et al. / Concept, Setting Up and First Results from a Real Life Installation 169 up/down, tilt forward/backwards, toilet flush, alarm call) as well as of the entrance door (open/closed) and the status of the local nurse call system (nurse call active / not active). Remote maintenance of the PC as well as downloading daily sensor data was possible via an internet connection using the LAN of the care institution.

2.3. User Description

Of the 60 daily guests at the MS day care centre, 29 actually participated in the real life test. According to the definitions of target groups they are called "primary users (PU)" of which 22 were female and 7 male. All participants were MS patients living with many different kind of impairments and therefore offer the opportunity to explore a very large range of individual needs. The age of the PU ranged from 39 years to 79 years with an average of 57 years. 14 persons were wheel chair users, 3 used crutches, 6 a so called Rollator, 2 used a so called Rollmobil, 4 walked without any aid, 7 of the PU made the transfer with help from 1 or 2 persons from the nursing staff ("secondary users", SU).

Figure 2. A personal computer (PC) for automatic documentation of toilet movements and user activities (technical logging) was installed next to the toilet (left) including also electronics for RFID system; RFID antenna for the FRR Card detection was mounted behind the back cover of the toilet (right).

Beneath simple demographic characteristics like gender and age, the well-known method of ADL (Activities of Daily Living) staircases2 was applied to describe aspects of the test person's dependency in daily life [9,10]. The average grade of disability or

2 ADL staircases are a common tool that enables therapists as well as researchers to evaluate the range of care a person needs. Literature describes many ways to design an ADL-staircase – there are different opinions about which items to include and about how to put the different items in order. We decided to include 8 common ADL-items and we used an adapted version of Sonn´s staircase. Description of steps: Step 0, Step 1 Heavier housework, Step 2 Grocery shopping, Step 3 Going out, Step 4 Light housework, Step 5 Bathing & dressing, Step 6 Walking in the home, Step 7 Going to bed, getting up, Step 8 Eating and drinking. The higher the score, the higher is the grade of dependency. 170 N. Gentile et al. / Concept, Setting Up and First Results from a Real Life Installation use of care respectively of the participants was middle to high. On the ADL-scale the participants ranged between 0 (min) and 8 (max) with an average of 4.5.

3. Expected Benefits

The main expectations or goals of the field test were that the users should be satisfied at the end of the tests and for all participants usefulness should be noticeable. The satisfaction and the safety of the users (e.g. avoiding of problems and accidents) were the top priorities. Before the onset of the real life test phase, the local FRR-project team agreed that the ideal scenario would be if the day care guests would like to use the FRR toilet as "normal" part of their daily life (meaning, not to consider at it as “test object”): as a useful, comfortable and functional object that helps them and makes them more independent. One objective was also to get hints with regards to future improvements and developments of the system.

4. Methods

4.1. Data Collection

To ensure the validity of our findings different methods and data from different sources have been combined in a process of data triangulation3 to give a more complete picture of the FRR real life case study [11].

Participant observation (Interaction between users and the FRR system) Statistical data (ADL score, age, gender) Expert knowledge of service provider(s) (in-depth interview with head nurses, occupational therapist, physiotherapist, etc.) Observation sheets and notes from nurses Feedback of experts, PU and SU Comparison/reference to technical log files Questionnaire on users’ degree of satisfaction

Participant observation is a method of research used in qualitative social research [12,13,14]. The scientists try to get answers to their questions by going into the field and get into interaction with the people, talk to them and when it is possible or necessary, take part in their daily life [15,16,17]. People interact with objects and other people on the basis of the meanings that the objects have for them [18]. In the real life field test this was of relevance as it turned out very soon that context knowledge generated with the help of the PUs was indispensable to understand how the toilet was used and accepted by the daily guests [19]. These data have been compared and related to technical log files gathered by the computer [1,2]. Finally a questionnaire was used to assess the users' degree of satisfaction with the FRR [20,21]. Data were collected from the middle of December 2004 to the middle of February 2005. Photography was used as additional means of documentation [22,23].

3 According to [13] and [24]. N. Gentile et al. / Concept, Setting Up and First Results from a Real Life Installation 171

4.2. Data Collection Log File

All sensor data that were taken up by the system (information about height and tilt of toilet, status of buttons on the remote control, status of the emergency call system, status of door and the identification numbers of the recognized FRR smart cards) were logged in a dedicated log file on the monitoring PC. Each day at midnight a new log- file was automatically created by the FRR software. The existing log files were downloaded manually the following days for data storage, backup and off-line evaluation. The log files contain, besides some header information, all sensor data and additionally data for plausibility checks. Before the data are evaluated the files undergo consistency checks. After that the logged data are transformed to make visualisation with diagrams easier (Figure 7). The diagrams are then used to extract single toileting events. Additional tables of events (door open/close, button presses, tag detections etc.) are generated to support detailed investigation of the data.

4.3. Ethical and Safety Considerations

4.3.1. Informed Consent Procedure Like in all other project phases, the users (both SU and PU) received written information about the project and its purpose, about the researchers involved, about the functions of the prototype and the test [25]. Also a signed form of informed consent from participants was collected. Verbal information and training of the employees followed the written information. During this theoretical and practical training the SU showed great enthusiasm even if their prime work in the day care centre was affected by it (see Figure 3). The training of the PU was done in some steps over a period of a few days. The PUs were mainly instructed by the staff of the day care centre since they are better trained to explaining the contents in a simple and clear way (see Figure 4).

Figure 3. Primary and secondary users during the initial training with the FRR-Toilet in December 2004. Left: View into the toilet room from outside. Right: Entrance door seen from inside the toilet room. 360 degrees views from inside and outside the toilet room are available on [11]. 172 N. Gentile et al. / Concept, Setting Up and First Results from a Real Life Installation

4.3.2. Safety of the Toilet A real life test requires a high level of safety and hygiene; therefore it is reasonable to concentrate only on few components that absolutely fulfil these requirements. From a technical point of view, the safety of the system was ensured by the fact that a standard product was used as a basis and that technical changes did not influence the safety level of the system. Sensors used for measuring were only passive ones, the PC used for data gathering and storage was passive, i.e. only measuring and not actively steering the system. Therefore possible malfunction of the PC would not influence the toilet. The electrical safety of the used RFID system was ensured by the supplier. Personal data of the participating users were not stored. The used FRR-Cards only held a unique number that could be detected by the system when using the toilet; no additional data were stored on the cards.

Figure 4. A training situation which happened unplanned and spontaneous, out of the interest of the day guests (left); a guest with the FRR-Card (RFID) around her neck (right).

5. Preliminary Findings and Outlook

5.1. Preliminary Findings from Observations and Interviews

In the time before the tests actually started, the day care centre management and the employees were not sure whether the FRR would be accepted or even appreciated by the day guests. It was supposed that the guests’ interest in testing something new could be quite limited. Routine activities and habits are difficult to abandon, because they give you security. However, the status transition of the FRR from being "news" to getting used in a rather economical and un-commented way happened in a faster and more seamless way than it was expected. At the end of December 2004 the presence of the FRR was already evident for the external observer, as many guests wore their FRR- cards. Nevertheless, in the communication among the guests, the FRR was not a big issue. For what reason ever, this changed in the second week of January, when the participants started to wait in front of the FRR until it was free/accessible. In an interview on this phenomenon, a nursing auxiliary reported "The people are highly N. Gentile et al. / Concept, Setting Up and First Results from a Real Life Installation 173 motivated; they already ask in the morning whether they can have their cards. It’s unusual, because normally they keep forgetting things". However, some of the guests in the day care centre did not like to participate at the test. The use of a modern technology like the FRR, respectively the use of assistive tools in general can be an indicator for the grade of dependency. For some of the guests, the participation in the FRR test would have meant to admit a higher degree of "dependency" than they actually have and/or than they want to admit to themselves and their environment. One guest said that she does not use the FRR, because it is "work", she would have to learn something and it is easier with the known, commonly used toilet.

5.2. Preliminary Findings from Log Files

Due to the tremendous amount of data gathered, only some first findings are presented here. However, they provide a good overview of the capability (and usefulness) of the system. The toilet was used on 39 days during the testing period. The remaining 20 days were holidays or weekends where the day care centre was closed. During this time 316 toilet usages were detected giving an average of about 8 toileting events per day. The maximum was at 14 events on a single day, the minimum at 2 usages per day (Figure 5). Of these events 149 (approximately 47%) could be assigned to specific test- persons via the FRR-card. The remaining 167 events are those where no FRR-card was detected by the system.

Figure 5. Number of toilet usage per day during real life validation in the MS day care centre at Caritas Socialis in Vienna, Austria, between 22.12.2004 and 18.02.2005.

174 N. Gentile et al. / Concept, Setting Up and First Results from a Real Life Installation

Figure 6. Comparison of possible and actually used values of height (left) and tilt (right) of the adjustable toilet bowl. Height was actually used between 43.6 and 67.9 cm (possible adjustability is between 43.6 and 75.8). Tilt was used between 0 and 6.5 degrees which is the full range of possible tilt values.

(1) Height of bowl [43.6 to 75.8 cm]

(2) Tilt of bowl [0 to 6.6 deg]

(3) Entrance Door open (curve top) closed (curve down)

(8) Flush valve open (curve top) closed (curve down)

Figure 7. Example of data gathered during a day (subset of available data). Four curves over time axis show (from top to bottom): height position of toilet bowl between 43.6 and 75.8 cm (1), tilt position of toilet between 0 and 6.5 degrees (2), status of entrance door (3) open/closed and flushing of toilet (8) as binary event. The four curves are shown between approx. 8 and 17 o'clock when the day care centre is open (on a working day).

A total of 23 different PU and 6 SU were detected by their FRR-Cards. The PUs used the toilet between one and 29 times each. Although not all users were detected very often, 43% of them were identified at least 10 times. The available range of height and tilt was extensively used, only the maximum possible height was not used to full extent; however it was set to values that are far higher than a standard toilet (Figure 6). Toilet usage differs of course each day and with each user. An example of visualized sensor data gathered during one day is shown in Figure 7. It can be seen, that tilt and height are changed in the morning mainly, and the toilet was then used in the afternoon with no changes. The flush events can be related to single toileting events N. Gentile et al. / Concept, Setting Up and First Results from a Real Life Installation 175 each. From daily diagrams, the different single toileting events can be extracted and evaluation of toileting events of identified users can be done. These data will then accompany the sociological evaluation of the tests. Only a limited set of possible enhancements which were tested in laboratory (see for example [1,2,5,6,7]) was presented to the users and tested by them during the real life evaluation. However, it can be stated, that these features actually have improved toileting for the target group of users. The results which are outlined below in more details show, that adjusting height and tilt of the toilet is not only accepted very well by the test persons but also provides great benefit for both primary and secondary users [11,26]. This is outlined in the following sections.

5.3. Preliminary Findings from Data Triangulation

The documented results were very satisfying. Some of the users, the CS management and staff members were very happy having been included as experts in this project: “it was time to ask those who in their everyday life and work are confronted with such situations and problems” stated for instance a staff member. Even if some functions have to be adapted, all the participants stated that the FRR was able to improve the quality of life of the daily guests and to relieve the staff. The transfer is easier and safer (see Figure 8 and 9), the remote control and the possibility to adjust the toilet high and tilt is very useful and increases autonomy: some users with a high degree of dependency now are able to flush independently or to touch the ground with their feet while sitting on the toilet. This provides more stability and in general the feeling to be more autonomous and safer. The users also stated that the contact with the floor will be helpful to activate the belly musculature when defecating. There is indication that FRR enables persons who are completely depending on help to discover resources that might increase autonomy; further, it helps MS patients to maintain independence for a longer time. A daily guest (wheelchair user) who cannot use the toilet alone because of the transfer, stated at the end of the test: “Such a toilet could have postponed the decrease of my autonomy”. Another test participant added “The autonomy in pressing the nurse alarm button makes me happy!!!“.

Figure 8. Closing the door as wheelchair user requires a lot of efforts (left, view from inside of the toilet room); A Secondary User accompanied a Daily Guest in the FRR (right, seen from outside).

176 N. Gentile et al. / Concept, Setting Up and First Results from a Real Life Installation

Despite the positive and encouraging evaluation so far, there are still some things to be improved. A user recognition system that is able to rapidly adjust the toilet according to the user needs would be good and bring many advantages, e.g. “because everything goes much faster”4. In general, we have to remember that people with impairments, particularly with wheelchair, often have to search for a long time before they find an adapted toilet. When they finally find a proper toilet, they need to use the toilet very urgently. The future development must absolutely consider this aspect. We also have to take into account that every automatic function, (including the “automatic door “) that some of the users would appreciate, can be a disadvantage for people with cognitive impairments or older people who have problems to understand new technology. As regards the horizontal bars, they were assessed as very helpful, in particular for the transfer. The transfer is faster and safer and many of the users now can make the transfer without any help. This reduces the „stress“, makes “happy“ and the transfer back “easier”, also for the secondary user. The adjustability of the handles in height and in width would be important because some people need them shorter, the other ones longer. The door handle [5] was assessed as being very useful, despite the fact that some users refused to test the toilet because the door handle was too large, looks “unfriendly” or like a “safe”5. In general we observed that doors are actually the first barrier for people who are going to use the toilet – many of the daily guests have quite some problems in opening and closing the doors. The new door handle at the FRR door has brought improvements for them. It is very helpful for persons using crutches, because you can operate it also with your elbows. For wheelchair users there was however no evident improvement – especially closing the door requires long “to and fro” manoeuvres. The door currently opens to the inside. The new door handle was useful but it should be implemented in a whole concept (also a bigger room would be helpful). Most of the users benefit from the transfer with the FRR, but not all of them. This can be illustrated by two very opposed cases. We observed a female wheelchair user who several times was waiting 5 to 10 minutes in front of the FRR door, undertaking complicated manoeuvres to go to another toilet if she had to wait longer, only to “reverse” everything when the FRR was free again. Why did she undertake all those efforts to get into the FRR? Because of her sense of duty or does she believe in the benefits of using it? How significant must the benefit be to compensate the efforts made? The question could not be answered by comparing this observation with the pure technical log files data collected by the embedded PC. From the technical point of view these data show that one user used the toilet without changing anything. Afterwards she was interviewed and she said that for her the “long waiting” period was nothing unusual because the FRR “is simply perfect for the transfer” and she “would love to take that toilet home” with her. Most of the time she finds the toilet in the right height/angle, which suits her needs, which means she does not have to change anything.

4 Please note that for safety and other reasons the RFID system used during the field trial served only for identification of the current user in the toilet room. During field trial FRR smart cards (RFID) were not used for automatic adjusting the toilet parameters (e.g. height and tilt) to the individual preferences. This was implemented and successfully tested only in laboratory environment as described in [1]. 5 A “safe” is something that can be locked hermetically, you can only enter if you know the combination (i.e. eventually too complicated, strenuous) and perhaps you might have problems in leaving the room afterwards. Such fears were also expressed in the course of previous test phases, in general in the context with automatically controlled devices/functions (dependence, you have no influence on it, you have to rely on the technology) and also with doors that can only be opened and closed automatically. N. Gentile et al. / Concept, Setting Up and First Results from a Real Life Installation 177

If she does not need to go to the toilet urgently, she prefers to wait instead of using another toilet. The second example is a guest, also a wheelchair user, who stopped going to the FRR because she cannot manage the transfer alone in there. She normally drives close to the wall, supports herself with her legs at the wall and uses the vertical handle to move her body up. At the FRR it is not possible to do that and thus she uses another toilet which meets her demands. The high benefit for the first user (as described before) especially with the transfer corresponds 1:1 to the high effort of the second user.

Figure 9: Guests waiting in front of the FRR (left). A test participant demonstrates the best transfer position for her (right).

6. Discussion

As we reported at the beginning, the main goals of the field test were that the users should be satisfied at the end of the tests and usefulness should be noticeable for all participants. The response of the users proves that we have reached these expectations. The FRR is an advantage for both primary users and secondary users and the daily guests welcomed that the FRR-Toilet in the future will remain in the MS-Day Care Centre. Despite the fact that both, the technical and the sociological data are so rich that it is necessary to continue evaluation, the implementation of the results that were gained so far form the basis for future developments and should also lead to compulsory implementation of findings from the FRR project on local, national and European level. And, as one of the users stated at the final conference [26] (see Figure 10), “the FRR would bring a win-win effect both for users (longer autonomy) and caring staff (relieve in their health condition) which is equal to a benefit for national economies!” 178 N. Gentile et al. / Concept, Setting Up and First Results from a Real Life Installation

Figure 10. “Voice of the User’s” at the final conference of the Friendly Rest Room (FRR) project organised at Caritas Socialis in Vienna; March 17th, 2005 [26].

7. Conclusions

Even simple features like height and tilt adjustability of the toilet system were found to be of high value and usefulness for primary users and carers in the daily activities of the day care centre. Over a period of 2 months 316 toilet sessions were recorded with 29 primary users and 12 carers being involved. It could be shown that the adjustability of height and tilt of the toilet bowl, the remote control of the toilet flush and the call for nurse actually were used in daily routine and were considered as very useful from point of view of the test participants. Observations from sociologist and interviews with primary and secondary users have confirmed these findings. Personal statements from participants were given during the final conference of the FRR project and are documented in [26,27,28]. Some selected examples from primary users’ perspective: The transferring from the wheelchair to the toilet and back again is supported significantly. The adjustment of height of the toilet ensures that feet have contact with floor which increases safety. “Such a toilet would have delayed the limitations that my independence suffers from!” The independence in pressing the alarm button (call for support) increases the autonomy and feeling of personal independence. Important benefit is that “it reduces stress when using the toilet” [26]. From the care team it was noted that the physical workload of the care personal is reduced by the height adjustment of the toilet. “FRR offers persons who, in my point of view, are dependent on help, the possibility to discover own resources which mean independence for the person” and it also “provides the possibility to keep resources and independence for a longer time (rehabilitation)” [26]. It also can be concluded that most but not all users found their needs met by the toilet system. The experience and satisfaction of the users can be quite different or even opposite and apparently these are depending on the different coping strategies the individual user has. By the time of final revision of this chapter (June 2009) the toilet system installed at the day care centre in December 2004 still is in continuous and successful use. The real life evaluation of the FRR toilet system 2004-2005 is an example of successfully N. Gentile et al. / Concept, Setting Up and First Results from a Real Life Installation 179 transferring an innovative system into daily life and ensuring the necessary technical maintenance work by engaged local companies. It is worth noting that functional and technical specifications similar to those of the installed toilet system were included to the tender of the Vienna International Airport terminal extension (“skylink”) project where the reader might be able to use such toilets in near future [29]. Some of the wishes for the future are the integration of speech control and automatic adjustment via RFID cards into the system. These features were tested successfully under laboratory conditions (cf. [1]) but were not yet included in the field evaluation reported about here.

Acknowledgements

We gratefully acknowledge the intensive contributions provided by all the persons who have participated in the prototype testing phases and in the real life evaluation of the toilet system at the day care centre. Special thanks to all clients and nursing staff, especially to Christine Pauli, Ramona Rosenthal and Franziska Sonntag from ‘Caritas Socialis Pflege und Sozialzentrum Rennweg’ in Vienna and to Robert Schlathau from the board of the Austrian Multiple Sclerosis Society. Without their extraordinary support and engagement the FRR real life test in the day care centre would not have been possible.

References

[1] Panek P, Edelmayer G, Mayer P, Zagler WL. Laboratory Tests of an Adjustable Toilet System with Integrated Sensors for Enhancing Autonomy and Safety. This volume [2] Magnusson C, Alm N, Edelmayer G, Mayer P, Panek P. Rapid Prototyping of Interface and Control Software for an Intelligent Toilet. This volume [3] Design Partner of the FRR Consortium: Landmark Design Holding bv [Internet] 2005 [cited 2005 May 16]. Available from: http://www.frr-consortium.org [4] Manufacturing and engineering partner of the FRR Consortium: Clean Solution Kft., Debrecen, Hungary [Internet] 2005 [cited 2005 May 16]. Available from: http://www.cstechnologie.com/ and http://www.conplan.org [5] Groothuizen TJJ, Rist A, Weeren MJ van, Dekker D, Bruin R de, Molenbroek JFM. The Final FRR Components. This volume. [6] Sourtzi P, Menezello T. Elderly and People with Disabilities: Limitations in their Everyday Life. This volume. [7] Knall G, Sourtzi P, Liaskos J. Experience of Testing with Elderly Users. This volume. [8] Panorama View (360 degrees) from inside the FRR toilet room in the day care centre in Vienna [image on the Internet]. 2009 [cited 2009 June 20]. Available from: http://www.is.tuwien.ac.at/fortec/reha.e/projects/frr/panorama/inside.html [9] Sonn U. Longitudinal Studies of Dependence in Daily Life Activities among Elderly Persons. Methodological development, use of assistive devices and relation to impairments and functional limitations. Scandinavian Journal of Rehabilitation Medicine. Supplement. 1996;34:1-35. [10] Strainer DL, Norman GR. Health measurements scales: A practical guide to their development and use. Oxford: Oxford University Press; 2004. [11] Real Life Validation of FRR prototype system at MS day care centre of Caritas Socialis [Internet]. 2009 [cited 2009 June 20]. Available from: http://www.is.tuwien.ac.at/fortec/reha.e/projects/frr/frr_reallife.html [12] Cicourel AV. Method and Measurement in Sociology. London: The Free Press Glencoe, Collier- Macmillan Limited; 1964. [13] Denzin N. The Research Act: A Theoretical Introduction to Sociological Methods. New York: Aldine Publication Company; 1970. [14] Strauss A, Corbin J. Basics of Qualitative Research. Grounded Theory Procedures and Techniques. Newbury Park, CA: Sage Publications; 1990. [15] Glaser A. Basics of Grounded Theory Research Analysis. Mill Valley, CA: Sociology Press; 1992. [16] Goffman E. Relations in Public. Basic Books; 1971. [17] Strauss A, Corbin J. Grounded Theory Methodology: An Overview. In: Denzin NK, Lincoln YS, editors. Handbook of Qualitative Research. Thousand Oaks, CA: Sage Publications;1994. p.273-285. 180 N. Gentile et al. / Concept, Setting Up and First Results from a Real Life Installation

[18] Blumer H. Symbolic Interactionism, Perspective and Method. Berkeley, Los Angeles, London: University of California Press; 1969. [19] Jönsson B, Malmborg L, Svensk A, Anderberg P, Brattberg G, Breidegard B, Eftring H, Enquist H, Flodin E, Gustafsson J, Magnusson C, Mandre E, Nordgren C, Rassmus-Gröhn K. Situated research and design for everyday life [Internet]. 2004 [cited 2005 May 16]. Available from: www.arkiv.certec.lth.se/doc/situatedresearch/ [20] Demers L, Weiss-Lambrou R, Ska B. Development of the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST): A new outcome measurement. Assistive Technology. 1996; 8(1): 3-13. [21] Weiss-Lambrou R. Satisfaction and Comfort. In: Scherer MJ, editor. Assistive Technology. Matching Device and Consumer for Successful Rehabilitation., Washington DC: American Psychological Association; 2002. p.77-94. [22] Becker HS. Photography and Sociology. In: Becker HS, editor. Doing Things Together, Selected Papers. Evanston: Northwestern University Press; 1986. p. 221-271. [23] Collier J, Collier M. Visual Anthropology. Photography as Research Method. Albuquerque: University of New Mexico Press; 1986. [24] Yin RK. Case Study Research, Design and Methods. 3rd ed. Thousand Oaks: Sage Publications; 2003. [25] Dayé C, Egger de Campo M. User-Driven Research - How to Integrate Users' Needs and Expectations in a Research Project. This volume. [26] Adolf S, Fink B, Freist A, Rosenthal R, Pauli C, Schlathau R. Voices of the Users. Presentation during FRR final conference, Caritas Socialis Sozialzentrum Rennweg; 2005 Mar 17; Vienna, Austria. [Internet] 2005 [cited 2005 May 16]. Available from: http://www.fortec.tuwien.ac.at/frr and http://www.is.tuwien.ac.at/fortec/reha.e/projects/frr/conference/1630_Voices_of_the_users_en.pdf [27] Presentations Final Conference of Friendly Rest Room (FRR) project consortium, Caritas Socialis; 2005 Mar 17; Vienna, Austria [Internet]. 2005 [cited 2005 May 16]. Available from: http://www.fortec.tuwien.ac.at/frr [28] Press Release of Caritas Socialis. Mehr Selbständigkeit durch Toilette mit Hirn - More independence provided by a toilet “with brain” [Internet]. 2005 [cited 2005 May 16]. Available from: http://www.cs.or.at/presse-detail.asp?ID=19 [29] Egger de Campo M, Dayé C, Panek P. Creating Friendly Rest Rooms by Involving Older and Disabled Users in the RTD Process. Invited presentation at Research Benefits for the Ageing Population - Dissemination Conference for European Research Results, STAKES and the European Commission under the Finnish EU Presidency; 2006 Sep 14-15; Helsinki, Finland [Internet]. 2005 [cited 2006 Nov 23]. Available from: ftp://ftp.cordis.europa.eu/pub/life/docs/egger_de_campo_session_4.pdf

Section 4 Aspects of Human-Product Interaction in the Toilet Environment

This page intentionally left blank A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People 183 J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-183 Fall Prevention in the Toilet Environment

Sonja N. BUZINKa,1, Renate DE BRUINa, Theo J.J. GROOTHUIZENb, Eva M. HAAGSMANa and Johan F.M. MOLENBROEKa,1 a Delft University of Technology – Faculty of Industrial Design Engineering – Section Applied Ergonomics and Design, Delft, The Netherlands b Groothuizen Beheer bv, Rotterdam, The Netherlands

Abstract. This study was carried out to determine the need for more appropriate fall preventive measures and create a knowledge base for design criteria to be implemented in the Friendly Rest Room project. Literature research and interviews with users and caretakers were used to create the FRiTA Model, which was used to identify ‘basic toilet activities’ with an increased fall risk within the ‘Dutch’ toilet ritual. Next, a new toilet support was developed which provides a fine-tuned all-in- one support solution with an inviting appeal, representing luxury, serenity and hygiene. Several elementary aspects have been implemented in FRR prototypes. The results of usability tests with these functional FRR prototypes look affirmative and promising.

Keywords. Slips, Trips and Falls, Inclusive Design, Toilet, Support, Assistive Devices

1. Introduction

Statistics show that people are getting older and in the near future, elderly people will represent an increasingly larger group of the population. Social structures are changing and many elderly people expect to enjoy a more active lifestyle and benefit from better living conditions [1,2,3]. Fall accidents are responsible for the majority of serious injuries amongst the elderly in the category of home accidents. More than one out of three people over 65 and about 50% of the elderly over 85 years of age fall at least once a year. The consequences of these fall accidents for elderly people are diverse and can affect the mental, social and physical condition of the elderly individual. That is why falls often have a strong impact on daily life [1-7]. The prevention of falls in the toilet environment is an important theme within the FRR project.

2. Investigating Fall Accidents in the Toilet Environment

The research project was started with the general aim to help prevent fall accidents of elderly people when they visit a public or semi-public toilet. The first phase existed of a profound literature investigation on related aspects in the multidisciplinary field including the geriatric process, falls and fall prevention, Dutch legislation and

1 Corresponding Authors: Sonja Buzink and Johan Molenbroek, Faculty of Industrial Design Engineering, Delft University of Technology; Address: Landbergstraat 15, 2628 CE Delft, The Netherlands; Email: [email protected], [email protected] 184 S.N. Buzink et al. / Fall Prevention in the Toilet Environment standards on rest room design and the toilet routine in general. This was complemented with a set of investigations on current available assistive devices for the toilet environment, the present-day situation for Dutch (semi-)public toilet environments for elderly people and the handicapped, the view of elderly people (n=10) and nursing professionals (n=6) on falls and fall prevention by interviewing them [2]. This knowledge was used to develop the FRiTA model for fall risks assessment in toilet routines [2]. The model was used to identify toilet activities with an increased fall risk within the ‘Dutch’ toilet routine and reveal potential problem areas (locations and actions) within the toilet environment and ritual. This resulted in a set of recommendations for fall preventive measures in the toilet environment as a whole [1,2,3], preliminary design criteria and a refined design assignment focussing on physical product interactions in one specific problem area and aesthetic experiences. Additional research focussed on area-specific aspects of fall prevention, ergonomics, usability, aesthetics, and stigmatising design aspects [1,2,3]. Input on the latter aspects was obtained by literature, using collages and by means of a questionnaire filled out by seniors (n=19) on their perception of toilet environments.

2.1. The Consequences of Falls for Elderly People

For elderly people falls are, more often than in other age groups, the cause of severe physical injury and rank high on lists of causes for accidental death [2,6,8]. In the group of elderly people, 25-50% of falls cause some kind of physical injury [2,5]. Although less than 10% of all falls lead to a fracture, about 52% of fractures in the older age group are caused by a fall, with hip fractures as most frequently occurring type of fracture [7]. According to Spirduso [6], more than half of the elderly hospitalised due to a fall die within one year, and Fuller [8] additionally reports that approximately 25% of the elderly with a fractured hip as result of a fall die within six months. In general, elderly women appear to fall more often than elderly men do, whereas elderly men have a higher mortality rate due to falls. The fear to fall alone can affect the daily life of an elderly person significantly. Next to the fear of falling again, elderly people are often afraid of their first fall accident. Many consider the occurrence of falls a sign for the beginning of the end [6]. Fall-related fears repeatedly result in stiffened locomotion, loss of self-confidence, and subsequently lead to self-inflicted functional limitations. This, unfortunately, mostly brings about an increased risk of falling and growing social isolation [2,6,7]. The fear to fall (again) often makes elderly people decide not to lock the rest room door, not even in a public or semi-public environment. The anxiety of ending up injured inside a toilet booth, helpless or even dying after a fall is stronger than the potential embarrassment of a complete stranger entering while using the toilet [2,9].

2.1.1. Risk Factors in General A broad variety of intrinsic (individual/personal) and extrinsic (external/environmental) factors influence the extent and presence of the risk to fall for elderly people. These affect either the stimulus responsible for the initiation of a loss of balance, the capability to recover a loss of balance or, in some cases, have an effect on both. Most often though, falls are caused by a combination of several intrinsic and/or extrinsic factors [2,6,7,10]. S.N. Buzink et al. / Fall Prevention in the Toilet Environment 185

Falls themselves are, apart from any fall-related fear, also responsible for increasing the risk to fall, especially when multiple falls occur within one year [2,5]. A repetitively falling person does not necessarily fall due to a similar combination of factors each time. And while many single risk factors by themselves do not entail a notably increased fall risk, interaction between risk factors can intensify the fall risk significantly. Many times, they create a vicious circle, eventually leading to a fall accident [2,6,8]. Decrease of physical activity and difficulties during the execution of movements are important contributors to the in intrinsic causes for fall accidents, while physical limitations together with a more cautious performance of movements reduce the exposure to extrinsic fall risk factors. This subsequently causes a further decline of the capability to act in response to danger and risks [5,6].

3. Preventing Falls When Using the Toilet

Everybody has their own toilet ritual, which includes a variable number of relatively small movements and tasks. In early childhood, one is trained in these activities and the tasks unite to become, as it were, one activity to be performed almost automatically, without thinking. This changes when people get older. The ageing process often affects some of the movements and postures that are part of the toilet routine. This causes the ritual as a whole to disintegrate, and a task within the toilet ritual previously without a significant fall risk can suddenly change into a hazardous activity [2,11,12]. In most cases, people will first try to compensate and slightly adjust their ritual, or use already present objects for support to accommodate geriatric complaints, before relying on any additional assistive device [2,9,10].

3.1. Current Fall Prevention Strategies

Currently, a diverse range of fall prevention strategies is in use, which all attempt, by following various paths, to reduce the occurrence of falls, also for the toilet environment. The first major step in almost all of these prevention programmes is to create awareness of fall risks present in the surroundings of an elderly individual. Multi-faceted approaches tailored to the elderly individual, assessing and modifying both intrinsic and extrinsic fall risk factors, appear to be the most successful in reducing the number of fall accidents [2,6,7]. Fortunately, the use of assistive devices in toilet environments seems to be less affected by the reluctance often shown with other assistive devices [4,11]. Supports in the toilet environment are the second most frequently used type of assistive devices after ambulatory aids. For various reasons, their presence, though, does not always imply (correct) usage. Some elderly people state they not always recognize grab bars as such. In some cases they are thought to be a towel rack [10], in other cases the user lacks the necessary strength to use a particular type of support [2]. Proper installation of assistive products in toilet environments is determinative for the suitability and amount of support offered in real use [1,2,3,10,12,13]. The design of public or semi-public toilet facilities generally follows a minimal set of accessibility regulations and guidelines, which are mostly based on average dimensions. In many situations, anthropometrics guidelines based on averages are acceptable; applying these guidelines in assistive products for elderly people though, will result in excluding a 186 S.N. Buzink et al. / Fall Prevention in the Toilet Environment considerable number of people from (comfortable) use, since elderly people are, anthropometrically speaking, far from average.

3.2. Risk Factors within the Toilet Environment

Implementation of a broader range of fall-preventive measures in building regulations, for instance, should be considered as very important to bring down the number of falls in toilet environments. Extrinsic aspects of toilet environments can be divided into two categories: ‘fixed toilet environment’ (the floor, toilet bowl, etc.) and ‘additional objects’ (towels, floor carpets, etc.). Both categories entail a varied, though different range of risk factors. As the Friendly Rest Room project concentrates on public and semi-public toilet environments, the fall risk factors incorporated in the ‘fixed toilet environment’ will be focussed on. The layout and interior design of the toilet environment has to be spacious, practical and clear to be easily accessible for elderly people. The space to manoeuvre in many toilet environments is very limited, which hinders many, especially those using a mobility aid like a rollator [2,11]. In a confined, narrow rest room it is easy to find support against walls; getting up after a fall, though, becomes almost impossible. A toilet environment accessible for people using a mobility aid like a rollator should at least have the dimensions of a rest room ‘plus’, see Figure 1. Non-elderly users will most likely appreciate this relatively new type of spacious public toilet environment as well, for example obese people and people with infants. This set-up simultaneously removes the first barrier for many elderly to visit a public toilet, as they no longer will depend on the stigmatised toilet for the handicapped [1]. The nature of the floor surface influences the fall risk strongly. The level of slip resistance should be sufficient, both in dry and wet circumstances. Various gaits and types of shoe wear should be taken into consideration in the assessment of the floor surface as well, as combinations suitable for some can be hazardous for others [2,6].

Figure 1. Dimensions of a toilet room ‘plus’ Figure 2. The toilet bowl as object to trip over (upper left), lack of contrast (lower left), visual support and a deceptively continuing floor (both on right) S.N. Buzink et al. / Fall Prevention in the Toilet Environment 187

The floor should be level, without any thresholds or other trip objects. Wall- mounted toilet bowls are preferred over floor-mounted ones, as feet or rollator wheels easily hook behind them [2], see Figure 2. Elderly people often experience visual difficulties. For this reason sufficient contrast between all objects in the toilet environment, including walls and floor, is indispensable, see Figure 2. Clear visual support as in contrasting vertical or horizontal lines, at or above eye height, will help many elderly people to maintain postural balance [1,2], also see Figure 2. Usage of wall plinths in the same colour as the rest room floor should be avoided. They complicate the assessment of the environment for the visually impaired by creating a deceptively continuing floor [2], see Figure 2. Blinding or disorientation due to glare or reflections should be avoided. Sufficient lighting is essential for elderly people to assess the interior of the rest room properly, but light transitions should be gradual to avoid dizziness or disorientation when entering the room [2].

Figure 3. Manikin Mathilde demonstrates the basic toilet activities with the highest fall risk (by Landmark Design Holding BV)

The style and ambience of a toilet environment can be of influence on the possible risk to fall. Activities connected to urination and defecation are generally considered very intimate and private [11]. Thoughts about our own toilet ritual already raise some negative, uncomfortable feelings; those of strangers are seen as even more unpleasant. The more publicly accessible a toilet is and the less familiar the people are who use it, the more important it becomes that the environment appears hygienic and ‘as if never used before’. In different ways, this is connected to the perception of the toilet environment and the behaviour of people during a toilet visit [11]. The way people perceive the environment determines their well-being, which in turn influences the use of the facilities and therefore the potential fall risk. Hygiene, privacy and a safe, 188 S.N. Buzink et al. / Fall Prevention in the Toilet Environment comfortable surrounding should therefore also be considered as essential attributes within the overall toilet environment design to avoid fall accidents [1,3]. Elements, like assistive devices, bearing a stigma should be banned or redesigned to become an integral part of the environment.

Figure 4. Several preliminary scale models in different stages of the design process

3.3. Risk Factors within the Toilet Ritual

Transfers onto and from the toilet are well known as one of the most difficult personal care activities to perform for elderly people [2,10,11]. Many elderly people also experience difficulties when rising, standing, turning, (un)dressing and reaching [9,13]. Heightened toilet seats can cause constipation problems and prolonged sitting can cause legs to ‘fall asleep’ [2,11]. To obtain a complete and proper impression of the potential risks within the toilet ritual of elderly people, a process tree of the ‘Dutch’ toilet routine was created. A broad range of over 40 activities was identified with changing movements and postures [2,11]. The basic toilet activities, which were always performed by nearly all users, are most important to focus on when designing a public or semi-public toilet environment. An evaluation of hazardous movements within the toilet ritual was performed which revealed that the activities of opening and closing the door, manoeuvring through the rest room, turning in front of the toilet, (un)dressing, sitting down, performing perineal cleansing, rising and checking clothing after dressing were the ‘basic toilet activities’ with the highest fall risk [1,2,3,5,11]. In Figure 3, Mathilde, a manikin designed by Landmark Design Holding Bv for the FRR project, illustrates these activities. S.N. Buzink et al. / Fall Prevention in the Toilet Environment 189

4. The Design of a New Assistive Product to Prevent Falls

The study above was used as an outline to describe the need for an assistive product to prevent falls in toilet environments, and to define a design assignment for such a product. To design a support for a (semi-)public toilet environment with an as large assistive effect as possible, the design phase focuses on basic toilet activities, as those activities are performed almost every time by nearly all users. The largest number of fall-riskful basic toilet activities is performed by Dutch elderly people in the vicinity of the toilet bowl [2]. Therefore, the design focuses on assisting elderly people properly during their movements and postures while standing still and manoeuvring in front of the toilet bowl, (un)dressing, sitting down, performing perineal cleansing and standing up. The target group consisted of people older than 60 years of age that are able to visit a public toilet autonomously (whether or not using a simple mobility aid like a walking stick or rollator) and use the facilities in it without the help of another person. The product should in no way (physically or mentally) hinder or complicate the use of the toilet environment by any user, including secondary and tertiary users. The semi-public environment the product is designed for implies a setting with durable products, used by multiple users with varying demands and styles of usage. This also means a relative high level of cleaning and maintenance by specialised staff (and not/less by the primary user self), and makes a product with a relative higher level of luxury, compared to a fully public situation, possible. The emphasis in most current assistive products is on technical functionality and reliability in assistive behaviour. The new design should distinguish itself from those products by taking also the usability, ergonomic functionality and aesthetics into account as equally important. Through a creative design phase, involving various design techniques, a broad range of ideas was generated. The most promising ideas were combined to form interim conceptual solutions. Next to additional research and design sketches, preliminary scale models played an important role during the following design process, see Figure 4. In subsequent design phases, the conceptual design was further developed to a more detailed level, mapping experiential aspects to physical properties. Design decisions were made based on aspects of usability and perception of hygiene. The limited space of toilet environments and the potential big influence of an assistive device on the perception of the whole environment require the manifestation of the design to be simple, open, and inviting. Next to a 3D computer model (see Figure 5), a full-scale visual model of the grab bar section (see Figure 6) was made as well to evaluate the manifestation of the grab bar in full scale [1,3].

4.1. S’wing

The final support proposal, named S’wing, consists of several specially designed components (see Figure 5): a toilet lift module, a toilet seat and two grab bars alongside the toilet [1,3]. Each component provides users assistance when performing their toilet ritual and helps them prevent fall accidents. When applied collectively, though, they reduce the fall risk even further, as they intensify and supplement each other’s fall- preventive qualities. 190 S.N. Buzink et al. / Fall Prevention in the Toilet Environment

Figure 5. The 3D computer model of S’wing

The design of S’wing facilitates a varied range of support to choose from for elderly users. The design enables sufficient support and assistance for elderly people between the 5th (often a small female) and 95th (often a tall male) anthropometric percentiles during various activities of the toilet ritual. The toilet seat and grab bars are height-adjustable because they are mounted on a lift module. Ergonomic research during the design process showed that when choosing for such a type of adjustability, anthropometric needs could be met with a design that is more compact and less visually present in direct sight. Next to a less complex product to use for the elderly, this helps to avoid a potentially deterring and stigmatising effect caused by the dimensions of the supports. The curved surface of the toilet lift module also includes a back support to provide extra stability while seated. The toilet bowl applied is a wall-mounted type. The fact that it hangs free from the floor decreases the fall risk by tripping. The design of the toilet seat is trapezoidal. Together with the enlarged and slightly concave curved surface this shape ensures (more) stability while seated. This also reduces the hazard of sliding off the seat, while sitting on one side for wiping ones buttocks, for example. Furthermore, it eases sitting down and standing up as it offers enough space to place both hands on the seat next to the upper legs. S.N. Buzink et al. / Fall Prevention in the Toilet Environment 191

S’wing offers various types of support and can be used in many different ways, according to the wishes of each individual toilet visitor (see Figure 7). When a user enters the toilet environment without a FRR personified data carrier, the grab bars will be in the position shown in Figure 5, this way the user will know that at least two positions are possible. When rotated backwards, the support bars present a grip to grasp while sitting down, as well as an armrest to use when seated. When rotated upwards S’wing offers grip in front of the toilet seat, and can also be used to lean against with the hip. The design of S’wing gives the user options to store a walking stick or small bag while toileting, for example by placing it through the V-shaped opening in the grab bars or hanging it over the vertical grab bar. In the backwards position, they present a grip to grasp while sitting down, as well as an armrest to use when seated. The support and grab bars can be rotated between an upward (vertical) and backward (horizontal) position and fixed in in-between positions. To change the position of a grab bar the user grasps and squeezes the button on the lower arch and give it a slight push or pull in the desired direction until the preferred position is reached. During this, the mechanism inside carries the largest part of the weight. To lower or raise the whole toilet unit (including the grab bars), to flush or call someone for help, the user can use the buttons on top of one of the grab bars. In the described version of S’wing, the handles are adjustable and actively rotated by the user. The seat can be adjusted in height and tilt, but still provides a static type of support. In a more elaborate design, S’wing could offer dynamic assistance. Sitting down and standing up could be actively assisted by a rotating movement of the support bars, for example. This would help the user to initiate and coordinate these motions. Moreover, a more simplified edition could be marketed, which for instance only offers the grab bar(s) without the toilet lift to be installed at a personally defined, fixed height. The colouring and use of materials is chosen such that it helps to increase the perception of hygiene and serenity. In most sanitary situations, light/pale blue appeals as more fresh and new to a user, as it is less sensitive for visual contamination and yellowing due to cleaning chemicals than white, for instance. Parting lines, surface curves and edges are designed such that they will not collect dirt, and if minimal amounts of dirt might collect, it will be out of the line of vision for users. Materials to be used will conduct heat sufficiently to maintain a relatively cold and fresh feeling when touched by human skin.

Figure 6. Computer-simulated usage examples by a small elderly female, a tall elderly male and an average elderly person 192 S.N. Buzink et al. / Fall Prevention in the Toilet Environment

Figure 7. The visual full-scale model of the grab bar and some details

5. Conclusions

The fall risk present in toilet environments is determined by the combined action of a variety of factors. When applying fall-preventive measures in the toilet environment, the most important thing is to assess and modify the environment as a whole, taking both intrinsic and extrinsic factors into account. It is possible to reduce the influence of these factors by applying a full set of appropriate fall-preventive measures. The conceptual support developed during this graduation project, offers an innovative and appropriate solution to prevent falls in the toilet environment. Its components together form a fine-tuned whole with an inviting appeal representing luxury, serenity and hygiene. In various ways, it offers an enormous improvement compared to existing assistive products for the toilet environment. Elderly toilet visitors will no longer be forced to alter their toilet behaviour to obtain suiting support, as it offers an integrated mix of different types of support. This ensures that the number of users excluded from usage is minimal. S.N. Buzink et al. / Fall Prevention in the Toilet Environment 193

6. Recommendations

The next step should be the development of a fully functional prototype of the conceptual design as a whole for usability testing. Only this way it will be possible to actually verify the design decisions that have shaped the design. Additionally more fundamental research on topics that have not thoroughly been studied before would create a better basis to determine the genuine value of the new design. This includes research into support preferences of elderly, interaction patterns with different types of support within the toilet environment, as well as a more elaborate study into the perception of toilet environments by elderly people. This will create a profound basis for further developments in the field of fall prevention in the toilet environment. Finally, it is advisable to re-evaluate current accessibility regulations and guidelines for toilet environments in detail to include a broader range of criteria concerning fall prevention.

References

[1] Buzink SN, Molenbroek JFM, Haagsman EM, Bruin R de, Groothuizen ThJJ. S'wing; a fall prevention product for the toilet environment. Development of a product to prevent falls in the toilet environment [in Dutch]. Tijdschrift voor Ergonomie. 2004;29: 4-11. [2] Buzink SN, Molenbroek JFM, Haagsman EM, Bruin R de, Groothuizen ThJJ. Falls in the toilet environment: a study on influential factors. Gerontechnology. 2005;4:15-26. [3] Buzink SN, Molenbroek JFM, Bruin R de, Haagsman EM, Groothuizen ThJJ. Prevention of falls in the toilet environment. In: Pikaar RN, Koningsveld EAP, Settels PJM, editors. Meeting diversity in Ergonomics. Proceedings of the 16th Triennial Congres of the International Ergonomics Association, IEA2006. 2006 Jul 10-14; Maastricht, The Netherlands. Elsevier Ltd.; 2006. [4] Aminzadeh F, Edwards N. Exploring seniors' views on the use of assistive devices in fall prevention. Public Health Nursing. 1998;15:297-304. [5] Bueno-Cavanillas A, Padilla-Ruiz F, Jiménez-Moleón JJ, Peinado-Alonso CA, Gálvez-Vargas R. Risk factors in falls among the elderly according to extrinsic and intrinsic precipitating causes. European Journal of Epidemiology. 2000;16:849-859. [6] Spirduso WW. Physical dimensions of aging. Champaign: Human Kinetics; 1995. [7] Til J van, Michels PH, Delobelle M. Privé veiligheid: voorkómen van vallen. In: Handboek lokaal ouderenwerk voorkomen van vallen [in Dutch]. Amsterdam: Stichting Consument en Veiligheid; 2003. [8] Fuller GF. Falls in Elderly. American Family Physician. 2000;61:2159-2168. [9] Plante RA. Toilet customs of the elderly; an exploration to find problems caused by the symptoms of old age and injury into the problems that exist when using the raised toilet seat [Student research report, in Dutch]. Delft: Delft University of Technology, Faculty of Industrial Design Engineering; 2002. [10] Aminzadeh F, Edwards N, Lockett D, Nair RC. (2000). Utilization of bathroom safety devices, patterns of bathing and toileting, and bathroom falls in a sample of community living older adults. Technology and Disability. 2000;13:95-103. [11] Kira A. The bathroom. New and expanded edition. New York: Viking; 1976. [12] Crawford J. Design regulations and bathroom accessibility for the elderly. In: Özok AF, editor. Advances in Applied Ergonomics, ICEA’96. West Lafayette: USA Publishing; 1996. p. 724-727. [13] Bosman J. Toilet usage in the living environment of elderly, research into preferences of grips and grab bars (in Dutch). Tijdschrift voor Ergonomie. 1999;24:36-41.

194 A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-194 User Preferences Regarding Body Support and Personal Hygiene in the Toilet Environment

Dries DEKKER , Sonja N. BUZINK and Johan F.M. MOLENBROEK1 Delft University of Technology – Faculty of Industrial Design Engineering – Section Applied Ergonomics and Design, Delft, The Netherlands

Abstract. In the development process of the friendly restroom, information was needed about user preferences regarding supports and personal hygiene in the toilet. As literature studies did not yield the required information, two user tests were held with supplemental questionnaires. The main test was carried out with seniors, the preliminary test with students. The preliminary test helped to fine tune the main test and to assess its risks. The test was held with a setup that consists of an height adjustable toilet bowl and various adjustable supports around it. The setup also contained a newly designed washbasin. The results from this study are a preliminary insight in the preferred types of supports and corresponding preferred heights and positions for these supports among elderly. Furthermore, insight was acquired in attitudes towards personal hygiene in the toilet.

Keywords. User Preferences, Personal Hygiene, Body Support, Toilet, Seniors, User Test

1. Introduction

In the development process of the friendly rest room within the FRR project, detailed information was needed about the positioning of supports in the toilet environment and a newly-designed washbasin with a sprayer and blow-dryer for perineal cleansing. Literature study showed that currently no guidelines for applying appropriate support facilities in toilet environments exist [1,2]. It was therefore decided to execute two studies to gain insight in the use, preferred placement and acceptance of and need for different types of supports and a new design for a washbasin and its aids for perineal cleansing, both for private and semi-public toilet environments [3,4]. The objectives of these studies were:

To gain insight in the use of supports during the toilet ritual, To determine the range of preferred positions of supports for sitting down on and standing up from a toilet, both relative to the body and absolute, To determine the preferred type of support and the usefulness for each type for standing up from, sitting down on a toilet and during wiping of the buttocks,

1 Corresponding Author: Johan Molenbroek; Address: Delft University of Technology; Address: Landbergstraat 15, 2628CE Delft, The Netherlands; Email: [email protected] D. Dekker et al. / User Preferences Regarding Body Support and Personal Hygiene 195

To verify whether familiarity with supports in the toilet environment is related to the preference for a particular type of support, To gain insight in the attitudes towards several methods of perineal cleansing, both in private and semi-public toilet environments, To determine the need for the newly-designed washbasin, both in semi-public and private situations, To gain insight in the use of the newly-designed washbasin for washing hands To determine the range of positions of the washbasin for washing hands comfortably.

2. Method

2.1. Subjects

In order to gain insight in the use of the washbasin and supports and to fine-tune the test set-up, a pilot test was done with five students of the Faculty of Industrial Design Engineering of the Delft University of Technology. During this test, the students wore an old-age simulation kit (see Figure 1). The pilot test was held with students, because students are more readily available than the actual target group of seniors and to avoid exposing the seniors to unknown risks of the test equipment.

Figure 1. Student wearing the old-age simulation kit

196 D. Dekker et al. / User Preferences Regarding Body Support and Personal Hygiene

The main study was held with fourteen persons from 58 to 78 years of age after the test was fine tuned and evaluated in the preliminary test. The senior subjects were asked to fill out a questionnaire about their experience with supports in the toilet and to record their home situation. The subjects of both studies were asked to demonstrate several specific activities of the toilet ritual in the simulated toilet environment.

2.2. Equipment and Environment

The test equipment consisted of a toilet bowl, several adjustable supports and a prototype of the washbasin for both tests. The toilet bowl was hydraulically height- adjustable over a range large enough to accommodate all subjects, thereby eliminating the possible influence of a fixed toilet height. The students in the pilot test wore an old- age simulation kit during the test.

2.2.1. The Old-Age Simulation Kit When ageing the joints in our body tend to get stiffer and our senses deteriorate. In the student test this process was simulated by applying braces around wrists, elbows, ankles and knees, and sport tape wrapped around fingers to reduce the agility. To reduce the sensory perception, cataract-simulating glasses were incorporated in the kit and the students wore rubber gloves. Finally, weight belts were attached to the wrists and ankles to simulate deterioration of muscle strength. The kit is illustrated in Figure 1.

2.2.2. The Support Configuration The support configuration consisted of a frame with three types of supports: two vertical supports, a front support, and two side supports. Both the front support and the side supports were adjustable in height from just above the toilet up to 1800 mm from the floor. The distance between the side supports was fixed at about 700 mm. In the test configuration with the elderly people, the distance between the toilet seat front and the vertical supports was adjustable from 120 mm to 580 mm, see Figure 2. After measuring some anthropometric variables, the subjects were asked to stand up and sit down using the three types of supports successively. The supports were placed around the toilet in the following order: first the vertical supports, then the front support, and finally the side supports. Each type of support was tried in different positions (three for the students and two for the elderly), based on the anthropometric data of the subjects. The purpose of these variations was to let the subjects feel the effect of different support positions on their comfort-level during standing up and sitting down. After these trials, they were asked to indicate an optimal position for the different types of supports. The elderly were asked to pretend to wipe their buttocks with a piece of toilet paper to find out how each type of support would be used during this activity. This is an activity with an elevated risk for falling, because a shift of the body’s centre of gravity is needed. Finally, with all types of supports present and in their most comfortable positions, the subjects were asked to indicate which of the supports provided the most comfortable assistance when sitting down, standing up, and wiping their buttocks. D. Dekker et al. / User Preferences Regarding Body Support and Personal Hygiene 197

2.2.3. The Washbasin Prototype The usage and acceptance of a new washbasin design was investigated by testing a wooden prototype. Afterwards the test users were interviewed with a questionnaire, especially made for this purpose. Use situations, often regarded awkward for toileting and cleansing is a sensitive topic, were represented in this questionnaire by friendly drawings. In this way test users were not confronted with blunt text or the need the phrase themselves, just pointing would suffice. The washbasin prototype was adjustable in height and horizontal position, however was not connected to the water supply.

Figure 2. The toilet environment and its adjustability in laboratory at TU Delft

198 D. Dekker et al. / User Preferences Regarding Body Support and Personal Hygiene

The students were asked to show how they would cleanse themselves after defecating, how they would clean a small plastic bag (representing a stoma), how they would wash their hands seated as well as standing. They had to do this using the washbasin including the sprayer and the dryer. The student test revealed that the washbasin prototype needed more detail for usability testing. After the students’ test, the focus of the test set-up was changed from usability to acceptance and the attitude towards the newly-designed washbasin. The students had to find out how to use the washbasin on their own to verify whether they understood the functions and given usecues. Before the test with the elderly subjects, all the functions of the washbasin were explained to the subjects. By ensuring that the elderly subjects understood all the functions of the washbasin and its aids in their test, it was possible to ask the subjects their opinion on these functions. The elderly were asked to pretend to cleanse themselves after defecation with the available equipment on the washbasin. Following they were asked to pretend to wash their hands, both while seated and standing (see also height-adjustable washbasin in Figure 2). Finally, the elderly were asked for their opinion about the washbasin, for use at home as well as in a semi-public toilet environment. After the prototype tests, all subjects were asked to fill in a questionnaire about their experience with different cleansing methods and their attitude towards these methods, both in private and semi-public situations. The elderly were also asked to fill in a questionnaire concerning common postures and cleansing methods in a semi- public toilet environment.

3. Results

In general, all subjects used the supports two-handed with a power grip (see Figure 4) . The most common way of applying force was by pulling or hanging, except for the side supports to which a pushing force was more frequently applied. The difference is illustrated in Figure 3.

D. Dekker et al. / User Preferences Regarding Body Support and Personal Hygiene 199

Figure 3. Common way of sitting down using the vertical supports by a senior (a) and a typical sequence for standing up with the side supports by a senior (b)

Figure 4. Power grip, thumb grip and hook grip respectively

200 D. Dekker et al. / User Preferences Regarding Body Support and Personal Hygiene

Figure 5. Body-related preferred heights of support for the elderly subjects

3.1. Vertical Supports

The subjects most frequently grasped the vertical supports at elbow height while standing. The elderly showed a lot of variety in grip posture, as can be seen in Figure 5. Generally, the subjects did not change the positions of their hands between sitting down and standing up.

3.2. Front Support

For the front support, most of the subjects considered a position slightly lower than elbow height while standing as most comfortable. The range was a bit narrower than for the vertical supports, as can be seen in Figure 5. As with the vertical supports, most subjects prefer to pull or hang to stand up and sit down using the front support. The support was held at about shoulder height while sitting by all subjects. From comments by and observation of the subjects, the front support appeared to have some practical and psychological disadvantages. Some subjects nearly bumped their heads against it, while others said to feel confined by it.

3.3. Side Supports

Most students liked the side supports best when they were placed at elbow height while sitting. The elderly mostly preferred them to be at buttock height while standing, as can be seen in Figure 5. This is lower than the heights considered comfortable for the other types of supports. In contrast to the other types of supports, a pushing force was used more often for sitting down and standing up with the side supports, as illustrated in Figure 3b. D. Dekker et al. / User Preferences Regarding Body Support and Personal Hygiene 201

3.4. Correlation of Preferred Positions of the Supports and Anthropometrics

The subjects were asked for the optimal heights of the three types of support for sitting down on and rising from the toilet. The heights of all supports were adjustable. The depths of the vertical and horizontal front supports were adjustable only in the test with the elderly subjects. The depths were measured from the front of the toilet seat and the heights from floor level. No strong correlations were found between the measured anthropometric dimensions and the preferred positions, as is illustrated in Figure 6.

3.5. Preferred Type of Support

When subjects were asked to choose between the different types of support, both students and elderly preferred the vertical support most frequently for standing up and sitting down, as shown in Figure 7. If stability is needed during use of the toilet, for example for wiping, the side supports also provide a good solution according to many elderly subjects.

3.6. Relation between Familiarity and Preference Supports

The elderly were interviewed at home prior to the experiment in order to investigate to what extent they were familiar with supports in the toilet environment and to record their home toilet situations. Familiarity with supports was mapped in order to verify whether there are relations between the familiarity with and the preference for a specific type of support. The results show that familiarity has a significant relation with preference as the five subjects familiar with supports favour the vertical supports for standing up and sitting down.

depth of vertical supports (mm) height of front support (mm) height of side supports (mm) 1400 500 1000

400 1200

800 300 1000 200 800 600 600 700 800 900 700 800 900 380 420 460 500 540 comfortable reach (mm) fist height standing (mm) popliteal height (mm) senior student

Figure 6. The preferred depths are measured from the toilet’s front and the preferred heights from floor level

202 D. Dekker et al. / User Preferences Regarding Body Support and Personal Hygiene

Figure 7. Preferred type of support for three phases in the toilet ritual

Figure 8. Different postures of elderly wiping their buttocks with toilet paper

Figure 9. Different postures while cleaning with the hand sprayer

D. Dekker et al. / User Preferences Regarding Body Support and Personal Hygiene 203

3.7. Personal Hygiene

Both the student and elderly subjects were asked to pretend to cleanse themselves with the aids available on the washbasin prototype. This resulted in a lot of different postures, as illustrated in Figure 9. As the washbasin prototype was not functional, the illustrated postures are only valid to indicate the variety of postures that will be used. On three moments during the test, the fourteen elderly subjects were asked to demonstrate how they would apply toilet paper for cleansing after defecation. A total of seven combinations of postures and approaches for application were identified, which are represented in Figure 8.

16 urinating 16 defecating bidet 14 14 toilet paper 12 12 humid tissues 10 10

bottle of Count 8 8 water

6 6 shower toilet

4 4

2 2 public private public private

Figure 10. Seniors’ preferences for cleansing aids after urinating and defecating

Figure 11. Different strategies for raising the washbasin

3.8. Preferences for Perineal Cleansing

Although the aids for perineal cleansing on the washbasin were accepted better than expected, the answers given by the subjects show that more traditional methods of cleansing (in the Netherlands, toilet paper or wet tissues) are still most preferred by the subjects, see Figure 10. Some elderly prefer a combination of dry toilet paper and wet 204 D. Dekker et al. / User Preferences Regarding Body Support and Personal Hygiene tissues, while others prefer the bidet or hand-sprayer for perineal cleansing. Wet tissues are especially popular after defecating. All students stated to prefer toilet paper for perineal cleansing after defecation and urination, although almost all of them say to use the hand-sprayer when no alternative is at hand.

Figure 12. Positions of the washbasin chosen by the elderly for washing hands while seated

Unexpectedly, it seems that students are not as open to new concepts for perineal cleansing as the elderly. The students state only to want to use a sprayer-dryer combination when no alternative is at hand. The difference could be explained by the fact that the students were only asked about their attitude in semi-public situations and that the elderly were questioned about both private and semi-public situations.

3.8.1. Using the Washbasin for Washing Hands The subjects were asked to pretend to wash their hands, both while seated and standing, and to put the washbasin in the most comfortable position for this activity. The washbasin was considered somewhat small, and the sprayer and the dryer on the sides limited the space to move the hands. In the students’ test, the most frequently used method for moving the washbasin up is by manipulating the handle in front of the washbasin see also Figure 11. The rubber buttons, originally intended for this operation, were used as well, and one subject tried to lift the whole of the washbasin to elevate it. The students’ test also revealed the lack D. Dekker et al. / User Preferences Regarding Body Support and Personal Hygiene 205 of sufficient contrast between the washbasin parts. This will create problems especially for the visually impaired. All subjects were able to find comfortable positions for washing the hands, both in sitting and standing posture. Some students stated to be too impatient to raise the washbasin to a comfortable height for a short activity like washing hands. The total heights’ range of the test of the elderly subjects varies between 470 mm and 1090 mm. It was expected that the elderly would prefer to place the washbasin over their lap or between their legs, as this position allows a more relaxed posture during hand- washing. This appeared not to be true as can be seen in Figure 12.

4. Conclusions

The studies resulted in several very valuable answers to questions of the designers on the usage of supports within the toilet ritual, in addition to information on the acceptance and usage of the newly-designed washbasin. The conclusions that can be drawn from these studies are that the test users:

Prefer vertical supports for standing up and sitting down, Consider the washbasin to be a valuable addition to the FRR toilet, but needs further development.

5. Recommendations

One of the most interesting topics for future study is the description of comfort and discomfort zones for the positions of the supports around the toilet, and whether there is a relationship between the boundaries of these zones and anthropometry. In a similar study, the influence of different types of support around the toilet on the sit-to-stand and stand-to-sit motion could be investigated. An analysis could be made of the influence on the trajectory of the centre of gravity, for example. This could eventually lead to the developments of supports in the toilet environment that better suit the variation of the human anthropometry for the sit-to-stand and stand-to-sit motion. Another interesting topic for future study regarding the use of the washbasin and its cleansing aids could be a real-life test of the functional cleansing aids on the washbasin when used for perineal cleansing. Most subjects in this study were not used to perineal cleansing using water. Therefore, it is also considered advisable to perform a longitudinal study in which the washbasin design and the aids for perineal cleansing are tested. This gives the usage of the ‘new’ aids for perineal cleansing a chance to evolve to a more automatic activity, like cleansing by toilet paper currently is for most Dutch people. The subjects in this study were mobile enough to come to the test facility. Therefore, the difference in behaviour and opinion between elderly people with more limitations and the subjects in this study could be verified. At the same time, still more data needs to be collected on common toilet habits and preferences concerning perineal cleansing, especially those of the elderly. Finally, one of the challenging aspects of this study was the issue of ethics. It would be very valuable to develop methods of user research in the toilet environment 206 D. Dekker et al. / User Preferences Regarding Body Support and Personal Hygiene or other taboo areas without compromising the privacy of the participating subjects and the concept of informed consent. These methods should ideally yield the same information as unobtrusive, observational user tests.

References

[1] Buzink SN, Molenbroek JFM, Haagsman EM, Bruin R de, Groothuizen ThJJ. S’wing; een valpreventie product voor de toiletruimte. Tijdschrift voor Ergonomie. 2004;29 (5): 4-11. [2] Buzink SN, Molenbroek JFM, Haagsman EM, Bruin R de, Groothuizen ThJJ. Falls of elderly in rest rooms: a study on influential factors. Gerontechnology. 2005;4 (1): 15-26. [3] Buzink SN, Dekker D, Bruin R de, Molenbroek JFM. Methods of personal hygiene utilized during perineal cleansing: acceptance, postures and preferences in elderly Dutch citizens. Tijdschrift voor Ergonomie. 2006;31(3, Special IEA06 issue): 36-44. [4] Dekker D, Buzink SN, Molenbroek JFM, Bruin R de. Hand supports to assist toilet use among the elderly. Applied Ergonomics. 2007;38 (1): 109-118.

A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People 207 J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-207 Biomechanical Aspects of Defecation with Implications for the Height of the Toilet

Chris J. SNIJDERSa,b,1, Johan F.M. MOLENBROEKa and Rozemarijn A. PLANTEa a Department Industrial Design – Faculty of Industrial Design Engineering – Delft University of Technology, Delft, The Netherlands b Department of Biomedical Physics and Technology – Erasmus MC – University Medical Center Rotterdam, Rotterdam, The Netherlands

Abstract. Study Design: Questionnaire on impairments, biomechanics of posture and anthropometrics of seating height. Objective: To question the suitability of a higher toilet for the elderly. Methods: The first study is a verbal inquiry held among fourteen elderly of which twelve were living independently in a care institute and two needed help for daily activities. This chapter is a selection of aspects related to toilet height. The second study deals with biomechanics of pelvic floor geometry in relation to sitting posture with in vitro and in vivo measurements. The third study was an analysis of anthropometric data for the determination of the optimal range of adjustable toilet height. Conclusions: Increase of height above the standard seems to be detrimental for defecation because of increase of hip angle and reduction of postural mobility. For standing up firm foot contact is a prerequisite which requires a toilet at popliteal height. Herewith hand grips in front of the impaired should be a basic convenience.

Keywords. Defecation, Constipation, Toilet, Height, Elderly, Pelvic Floor Muscle, Low Back Pain

1. Introduction

The coming 25 years predict an 88% increase in elderly of an age above 65 years, resulting in 800 million elderly worldwide. Symptoms of old age can be classified as follows: physical, psychomotoric, sensoric and cognitive. Decrease of balance, co- ordination, muscle force and joint mobility interfere with the use of a toilet. Dizziness and faint mean risk of falling which can also be provoked by a loose object on the floor like little carpets. Therefore, risk analysis provides strict requirements for the design of toilets. Standards are introduced for lay-out of toilets in relation to transfer from wheelchair to toilet seat. Few, however, is known about usability issues as described in other chapters. In the following we restrict ourselves to the height of the toilet seat which has implications for sitting down and standing up, urination, defecation, grasping of toilet paper and cleaning the buttocks and anal cleft. Special concern herewith is the rationale of elevation of the toilet seat. No studies are known to us that measured the advantages of toilet elevation. In contrast, squatting is supposed to be the only natural defecation posture for a human being [1,2]. This lead to the idea that a

1 Corresponding Author: Chris Snijders; Email: [email protected] 208 C.J. Snijders et al. /Biomechanical Aspects of Defecation with Implications sharp angle between thigh and trunk promotes defecation [3]. Therefore studies were designed using cinedefecography for the measurement of parameters such as anorectal angle, perineal descend and puborectal length in relation to patient position in sitting [4,5]. The study of squatting would not be representative for the Western population. The anorectal angle was found to be sharpened in the erect standing position and significantly wider during pushing in sitting position. The length of the puborectalis muscle sling was increased during pushing as well [4,6]. The puborectalis muscle is the most important muscle of continence because of its sensitivity as well as its motor activity. It contains sensory receptor organs which trigger off the rectal sphincter reflex mechanism and produce a feeling of fullness. It is assumed that its contraction in erect posture will cause the anorectal angle and with it the reflex and voluntary contractions of the puborectalis. The internal anal sphincter has ambivalent properties because it is the most important factor in maintaining the anorectal barrier to pressure at rest and at the same time relaxation of the internal sphincter will initiate defecation [7,8]. Phenomenological studies are consistent with respect to the positive influence of lowering seat height. Therefore, defecation may not be improved by raising the seat height. Because this issue is not reported in literature we decided to study the use of a toilet with special attention to elderly and higher seats than normal.

2. Methods

The present study consists of three parts, a questionnaire, a biomechanical study and an anthropometric analysis. A verbal inquiry was held among 14 elderly of which 12 were living independently in a care institute. Two needed help for daily activities, including the use of the toilet. The average age was 77 years (67-98). The average condition was considered poor as compared with the peer group. This was particularly related to grip force [9]. In the biomechanical study the so-called click-clack movement was induced in 3 male and 3 female human bodies (age range 51-99 years), admitted for embalming at the department of Neuroscience. The experiments were performed prior to embalming since a pilot study showed that embalmed specimens were too stiff for this experiment. The bodies were positioned on a specially designed apparatus which allowed for control of postural change while seated. One forward-backward translation of the trunk was performed with shoulder support only. This allowed for free backward tilt of the pelvis combined with forward flexion of the spine (Figure 1). In the sagittal plane needles (1.5 mm diameter) were inserted into the ilia (posterior superior iliac spine), sacrum (the medium sacral crest of S1) and L5 (the spinal process). The backward translation of the upper body was accomplished using a spindle, moving the shoulder rest in steps of 1 cm. After each step, photographs were taken from the side view and the top view. The limited experimental conditions excluded the use of video cameras and markers. Angles were measured (all photographs by 4 persons) on a drawing table, with an accuracy of 0.25º. This study was approved by the Medical Ethical Committee of the Erasmus MC, University Medical Center Rotterdam. The third part of the study dealt with anthropometric data as reported in articles and books, with special attention to popliteal height.

C.J. Snijders et al. /Biomechanical Aspects of Defecation with Implications 209

Figure 1. In sitting translation of the upright trunk from a forward position (right) to a backward position (left) involves transition from one stable position to another. This transition from lumbar lordosis to lumbar kyphosis is called the lumbopelvic click-clack movement [10,11].

3. Results

Problems with the use of a toilet were experienced by 8 of the 14 elderly. In their homes an elevated toilet was installed. All respondents used the hand grip when standing up whereas all women experienced problems with reaching the ground with the feet. Four elderly reported constipation while 3 of them had a toilet raiser. This meant that problems with defecation arise with a seat surface 4-6 cm above normal (8- 10 cm above 39 cm standard bowl height). The opening of the toilet raiser was considered insufficient because it necessitates shifting forward for cleaning and shifting backward for urination. Shifting forward to achieve foot contact can dirty the seat with faeces. With the view on defecation Figure 2 shows the result of the rotations of L5, sacrum and ilium with respect to each other. Backward movement of the trunk widens the L5- sacrum angle. During ventral flexion of L5 the sacrum rotates in opposite direction with respect to the ilium (counternutation, see also Figure 3). The model becomes three-dimensional and complete by adding Figure 4. It illustrates the agonist-antagonist action about the sacroiliac joints of the pelvic floor muscles and the deep back muscles which attach to the sacrum (sacral part of multifidus). This relates back muscle dysfunction with pelvic floor muscle dysfunction [12,11] which was verified in a clinical study [13]. Furthermore, Figure 4 illustrates the action of transverse oriented muscles in the abdominal wall. 210 C.J. Snijders et al. /Biomechanical Aspects of Defecation with Implications

Figure 2. Stepwise backward movement of the upright upper body progressively widens the L5-sacrum angle dorsally (grey line), while the sacrum rotates backward with respect to the iliac bones (counternutation, black line). Horizontal axis: estimated horizontal position of centre of gravity of upper body in cm with respect to the ischial tuberosities. Vertical axis: average values of relative rotations of L5, sacrum and ilium in the sagittal plane of all specimens (n = 6) in degrees. SD values at –10, 0 and +10 are respectively 0.5º, 0º and 1.44º for sacrum-ilium, 0.95º, 0º and 0.60º for L5-sacrum.

In particular the transversus abdominis can pull between the hip bones which results in compression of the sacroiliac joints. This is called self-bracing [14]. In an in vitro study it was demonstrated that pelvic floor muscles can have such a stabilizing effect as well [15]. The model presents a deep muscle corset for pelvic stabilisation and shows co-ordinated action of muscle groups with change of muscle stretch by change of upper body posture. This model was supported by observations in the microgravity environment [16]. During space flight it was reported by a cosmonaut that prolonged lumbar kyphosis was related with low back pain as well as constipation. The latter can be explained as follows: in space loss of lordosis occurs, which may cause strain in ligamental structures as the iliolumbar ligaments inserting on the iliac crest (the site of pain described by the cosmonaut). In order to stabilize the spine and pelvis the intra- abdominal pressure can be increased and the pelvic floor muscles can have a higher C.J. Snijders et al. /Biomechanical Aspects of Defecation with Implications 211

Figure 3. The relation between ventral rotation of L5 and backward rotation of the sacrum (counternutation). Lumbar lordosis represents movement in opposite direction [11]. Waste of multifidus force or hyperactivity may result in dysfunction of the pelvic floor muscles resulting in e.g. urine incontinence, frequency, constipation or sexual complaints. Iliolumbar ligament (1), axis of rotation of sacroiliac joint (2), sacroiliac joint surface (3), pelvic floor muscles (4), anus (5), vagina (6), urethra (7), pubic symphysis (8).

Figure 4. Deep muscle corset being subject to wasting and loss of co-ordination which relates low back pain with pelvic floor problems. Biomechanical model on sacroiliac joint stability with transversely oriented abdominal muscles (transversus abdominis), back muscles (sacral part of multifidus) and pelvic floor muscles (a.o. coccygeus) [12,16]. 212 C.J. Snijders et al. /Biomechanical Aspects of Defecation with Implications level of activity. This higher level of activity can lead to constipation, as demonstrated in a population of low back pain patients [13]. For the anthropometrics popliteal height is chosen. It was shown that this is a better measure than a percentage of body height for the choice of optimal, individual seat height [17]. For different countries different values of P50 have to be chosen. For an adjustable toilet height the range could be chosen between the P5 female adults in Spain and Portugal (34 cm) [18] and the P95 male adults in the Netherlands (53 cm) [9].

4. Discussion

This study questions the suitability of higher toilets for the elderly. Arguments against elevation of the toilet are the chance of constipation and loss of postural control. The assumption that elevating the toilet will facilitate seating oneself and raising to one’s feet lacks any evidence in scientific literature. One may find it a given to solve the problem of transfer by offering the elderly a firm support for the feet. In addition, hand grips can be offered which may be positioned perfectly in front of the individual’s trunk. Absence of foot support may cause loss of postural control, sinking in the toilet seat, and risk of fall during standing up. An example is stumbling over slippers fallen from the dangling feet. Answers to the questionnaire revealed that the opening of a toilet raiser is insufficient, which causes the elderly to shift forward for cleaning after defecation and shift backwards for urination. Shifting forward to achieve foot contact can dirty the seat. The ignored advance of a standard toilet is that it facilitates the changing of body posture. A biomechanical model describes the so-called click-clack movement which entails backward tilt of the pelvis combined with forward flexion of the spine towards lumbar kyphosis. This results in backward tilt of the sacrum with respect to the ilium. The opposite movement (the clack-click movement) towards a forward position of the trunk and hollow back may elongate pelvic floor muscles which could facilitate defecation by means of stretch induced sphincter response while pelvic floor relaxation may ease puborectalis tension. These speculations suggest that postural change with alternating click-clack movement as well as small lateral shifts may facilitate defecation. Such shifts are limited or even impossible when sitting unstable on an elevated toilet seat. Medical indications for toilet elevation may play a role in specific cases. For example, restricted flexion in hip and knee joints which possibly may be related to contraction of the rectus femoris muscles. The question is whether adequate physiotherapy can solve this problem. Another question remaining is whether physical aids induce the retardation of physical functioning. This is in accordance with the paradigms “invalidating invalidity” and “use it or lose it”. No research is known to us to how elderly make a transfer to standing, coming from being seated with dangling feet. A plausible solution to the previously mentioned problems may be a toilet which can be adjusted in height. Examples exist of sophisticated designs which can lift the elderly by means of a raising and forward tilting seat. For temporarily use the instalment is firm and simple. The range of sitting height for Europe could be 34- 53 cm. C.J. Snijders et al. /Biomechanical Aspects of Defecation with Implications 213

Elderly do not choose elevated toilets themselves, these are prescribed [19]. Here it can be noted that after use of a toilet seat much higher than the usual 43 cm (e.g. 53 cm) elderly return to their easy chairs (40-43 cm) or the dinner table (43-45 cm). An essential question which needs research to be answered is: which diseases and impairments require a special aid in toilet use. The present study leads to the conclusion that the use of a toilet raiser has only disadvantages for the users and should not be recommended as a solution for facilitating sitting down and standing up. Instead, hand grips at proper height in front of the impaired may offer a solution without the accompanied disadvantages of toilet elevation. The results of present study lead to the consideration that a toilet raiser should not be installed at random as a solution for facilitating sitting down and standing up. Instead, hand grips at proper height in front of the impaired may offer a solution without the accompanied disadvantages of toilet elevation. Thus, advocating against permanent instalment of toilets higher than normal is certainly justified.

References

[1] Sikirov D. Comparison of straining during defecation in three positions; results and implications for human health. Dig Dis Sci. 2003;48(7):1201-1205. [2] Sikirov BA. Primary constipation: an underlying mechanism. Med Hypotheses. 1989;28(2): 71-73. [3] Kira A. The Bathroom. Penguin Books 1966; 1976. [4] Altomare DF, Rinaldi M, Veglia A, Guglielmi A, Sallustio PL, Tripoli G. Contribution of posture to the maintenance of anal continence. Int J Colorectal Dis. 2001;16(1):51-54. [5] Jorge JM, Ger GC, Gonzalez L, Wexner SD. Patient position during cinedefecography; influence on perineal descent and other measurements. Dis Colon Rectum. 1994;37(9):927-931. [6] Piloni V, Montesi A, Amadio L, Giammarchi C. The coronal anatomy of the pelvis at rest and under straining. Radiol Med. 1994;88(5):612-619. [7] Dubrovsky B, Filipini D. Neurobiological aspects of the pelvic floor muscles involved defecation. Neurosci Biobehav Rev. 1990;14(2):157-168. [8] Holschneider AM. The problem of anorectal continence. Prog Pediatr Surg. 1976;9:85-97. [9] Steenbekkers LPA, Beijsterveldt CEM. Design-relevant characteristics of ageing users; backgrounds and guidelines for product innovation. Delft: Delft University Press; 1998. [10] Snijders CJ. The form of the spine related to the human posture. Agressologie. 1972;13B:5-14. [11] Snijders CJ, Hermans PFG, Niesing R, Spoor CW, Stoeckart R. The influence of slouching and lumbar support on iliolumbar ligaments, intervertebral discs and sacroiliac joints. Clinical Biomechanics. 2004;19(4):323-329. [12] Snijders CJ, Vleeming A, Stoeckart R Transfer of lumbosacral load to iliac bones and legs. Part II - Loading of the sacroiliac joints when lifting in stooped posture. Clinical Biomechanics. 1993;8:295-301 [13] Pool-Goudzwaard AL, Slieker ten Hove MCPH, Vierhout ME, Mulder PGH, Pool JJM, Snijders CJ, Stoeckart R. Relations between pregnancy related low back pain, pelvic floor activity and pelvic floor dysfunction. International Urogynaecology Journal. 2005;16(6):468-474. [14] Snijders CJ, Ribbers MTLM, Bakker JV de, Stoeckart R, Stam HJ. EMG recordingsof abdominal and back muscles in various standing postures: validation of a biomechanical model on sacroiliac joint stability. Journal of Electromyography and Kinesiology. 1998;8:205-214. [15] Pool-Goudzwaard AL, Hoek van Dijke GA, Gurp M van, Mulder P, Snijders CJ, Stoeckart R. Contribution of pelvic floor muscles to stiffness of the pelvic ring. Clinical Biomechanics. 2004;19:564-571. [16] Snijders CJ, Richardson CA, Pool-Goudzwaard AL, Hides JA. Low back pain in microgravity; causality and countermeasures. 15th IAA Humans in Space Symposium. 2005 May 22-26; Graz, Austria. [17] Molenbroek JFM, Kroon-Ramaekers YMT, Snijders CJ. Revision of the design of a standard for the dimension of school furniture. Ergonomics. 2003;46(7):681-694. [18] Jürgens HW, Aune IW, Pieper U. International Anthropometric Data FB587. International Labour Organisation; 1990. [19] Plante R. Inquiry among elderly on problems with toilet use. Intern report (in Dutch). Delft University of Technology, department ID of the Faculty of Industrial Design Engineering; 2002. This page intentionally left blank

Section 5 Design for Improved Toilet Environments

This page intentionally left blank A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People 217 J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-217 Designing for Older People’s Experience of Bathing

Stella U. BOESS1 Delft University of Technology – Faculty of Industrial Design Engineering – Section Applied Ergonomics and Design, Delft, The Netherlands

Abstract. Design work was done for the interior of an assisted bathroom in a sheltered housing complex for older people in England. The study included initial research with potential users, the design work and an evaluation of the design outcomes with actual users. An analysis is presented of the extent to which the outcomes of the design work contributed to the enhancement of well-being of users. Conclusions are drawn on a useful approach to the design of assistive environments. Firstly, an integrative perspective should be adopted that considers various stakeholder needs and integrates them in a desirable overall impression. Secondly, designers should regard assistive technology from the users’ perspective, including a critical view on it. And thirdly, designers should take what can be observed from users as a point of departure, and then project their own ideas of what is desirable over that situation, towards proposals that go beyond what already exists.

Keywords. Design Process, Assistive Environments, Well-Being, Design Evaluation

1. Introduction

This chapter analyses to what extent the outcomes of a design project contributed to the enhancement of well-being of users. Design work was done for the interior of an assisted bathroom in a sheltered housing complex for older people in England. The design process included initial research with potential users, the design work and an evaluation of the design outcomes with actual users. Some insights from an evaluation of this design project are presented here. Three aspects of the design process were identified that influenced the success of design outcomes for users. It is suggested that these three aspects, Integration, Proximity and Projection, should be taken into account in a design project that aims to enhance the well-being of users. There are parallels between the design case featured in this chapter and the design of accessible toilet environments that is the focus of this book. Both are situated in a semi-public area, involve personal cleansing functionality and are frequented by people who benefit from its assistive functionalities. The reflections on the design process might therefore be transferable. The analysis provides points of departure for further research into design approaches that seek to enhance users’ well-being.

1 Contact Information: Stella Boess, Faculty of Industrial Design Engineering, Delft University of Technology; Address: Landbergstraat 15, 2628 CE Delft, The Netherlands; Email: [email protected] 218 S.U. Boess / Designing for Older People’s Experience of Bathing

2. Issues in Users’ Experience of Assistive Functionalities

Connell and Sanford [1], in discussing disability generally, raised the issue that specialised provision was a “potential instrument of the stigma and stereotyping experienced by people with disabilities”. Mullick [2] set up experimental test situations of bathrooms and demonstrated empirically that people felt more disabled in an environment adapted specifically for disability, than in a conventional one. Sociological studies (e.g. [3]) highlighted the fact that assistive devices are often disliked and underused by older people in their daily lives. The devices are mostly provided through the mediation of medical professionals. Outlets are discreetly tucked away, because ownership and use of such products is perceived to be stigmatising their user. These sources point to issues of stigmatisation and ‘disablement’ that can arise from assistive technology.

2.1. Theoretical Aspects of Experience Issues

An important influence on how successfully people interact with their environment is the physical and physiological fit between one and the other. It is termed ‘environmental press’ [4,5] and should be researched contextually and experimentally. The environment as perceived by a person plays a role as well. From a phenomenological perspective, this was termed the ‘persuasiveness of things’, paraphrasing a concept developed by Heidegger [6]. Similarly, people’s well-being in relation to environments can be assessed by eliciting their own judgement on their situation. Mayer and Baltes [7] state that subjective assessment of well-being and objectively ‘measurable’ living conditions do not necessarily correlate, because of internal compensation processes on the part of individuals. Financial security, health and participation (family and friends) were named as more important than a good house by respondents in their study. However, Mayer and Baltes argue that the living situation does influence all that, although it is not quite clear in which areas and to what extent. Goffman’s theory of stigma [8] looks at ‘spoilt identity’ of individuals through symbolic meanings which might be attached to environment or behaviour, leading to cultural unacceptability. An individual affected by such unacceptability experiences feelings of guilt and shame. This, too, should be researched through eliciting people’s statements on their situation and other investigations of the symbolic meanings present in their environments. These notions point to two aspects that are important for the successful design of assistive functionalities:

The elicitation of potential users’ own statements on their situation in relation to their environment. Research on existing and potential assistive environments, investigating their symbolic meanings.

Besides these theoretical notions, there are precedent approaches to the design of assistive functionalities. A design project can profit from insights in them. Some precedents are looked at in the following section. S.U. Boess / Designing for Older People’s Experience of Bathing 219

3. Design Approach Precedents

3.1. Public and General Provision

Since the 1960s, architects and planners have addressed the problems of disability and access by establishing criteria for supportive housing, and especially for bathrooms [9, 10], and designing in accordance with them. Goldsmith [11] tells the story of the disability movement’s struggle in the UK and the US for access to public amenities, seeking to overcome their marginalisation in society. The movement succeeded in getting equal access legislation introduced (e.g. ADAAG [12]). By now, many types of equipment have been developed in industry in accordance with such guidelines, to assist disabled and/or older people in their daily lives. Recommendations and guidelines are being developed for the purpose of guaranteeing equal access, and their (ever-evolving) contents are ideally something of a ‘bottom line’ for consumer products as well as public access provisions.

3.2. Changes in Consumption Culture

The demographic change of recent years has also resulted in the emergence of initiatives that focus on access for and cultural integration of older people. These initiatives tend to focus on a change in consumption culture. Initiatives like DesignAge (founded in 1991) at the Royal College of Art in London raised the issue that older people are a target market waiting to be discovered, and stimulated designers’ interest in designing products for older people [13]. Such a change towards a more positive view is now becoming noticeable in Western societies. Manufacturers are discovering the ‘Third Agers’ [14], and this has created a shift in design and marketing towards more inclusivity, as well as increased demand for research into their lifestyles and preferences. Recent research on the topic of bathrooms therefore differs from traditional research on disability provisions by focusing on the preferences (e.g. [15]) and experiences of older consumers (e.g. [16,17]), rather than mainly on technical adaptations to compensate disabilities. Some findings and conclusions from a study by Boess et al [17] are reported next. The study reflects on those aspects of a design process that contributed to the enhancement of well-being for users.

4. The Design Project

A design project was carried out at Staffordshire University, UK, by the author and another designer researcher, and in collaboration with a sheltered housing provider. The sheltered housing provider sought design recommendations for the individual bathrooms of their residents and design proposals for an ‘assisted bathroom’. This type of room exists in most older people’s residences in the UK. The main purpose of an assisted bathroom is for carers to assist people in bathing who cannot do so in their own flats. Before any design work was started, the prospective users’ needs were researched:

220 S.U. Boess / Designing for Older People’s Experience of Bathing

Figure 1. Focus group session with Figure 2. An interactively usable scale model moodboard making

Figure 3. Three of the moodboards made by participants

Figure 4. The bathrooms of some of the interview participants

An initial qualitative study to research user needs and wishes comprised focus group interviews (Figure 1) which included participants making moodboards of their ideal bathroom (Figure 3), individual interviews and photographic documentation of participants’ homes, with in total 24 participants between 60 S.U. Boess / Designing for Older People’s Experience of Bathing 221

and 90 years of age (Figure 4). They were residents of various sheltered residences in England. The staff’s needs were researched through visiting existing assisted bathrooms, interviewing staff, and through interactive use of a scale model of the proposed design in discussions with the management of the older people’s residence (Figure 2).

Research methods and activities have been reported elsewhere [18,19]. The analysis of the initial research resulted in a model describing participants’ efforts to realise their needs and wishes by negotiating their well-being through physical, perceptual or projective interactions with their environment. The conclusions of the initial research were that the design of bathroom facilities for older sheltered housing residents should:

Answer cultural needs (“I’m not into putting on the style, not at my age, but I would like a nice peach bathroom and peach curtains […] and […] a few flowers in the window…”) Realise usability: adaptability in use and low physical demands on the user; unobtrusive safety (“Grab bars [are for] them, the disabled”.) But also: (“Getting in and out, it’s difficult, you know”.) Provide for an overall relaxing atmosphere (“I love a good soak. Get the Radox going ...”)

The research outcomes were applied in design work on the assisted bathroom of a newly built sheltered residence. In this sheltered housing residence, the assisted bathroom was situated in a semi-public central area of the building complex, and integrated with the sports facilities. The design interventions that were based on the research, and which were implemented in addition to the standard elements of an assisted bathroom (bathtub with seat, toilet with grab bars, wash basin), are shown in Figure 5. The author carried out a qualitative evaluation of the design work after the assisted bathroom had been in use for a year. Traces of use of the assisted bathroom were noted. For example, it was observed how objects in the room had been changed or not changed, how storage and decoration ledges were being used, and what objects had been placed in the room. Furthermore, short interviews with five residents, two carers and a longer interview with the manager of the residence were conducted. Methodological aspects of the evaluation have been explained elsewhere [20]. The evaluation resulted in an assessment of the successes and failures of the design intervention, on the basis of observations and emerging narratives. These were also used to look again critically at the initial study findings and design approach. This assessment led to the identification of three themes that influence to what extent a design process produces outcomes that enhance the well-being of users, by supporting them in their physical and physiological interactions with their environment, and by contributing to their ability to establish or re-establish an intact identity as individuals. The three themes are described in the following. 222 S.U. Boess / Designing for Older People’s Experience of Bathing

Figure 5. Schematic of the design interventions

5. Outcomes of Reflection on the Project: the Three Themes of Integration, Proximity and Projection

5.1. Integration

‘Integration’ means that a design approach needs to arrive at a central theme that corresponds to users’ experience of their environments, under which various disparate elements must be integrated. Users of the assisted bathroom liked the overall design. But they also pinpointed some shortcomings. For example, grab bars had been selected which were the standard choice to comply with the functional requirements for an assistive room of this kind. Users of the room found that the combination of design aspects which carried contrasting associations for them, disability versus homely bathing, detracted from the overall quality of their experience of using the room. The grab bars should have been integrated better with an overall impression suggesting homely bathing (Figure 6). Furthermore, a design process needs to investigate a design problem from the perspective of all stakeholders involved, even if the needs of one particular group are the focus of the design. The research had focused primarily on one group of users: the S.U. Boess / Designing for Older People’s Experience of Bathing 223

Figure 6. Standard grab bars and cleaning equipment versus a ‘homely’ bathroom feel.

senior residents who would bath in the room. The staff’s needs had been researched through interviewing and interactive use of a scale model as mentioned above, but not to a sufficient extent, as it turned out. It would have been necessary to also observe and follow actual activities. There was not enough space for the storage of cleaning equipment in the room (Figure 6). It ended up being left out in the open, which was perceived as a problem by users. The staff’s needs would have had to be researched better to also serve the senior users better. The needs of various kinds of user have to be integrated. Summarizing, a design process should deliver an integration of sometimes disparate elements towards one desired overall impression. It should involve an encompassing assessment of the stakeholder issues involved by looking at the design problem from several perspectives, and then integrating them towards one main goal.

5.2. Proximity

‘Proximity’ means that a design approach needs to be sympathetic to users’ experience of their environment. For example, a bench had been custom-designed for the assisted 224 S.U. Boess / Designing for Older People’s Experience of Bathing bathroom so that users could sit on it to undress (Figure 7). A custom-designed grab bar that had been planned to go next to it, had been dropped from the planning process. That meant it was not easy to get up from the bench. An extra chair of a kind that had been popular with participants of the initial research (it was represented in an image as part of the visual tool), was brought in later (Figure 7). The relatively cheap rattan chair had integrated arm rests which were found to be conveniently usable as supports. In the research, it had been found that participants were very resilient, compensating reduced physical fitness in coping with environmental demands. They asserted their individual preferences and sometimes rejected institutional or technological solutions, instead preferring informal and ad-hoc solutions. Designers should develop a sympathetic proximity to users’ experience of their environment. Through user research, designers can learn to view technology from the users’ perspective and examine its benefits critically. Technology can alleviate ‘environmental press’ but it can also, and this should not be overlooked by an overly optimistic designer’s view, cause people to get stuck in situations beyond their own ability to cope.

Figure 7. Custom-designed bench with rattan chair in front of it

5.3. Projection

‘Projection’ means that a design approach needs to realise that an observed status quo may bear little resemblance to a situation that would be desirable to users. Designers should take as a point of departure their observations and users’ statements on what enhances well-being. Then, designers should connect that to their own specially developed expertise of desirable aesthetics of environments. That way, ideas can be taken much further than the status quo. For example, while some participants of our initial study had said “I’m happy [with my disabled shower]”, some also said things like “this isn’t home”, “I’m ashamed of my bathroom”, “So we’re stuck again”. Some of the very environments which, presumably, had been specially geared towards answering residents’ needs and wishes, were apparently perceived by them as oppressive or limiting. Participants did not want “design for old”. How could a designer distinguish between ‘being the problem’ and S.U. Boess / Designing for Older People’s Experience of Bathing 225

‘being subjected to a problem’? How or how much are the things that surround users intrinsic to their lives, and how much are they just being attributed to them while looking on from an outsider perspective? In the case of this research, participants felt that a desirable bathroom environment would have a feel of fresh air and homeliness, would allow for them to realise personal care privately and possibly with informal help (friend or relative rather than carer), would provide them with readily available low-tech tools, and would be flexibly adaptable to the flow of their varying (rather than invariably declining) physical fitness. From wishes such as these, the following idea themes were generated for a better, even more user-oriented design of an assistive bathroom environment:

Home/Wellness. Aesthetic home- or wellness associations and functionalities. Such associations should be aesthetic guiding motives for design, with assistive functionality integrated into these notions. Soft tools. Functions in the room could be seen in terms of tools that can easily be manipulated and moved around, that are pleasing to the hand and that have an easy-access place where they ‘live’. Items might be grouped as ‘toolboxes’. Nature. The ability to stay connected with the time of day, with the weather, and the season of the year is desirable. Fold-up. Physical objects as well as forms of organization should be geared towards adaptability to use at a particular time, in a particular place, by a particular person, but not present an obstacle, e. g. through physical volume and weight, in carrying out other tasks. Walk-in. An ‘open space’ that can be furnished with appropriate functionality. Possibly also seating functionality set into a wall with water drain in the floor, to provide for walk-in semi-bathing.

6. Conclusions

This chapter has presented a set of guidelines for a design approach. These are based on the evaluation of a design project that was concerned with an assisted bathroom for older people in a sheltered housing residence in England. A design approach that seeks to produce outcomes that can enhance well-being of users, should; adopt an integrative perspective of various stakeholder needs and activities towards a specific chosen desirable overall impression, establish a sympathetic proximity to the ways people interact with their environments, learn to view technology from the users’ perspective and examine its benefits critically, take what can be observed and heard from users as a point of departure, and then project the designer’s own ideas of what is desirable over that situation, towards proposals that go beyond what already exists.

Recent reflections on design approaches posed challenges to the ways design is often carried out in practice. One of those challenges is that the distance between designers and users should be reduced, in order to prevent designers from considering their own experience sufficiently representative of users’ experience [21]. New approaches should be more collaborative [22]. Another challenge addresses the notion that a 226 S.U. Boess / Designing for Older People’s Experience of Bathing designer is a neutral entity, quasi-mysteriously producing designs that benefit others. Schön argued that to serve a user well, a design had to satisfy a designer and user alike [23]. This study sought to identify three characteristics of a design approach that can address these challenges. Further research needs to be done on design situations and how the three themes affect them positively. It should focus on how outcomes are produced that enhance users’ well-being.

Acknowledgements

Thanks to David Durling, Cherie Lebbon and Christopher Maggs for their much valued support and guidance as supervisors of my PhD study. They have been instrumental in helping me shape the ideas presented in this chapter. Thanks also to the DAAD (Deutscher Akademischer Austauschdienst), Germany, and to Staffordshire University, UK for each funding part of my PhD work on which the chapter is based.

References

[1] Connell B, Sanford JA. Research Implications of Universal Design [page 36]. In: Steinfeld E, Danford G Scott, editors. Enabling Environments: Measuring the Impact of Environment on Disability and Rehabilitation. New York: Kluwer; 1999. Chapter 2; p.35-55. [2] Mullick A. 1999. Bathing For Older People With Disabilities. The Idea Center at State University of New York at Buffalo [Internet]. 1999 [cited 2002 Mar 17]. Available from: http://www.ap.buffalo.edu/~idea/publications/free_pubs/pubs_bathing.html. [3] Mollenkopf H. Technical aids in old age. In: Report of the Arbeitsgruppe Sozialberichterstattung. Berlin, Germany: Wissenschaftszentrum Berlin für Sozialforschung; 1993, p. 96-103. [4] Lawton MP. Competence, environmental press, and the adaption of older people. In: Lawton MP, Windley PG, Byerts TO, editors. Gerontological Monograph No. 7 of the Gerontological Society. Aging and the Environment: Theoretical Approaches. New York: Springer; 1982. [5] Steinfeld E, Danford G Scott, editors. Enabling Environments: Measuring the Impact of Environment on Disability and Rehabilitation. New York: Kluwer; 1999. [6] Verbeek P, Kockelkoren P. The Things That Matter. Design Issues. 1998;14(3):28-42. [7] Mayer KU, Baltes PB, editors. Die Berliner Altersstudie (The Berlin Study of Ageing) [pages 518 and 540]. Berlin: Akademie Verlag; 1996. [8] Goffman E. Stigma: Notes on the Management of Spoiled Identity. Prentice-Hall; 1963. [9] Goldsmith S. Designing for the disabled. 3rd ed. London: RIBA; 1976. [10] Kira A. The bathroom. New York: Viking Press; 1976. [11] Goldsmith S. Designing for the Disabled, The New Paradigm. Oxford: Butterworth-Heinemann; 1997. [12] U.S. Architectural and Transportation Barriers Compliance Board. ADAAG. Americans With Disabilities Act Accessibility Guidelines , Checklist for Buildings and Facilities. Washington, D.C.: U.S. Architectural and Transportation Barriers Compliance Board; 1991. [13] Coleman R, editor. Working Together: A New Approach to Design. London: Royal College of Art; 1997. [14] Laslett P. A fresh map of life: The emergence of the Third Age. London: Weidenfeld; 1989. [15] Berlo A van. Ontwerp van veilige en comfortabele badkamerprodukten voor alle leeftijden. (Designing safe and comfortable bathing products for all ages). Eindhoven: Centrum Techniek Ouderen; 1996. [16] Mullick A. 1999 (ibid.) [17] Boess S, Lebbon C. Wellbathing, a study for design. In: Placencia Porrero I, Ballabio E, editors. Improving the Quality of Life for the European Citizen. Proceedings of TIDE (Technology for Inclusive Design and Equality). 1998 Jun 23-25; Helsinki, Finland. Amsterdam: IOS Press; 1998. [18] Boess S. An Indian who doesn’t know how to grow the maize. Reflecting on a designer’s experience of user-centred designing [Unpublished Doctoral Thesis]. UK: Staffordshire University; 2002. [19] Boess S, Durling D, Lebbon C, Maggs C. Participative Image-based Research as a Basis for New Product Development. In: Green WS, Jordan PW, editors. Pleasure with Products: Beyond Usability. London: Taylor and Francis; 2000. Chapter 17; p.231-246. S.U. Boess / Designing for Older People’s Experience of Bathing 227

[20] Boess S. An Indian who doesn’t know how to grow the maize. In: Durling D, Shackleton J, editors. Common Ground. Proceedings of the International Design Research Society conference. 2002 Sep 5-7; Brunel University, UK. Stoke on Trent, UK: Staffordshire University Press; 2002. [21] Margolin V. The Product Milieu and Social Action. In: Buchanan R, Margolin V, editors. Discovering Design: Explorations in Design Studies. Chicago and London: The University of Chicago Press; 1995. p. 121-145. [22] Scrivener S, Ball L, Woodcock A, editors. Collaborative Design. Proceedings of the Co-Designing conference. 2000 Sep 11-13; Coventry, UK. London: Springer; 2000 [23] Bennett J. Reflective Conversation with Materials, an interview with Donald Schön. In: Winograd T. Bringing Design to Software [Internet]. Addison-Wesley; 1996 [cited 2002 Feb 21]. Available from: http://hci.stanford.edu/bds/9-schon.html 228 A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-228 Anthropometrical Aspects of a Friendly Rest Room

Johan F.M. MOLENBROEKa,1 and Renate DE BRUINa,b a Section Applied Ergonomics and Design – Faculty of Industrial Design Engineering – Delft University of Technology, Delft, The Netherlands b Erin Ergonomics and Industrial Design, Nijmegen, The Netherlands

Abstract. To give an impression of the aspects involved in the study of body spaces in toilet environment. There are only a few anthropometrical sources about elderly and disabled people. For the purpose of toilet environment this is even rarer. First a new measurement study was prepared within the consortium to fill the gap. But after reconsideration of the time, budget and available human resources the plan was changed in using existing resources in close relation with observational studies. The data from the Geron-project (1993-1998) in Delft have mainly been used as a basic source of raw data. This seemed very relevant for this project and as a next step this knowledge was completed with the quantified usage studies done within the FRR-project in the laboratory at TU Delft but also at a selection of sheltered homes in the Netherlands. To set up an anthropometric study within a consortium of partners in different countries seems only possible if the main goal of the budget is to study anthropometry like in the Caesar-project. If as in this FRR-project anthropometry is only one of the aspects -though an important aspect-within the product development project, then it is better to integrate existing raw data with the results of observational research continuously during the development process.

Keywords. Anthropometry, Toilet Environment, Elderly, Disabled

1. Introduction

Product developers are becoming more and more aware of the importance of applying knowledge about the human body dimensions so called ‘anthropometrics’ in the early stages of design, in order to make their products better fit to the sizes of their customers. In some products the differences between people, with regards to their body dimensions as well as the behaviour that results from it, have unavoidably been recognized from the beginnings on. For instance in bicycle design; you can buy different sizes for every age, length and even the differences between the sexes are incorporated. In the period 1920-1950 when the popularity of bicycles as a means of personal transport was at its height, women in general wore dresses or skirts [1,2,3]. The bridge in between the saddle and the steering therefore was very hinder some and another construction was made to provide stability without obstructing any dresses and

1 Corresponding Author: Johan Molenbroek, Faculty of Industrial Design Engineering, Delft University of Technology; Address: Landbergstraat 15, 2628 CE Delft; Email: [email protected] J.F.M. Molenbroek and R. de Bruin / Anthropometrical Aspects of a Friendly Rest Room 229 skirt-clothing (however this not being the optimal solution; anyone who has ever tried knows about the many other problems with skirt-driving, like getting the fabric stuck in between the pedals or chain, blowing skirts and crawling skirts that go beyond the area one wants to expose in public). Even now one refers to the bike without bridge to as a ‘female-bicycle’ even though trousers are worn by women just as commonly now. In other products there seems to be hardly any developments with regards to applying anthropometrical knowledge, ever since the first designs were brought on the market. A typical example - and topic of this paper - is our modern water closet. It has stayed with its purely functional design up until now, without taking into account the variations between people. It seems rather strange that a product that is used several times a day and clearly will benefit from fitting to the customer’s body dimensions and behaviour is not available in more variations on the market (see Figure 1). In this particular case the reason probably can be found in the nature of the product; it is attached to the sewer system, which makes a quick change rather cumbersome. The subject of toileting also being a taboo to talk about in public might not help the developments either.

Figure 1. Available variations of toilet bowls in the local D-I-Y store

A first start to change something in toilet design was made though in the EU- funded Friendly Rest Room project. The goal of the project was to come up with a design for the toilet environment and the components in it (toilet bowl, water basin, support bars) that would better fit to the needs of physically more challenged individuals, like elderly and disabled, through taking into account the anthropometrics and behaviour variations in this user group and to combine this knowledge with a ‘smart’ content using the possibilities of building automation. A part of the FRR project consequently entailed finding and applying the right anthropometric data. In general there can be several reasons why anthropometric data are not being used or used properly in the development of the consumer products:

230 J.F.M. Molenbroek and R. de Bruin / Anthropometrical Aspects of a Friendly Rest Room

Lack of data on the specific type of users or specific dimension (e.g. nationality of the data sample or specific body dimensions of which there are no records) Representation of the data is incomplete or leads to reading errors (e.g. tables that only show the P5 and P95 values, while the P1 and P99 values are needed) Invalid data (e.g. errors made when measuring, using incorrect or unrepresentative data or when using a small sample size) Lack of knowledge to apply the data correctly e.g. in design-teams (e.g. when knowledge level with regards to the human anatomy and/or statistics is not sufficient)

The importance of implementing anthropometrics in product design and the product development process is recognized since long in the curriculum of Industrial Design Engineering at the Delft University of Technology and students are early on taught about it (see also www.dined.nl). Still in practice not all product developers are trained that well in applying anthropometrics2. In this paper the Friendly Rest Room project will be used as an example of how anthropometrics were implemented in a practical design problem and the limitations that were faced.

2. Anthropometric Data Resources

In order to design a better fitting toilet for elderly and disabled designers need to know in detail about the specific body dimensions of this group, their dynamic behaviour and preferences that are originating from their capabilities and incapabilities. Thus extensive anthropometric and ergonomic data is needed. In the last 40 years several studies have been carried out and published with regards to the anthropometry of elderly and disabled. Only some of these studies present real databases on empirical measurements, for example Damon and Stoudt [4], Hobson [5], Wright et al. [6], DIN 33402 [7], Molenbroek [8] and Steenbekkers [9]. Others present overviews, discuss or make estimations for other –unmeasured- variables like Diffrient [10], Kelly and Kroemer [11] and Pheasant [12]. Recently the World Engineering Anthropometry Resource (WEAR) group launched a web-portal to foresee product designers and developers in an overview of anthropometric data sources and an indication of their quality and application domain [13a]. Brown e.a. [13b] and Rogers e.a. [14] conclude that there is a serious lack of data for elderly and disabled that is appropriate for use by designers, particularly dynamic data. Referring to the objectives of the FRR project and the earlier mentioned obstacles in using anthropometric data in the consumer product development, we can conclude that typically ‘lack of data on the specific type of users and specific dimensions’ is at stake. In general there are not many anthropometric data resources with regards to the population of elderly and disabled. The data resources that are available do not contain

2 The research program Dynamic Anthropometrics of the section Applied Ergonomics and Design at Faculty Industrial Design Engineering, Delft University of Technology is in the process to develop an ergonomics information system (called EIS) for designers and investigators, which compensates their knowledge in the field of anatomy and statistics, but also compensates their knowledge in the anthropometric design process [15, 16, 17, 18]. J.F.M. Molenbroek and R. de Bruin / Anthropometrical Aspects of a Friendly Rest Room 231 much data on dynamic anthropometry measures (like dynamic patterns for support during sitting/rising), let alone specific data on user behaviour around the very sensitive topic of toileting e.g. with regards to cleansing and backward reach.

3. Methods

To solve the lack of appropriate anthropometrical data several methods have been used in the FRR project. We will discuss these methods following the flowchart of the anthropometrical design process in Figure 2.

3.1. Design Process

The flowchart of the anthropometric design process starts with the need for a new design that solves a certain design problem. In the FRR project the objectives were ‘to carry out the necessary research and design, the engineering and evaluation of prototypes for a more user friendly rest room for elderly and persons with disabilities’. The general design problem was consequently defined as: ‘The elements of the FRR should be able to adjust to the individual needs of older persons with functional limitations or disabilities, allowing them to gain greater autonomy, independence, self- esteem, dignity, safety, improved self-care and therefore enable them to enjoy a better quality of life.’ Research activities and design and development activities took place simultaneously in the project. The research results were translated into a set of design specifications gradually building up during the course of the project. Product ideas and design concepts were developed based on these growing design specifications. Several successive FRR prototype generations were tested at 5 European test sites, the so called User Research Bases (URBs). In these URBs the FRR prototypes or parts of the prototypes were tested by in total more than 230 test persons from the target group elderly and disabled. It was set at the beginning of the project that it would not be feasible to come up with a fully market ready prototype of a Friendly Rest Room within the project’s boundaries of time and budget. The final design therefore is equivalent to the last generation test prototypes. Findings of the user tests would serve as a basis for further developments of user friendly rest room products and disseminated as such.

3.2. Static Anthropometry: Defining the Target Group

The target group of the FRR consists of elderly and people with disabilities. Though differences in behaviour and preferences are without doubt to be expected, no specific differentiation was made in gender; men and women were equally subject of study. With regards to ethnicity and type of disability initially no distinction was made either. 232 J.F.M. Molenbroek and R. de Bruin / Anthropometrical Aspects of a Friendly Rest Room

Figure 2. Flowchart of the anthropometric design process J.F.M. Molenbroek and R. de Bruin / Anthropometrical Aspects of a Friendly Rest Room 233

This resulted in a fairly large and inhomogeneous target group, which made designing a rest room that would fit every individual in this target group a very difficult task, but also would simply be a too elaborate job for this project. As a compromise it was proposed to design for typological sample groups, categorised according to their limitation (see table 1), and let representatives of these groups test the successive FRR prototypes. Our ideal sample would have had an equal part of all the disabilities to be expected in the population of elderly and disabled and should have covered the extreme anthropometric values on the relevant design-variables. Yet the typological samples according to limitation made the designers really focus on the limitations that resulted from the disability, rather than focusing on a specific type of disease or disability. In this way it was easier for them to depict the effect of their design decisions; whom they had not accounted (enough) for or even made things more difficult for. The minimum number of test persons per homogenous group was set on 5, based on the studies by Kanis[19,20]. In these studies it was found that, when testing for use problems in consumer goods, the majority of problems are in many cases found by the first 5 test persons and that the 6th and further test persons do not essentially contribute after this to the already found list of problems.

Table 1. Typological sample groups according to limitation

Categories by limitation Number of test persons Male Female 1 Limitation of walking n = 5 n = 5 2 Limitation of sitting / rising (dynamic) n = 5 n = 5 3 Limitation of sitting / standing (static) n = 5 n = 5 4 Limitation in use of arms or hands n = 5 n = 5 5 Limitation in movement resulting from a n = 5 n = 5 disorder in balance 6 Limitation in the senses (vision, hearing, n = 5 n = 5 smell, touch) 7 Limitation in movement of the torso n = 5 n = 5 8 Limitation in the mind / memory n = 5 n = 5 Total n = 40 n = 40

In practice the successive prototypes were eventually tested by 230 test persons in total. The test person selection however had not been done following the structure from table 1, but was done according to the availability of test persons at the different test locations (URBs). Each URB focused on the typological sample groups they were in practice most close to, e.g. through former studies, experience or contacts. URB Lund therefore mainly tested limitation in vision and limitation of walking. URB Vienna gathered their test persons through the MS Society, and therefore tested limitations of walking, sitting/rising and use of arms or hands. URB Athens tested with both elderly 234 J.F.M. Molenbroek and R. de Bruin / Anthropometrical Aspects of a Friendly Rest Room and disabled and therefore did not focus specifically on certain limitations, but more or less covered them all. Cultural coverage and differences in ethnicity were covered as well, because every URB gathered their test persons geographically not far from their test location, which consequently resulted in a Swedish, Austrian and Greek sample.

3.3. Dynamic Anthropometry: Defining User Behaviour in order to Find the Relevant Variables

The next step in the anthropometric design process is to analyse the context of use. Goal of this analysis is to determine which anthropometric variables are relevant to the design. The analysis entails studying posture, movements and the sequence of movements. In toilet design one wants to know for instance about toilet rituals and the manual handling that has to be done. Especially in elderly individuals who have balance problems it turned out that the turning movements near the toilet, undressing/dressing and sitting/standing are experienced as cumbersome[21,22]. In order to find out more about the context of use in elderly and disabled – around this very sensitive topic of toileting – several explorative studies were performed. In these studies also the influences of socio-cultural differences, the use and handling of artefacts in the toilet area (clothing, tools, equipment) and the influence of the physical environment on the context of use were studied. First a visit to a home for elderly was made to explore the settings of the toilet facilities offered here and the common problems that were experiences, both by staff as elderly habitants themselves (see Figure 3). Addressing the problem elderly people have with the fixed height of standard Dutch toilets, next an explorative study into toilet heights and toilet raisers was performed [21]. In this study 15 elderly were interviewed about their toilet facility and a video was made of how they moved from their living area to their toilet area and sat/rose from their toilet (clothing on, see Figure 4). The results from these explorative studies showed that as one gets older more problems are experienced with sitting/rising from the toilet, with cleansing of body parts and the lack of proper (non-stigmatising) support for these activities. In order to find more about the exact needs for support during sitting/rising from the toilet and cleansing, a more controlled laboratory study was performed with 9 healthy elderly women and 6 healthy elderly man (see Figure 5) [23, 24]. Additionally a master thesis study [25] was performed on reducing the fall risks for elderly in the restroom and an innovative design for non-stigmatising toilet support bars was made [26, 27]. The results of both studies are described more elaborately in this volume as well [28, 29].

J.F.M. Molenbroek and R. de Bruin / Anthropometrical Aspects of a Friendly Rest Room 235

Figure 3. Visiting a sheltered home for elderly (Ede, NL)

Figure 4. Visiting elderly in their homes (Delft, NL)

236 J.F.M. Molenbroek and R. de Bruin / Anthropometrical Aspects of a Friendly Rest Room

Figure 5. Laboratory test environment to determine the location for support around the toilet (Delft, NL)

3.4. Anthropometric Measurements and Anthropometric Resources

After defining the target group and having analysed the context of use now a list of anthropometric variables relevant to the design of a toilet for elderly and disabled was available. Next step was to decide how to translate this list in a set of exact design specifications. These design specifications should enable all intended users of the toilet to use it effectively and efficiently, and not be limited by their size. The question was whether to perform the necessary anthropometrical measurements ourselves, or to look for appropriate anthropometrical data resources? In the FRR project it was decided to use an already available and fairly recent large anthropometrical data set on Dutch elderly (GDVV, measured in 1982 and Delft GERON-project, measured in 1993-1998) [8,9,30] and retrieve any other unknown data by measuring small user groups. In this way -amongst others- the difference between elderly from Greece and Sweden in comparison to Dutch elderly was retrieved, which resulted in a lowering of the minimum of the height adjustability. For measuring the small groups of elderly and disabled in the URBs, an anthropometrical measurement protocol was written and measurement chairs were built (see Figure 6 and 7).

Figure 6. Detail of the anthropometrical measurement protocol used in the FRR project J.F.M. Molenbroek and R. de Bruin / Anthropometrical Aspects of a Friendly Rest Room 237

Figure 7. Two anthropometrics measurement chairs

Table 2. Six relevant anthropometric dimensions for using a toilet (data from Molenbroek [8])

P1 P99 User variables Additional variables Product variables (mm) (mm) 429 583 Buttock-popliteal depth - Ca.50 mm (for rising from Toilet seat depth toilet seat) 344 516 Popliteal height + Heel height (for public Toilet seat height (adjustability use) range) - Thickness toilet seat 316 454 Hip breadth Toilet seat width Distance between horizontal support bars (adjustability range) 177 299 Elbow height bended Height horizontal support bars while seated (adjustability range) 690 1010 Reach depth envelope Forward reach distance vertical measured from back to support grip Location handles vertical support 40kg 120kg Body weight in kg Strength of toilet and support construction Thickness toilet seat 238 J.F.M. Molenbroek and R. de Bruin / Anthropometrical Aspects of a Friendly Rest Room

3.5. Anthropometric Estimations

The anthropometric data set on Dutch elderly that was used in the FRR project was used to determine the needed dimensions of the new toilet design. A transformation table was used to estimate the design specifications from the sitting measurements presented in this dataset (see table 2). A similar table was used in a former study of Molenbroek to determine the right dimensions of a wheelchair design [31].

3.6. Allowances

In any other product normally it is necessary to add allowances for clothing and shoes. In toilet design the influence of clothing is obviously not direct, since one uses the toilet bare skinned, but there is an indirect influence though. Particularly in the (semi-) public toilet environment one does not want the undressed clothing to fall onto (filthy) floors, which results in all kinds of strategic cloth handling positions, while performing the normal sitting/cleansing/rising activities. One can imagine that having to hold on to clothing limits the amount of comfortable body positions and can seriously lead to fall- risky situations. This problem is less serious in the ‘clean’ home environment, but still it is true that handling of cloths effects the way people act in the toilet area (see also Figure 8). Since in a home environment people use the toilet without their shoes on, but in (semi-)public environment they will definitely wear shoes, it was decided to design for both situations and adjust the range of height adjustability accordingly (see also table 2).

Figure 8. Balancing and handling of cloths during toilet use

3.7. Critical Values

Last but not least in the design process a decision has to be taken about the way the anthropometrics of the target group is dealt with. In other words, the choice for a certain type of anthropometric accommodation will result in critical values of product dimensioning. The following list will explain each type of accommodation and gives an example with regards to (current) toilet design solutions: J.F.M. Molenbroek and R. de Bruin / Anthropometrical Aspects of a Friendly Rest Room 239

Select users who fit the design; The standard height of a toilet bowl –fixed to the floor- is 40 cm. This height is based on the assumption that the general popliteal height is about this height. However there are many people for whom this height is too low, and others for whom it is too high. Even though most of these people can use the toilet nevertheless, it can be rather uncomfortable with folded legs, or even risk full when your feet are not touching the ground. In current toilet design you can conclude that nothing special is done to fit the product to its user; the user will simply have to fit or otherwise has to search for salvation elsewhere. Custom fit each individual; A so called ‘freely hanging’ toilet bowl can be positioned and installed according to your own personal needs. When in a family for instance, more than one individual is to use the toilet and his family members differ much in length for example, the problem is not solved unfortunately. Have several fixed sizes; In the market there are several types of toilet seat raisers. These extra high toilet seats can solve the problem that one family member needs a higher than standard toilet and the other family members do not. Toilet seat raisers are not an optimal solution though, because they often show problems with stability (or perception of stability) and hygienic issues (difficult to remove easily and clean). In addition to this they do not offer a solution to the individuals who are in need of a lower than standard toilet bowl. Make it adjustable; In the FRR project this solution was chosen for the final toilet design. The ‘freely hanging’ toilet bowl was adjustable in height and operated with a handheld control. Also a solution for the sitting/rising problems elderly face was offered, through the extra option of tilting the bowl. Design for the extreme individual: In the FRR project this solution was in fact chosen as well because the range of height adjustability of the toilet bowl was determined by the anthropometric of the smallest Greek test person and the tallest Dutch test person.

3.8. Design Guideline

The outcome of all the different phases in the anthropometric design process can finally be put into an anthropometric design guideline. In the FRR project this design guideline gradually was built up while going through the successive stages of prototype testing and user behaviour studies.

4. Results

The anthropometric design guideline was used on several moments within the design process. It was crucial to have short and frequent communication between the designers and the anthropometric specialist and the anthropometric knowledge transfer was especially important in the development of the following parts of the FRR:

The height and sizes of a patented door handle: it should be comfortable to be reached and gripped by elderly persons as well as wheelchair users. The shape, size and height of a wall mounted grab bar. 240 J.F.M. Molenbroek and R. de Bruin / Anthropometrical Aspects of a Friendly Rest Room

The range of the height and angle of the toilet bowl in- and excluding seat; it was discussed that the highest position, when sloped at maximum, also could be used as a urinal for men while standing. The size and the shape of the seat in close relation with the transfer-seat The range of the width and height of the horizontal and vertical grab bars. This described in more detail in the chapters from Dekker and Buzink [29]. The range in vertical and horizontal position of the wash basin. Also more elaborately described in Dekker and Buzink [29].

5. Conclusions

In the FRR project anthropometry has been tightly woven trough the design process and apart from a good communication between designers and researchers, it also requires the availability of a lot of data and -if not available- the ability to perform user studies with a small sample to find out which measurements are relevant. When no data exists on the relevant body dimensions, these will have to be measured in short time in an effective and efficient way. To set up an anthropometric study within a consortium of partners in different countries seems only possible if the main goal of the budget is to study anthropometry like for instance this is the case in the Caesar-project [32]. If as in this FRR-project anthropometry is only one of the many important aspects within a product development project, then it is often better to integrate existing raw data with the results of observational research continuously during the development process.

References

[1] IIAV, Internationaal Informatiecentrum en Archief voor de Vrouwenbeweging, 2007. Damesfietsers & emancipatie [online]. Damesfietsblog, The Netherlands. Available from: http://www.damesfietsblog.nl/damesfietsers-emancipatie [2] Mooncycle, Vrouwen met een passie voor fietsen, 2008. Techniek, Kies je type fiets, De juiste fiets [online]. Mooncycle, Belgium. Available from: http://home.versateladsl.be/vt6100788/fiets.html [3] Lesisz, R., 2004. Honderd jaar fietsen in Nederland 1850-1950. Over het begin van de fietscultuur. Thesis (PhD). University of Wrocław and Erasmus Leerstoel voor Nederlandse Filologie. [4] Damon, A and Stoudt, H.W., 1963. The functional anthropometry of old men. Human Factors, 5(10), 485-491. [5] Hobson, D.A. and Molenbroek, J.F.M., 1990. Anthropometry and design for the disabled-experiences with seating design for the cerebral-palsy population. Applied Ergonomics, 21(1), 43-54. [6] Wright, U., Govindaraju M. and Mital, A., 1997. Reach Profiles of Men and Women 65 to 89 years of age. Experimental Aging Research, 23 (4), 369-395. [7] Deutsches Institut für Normung, 1981. DIN 33402, Körpemasse des Menschen Beuth Verlag, Berlin. [8] Molenbroek, J.F.M., 1987. Anthropometry of elderly people in the Netherlands; research and applications. Applied Ergonomics, 18 (3), 187-199. [9] Steenbekkers, L.P.A. and Van Beijsterveldt, C.E.M., Eds., 1998. Design-relevant characteristics of ageing users; backgrounds and guidelines for product innovation, Series ageing and Ergonomics, Vol.1. Delft: Delft University Press. [10] Diffrient, N., Tilley, A.R., & Bardagjy, J.C., 1974). Humanscale 1/2/3. Part 3, Requirements for the handicapped and elderly. Cambridge, MA: The MIT Press. [11] Kelly, P.L. and Kroemer, K.H.E., 1990. Anthropometry of the elderly: status and recommendations. Human Factors, 32(5), 571-595. J.F.M. Molenbroek and R. de Bruin / Anthropometrical Aspects of a Friendly Rest Room 241

[12] Pheasant, S., 1996. Bodyspace: Anthropometry, Ergonomics and the Design of Work. London: Taylor & Francis Press. [13a] WEAR, World Anthropometry Engineering Resource [Internet] 2009 [cited 2010 Jul 1]. Available from: http://www.wearanthro.org [13b] Brown, R., Rogers, N., Ward, J., Wright, D. and Jeffries, G., 1995. The application of an anthropometric database of elderly and disabled people. Biomedical Sciences Instrumentation, 31, 235- 239. [14] Rogers N, Ward J, Brown R, Wright D. , 1996. Ergonomic data of elderly people and their application in rehabilitation design. Disability and Rehabilitation, 18(10), 487-496. [15] Huijboom, J.M., 1998. AIS, A tool to apply anthropometry to design. Thesis (MSc). Industrial Design Engineering, Delft University of Technology. [16] Molenbroek, J., Visser, R., 1997. Anthropometric Information System (AIS). Proceedings of the IEA 1997, P. Seppala, Finn.Inst.of Occup. Health, Helsinki, Finland, Volume 2, p. 76-78. [17] Visser, R., 1996. Anthropometric Information System (in Dutch). Thesis (MSc). Industrial Design Engineering, Delft University of Technology. [18] Stap, E.van der, 1995. Anthropometric Information System (in Dutch). Thesis (MSc). Industrial Design Engineering, Delft University of Technology. [19] Kanis, H. and Arisz, H.J., 2000. How many participants: a simple means for concurrent monitoring. In Proceedings of the XIVth triennial congress of the International Ergonomics Association and 44th annual meeting of the Human Factors and Ergonomics Society. Santa Monica CA (USA): Human Factors and Ergonomics Society, pp. 6-637-6-640. [20] Arisz, H.J., Kanis, H., and Rooden, M.J., 2000. How many participants: a simple statistic with some limitations. In: P.T. Mccabe, M.A. Hanson, & S.A. Robertson, Eds., Contemporary ergonomics 2000 London (UK): Taylor & Francis, 229-233. [21] Plante R., 2002. Inquiry among elderly on problems with toilet use. Intern report (in Dutch). Delft University of Technology, Faculty of Industrial Design Engineering. [22] Buzink, S.N., Molenbroek, J.F.M., Haagsman, E.M., & Bruin, R. de., 2005. Falls in the toilet environment: a study on influential factors. Gerontechnology, 4(1), 15-26. [23] Dekker, D., Buzink, S.N., Molenbroek, J.F.M. and Bruin, R. de, 2007. Hand supports to assist toilet use among the elderly. Applied Ergonomics, 38 (1), 109-118 [24] Buzink, S.N.,Dekker, D.,Bruin, R. de, and Molenbroek, J.F.M., 2006. Methods of personal hygiene utilized during perineal cleansing: acceptance, postures and preferences in elderly Dutch citizens. Tijdschrift voor Ergonomie, 31(3), 36-44. [25] Buzink, S.N., 2004. De ontwikkeling van een product ter preventie van valongevallen in toiletruimten (in Dutch). Thesis (MSc). Industrial Design Engineering, Delft University of Technology. [26] Buzink, S.N.,Molenbroek, J.F.M., Bruin, R. de, Haagsman, E.M., and Groothuizen, T., 2006. Prevention of falls in the toilet environment. In: R.N. Pikaar, E.A.P. Koningsveld, and P.J.M. Settels, eds., Proceedings IEA2006, Meeting Diversity in Ergonomics. Amsterdam: Elsevier, 4585-4591. [27] Buzink, S.N., Molenbroek, J.F.M., Haagsman, E.M., Bruin, R. de, and Groothuizen, T., 2004. S'wing; een valpreventie product voor de toiletruimte. Tijdschrift voor Ergonomie, 29(5), 4-11. [28] Buzink, S.N. Fall prevention in the toilet environment. This volume. [29] Dekker, D. and Buzink, S.N. User preferences regarding body support and personal hygiene in the toilet environment. This volume. [30] Molenbroek, J.F.M., Houtkamp J.J., and Burger, A.K.C., 1983. Anthropometry of elderly. Report Special Subjects Part 6 (in Dutch ) Faculty of Industrial Design Engineering, Delft University of Technology, Delft. [31] Molenbroek, J.F.M. and Zhang, B., 2000. Anthropometry of the elderly and the disabled with special attention to (wheel)chair design. In Proceedings of the XIVth triennial congress of the International Ergonomics Association and 44th annual meeting of the Human Factors Ergonomics Society. Santa Monica CA (USA): Human Factors and Ergonomics Society, pp. 4-704-4-707. [32] SAE International, 2008. Civilian American and European Surface Anthropometry Resource Project – CAESAR [online]. Available from: http://store.sae.org/caesar/

242 A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-242 Involvement of Users and Practitioners in Anticipating Future Usage with Design Models

Theo ROODEN1 Delft University of Technology – Faculty of Industrial Design Engineering – Section Applied Ergonomics and Design, Delft, The Netherlands and The Hague University of Applied Sciences – School of Human Technology, The Hague, The Netherlands

Abstract. User involved usability assessments during design processes improve the quality of the final product. These assessments take place with design models (e.g. drawings or foam models). Empirical studies yielded methodological recommendations. The design models should represent relevant characteristics of the design, such as innovative aspects, and designed use cues. Interactivity of the models is key, but this can already be achieved with a series of simple drawings. To get lifelike interactions during the user trials, participants should be given meaningful tasks, and they should be encouraged to use all means of expression, such as thinking aloud and gesturing. Furthermore, research showed that the involved practitioners make or break the assessment. Important factors are their observation sensitivity and their judgmental skills in filtering out artificial problems. They should also understand the limitations of these user trials in the lab, and combine them with other methods of user research.

Keywords. Usability, User Centred Design, User Trialling

1. Introduction

Usage-centred design processes are characterised by attention to the interaction of future users with a proposed product. The development of usable products can give competitive advantage and it may also be considered a designer's professional responsibility. A central difficulty in usage-centred design is that a product needs to be designed for a variety of users who will use it in a variety of ways in a variety of contexts. Another difficulty with usage-centred design approaches is the limited help derived from empirical data currently in ergonomics handbooks and ergonomics guidelines. These considerations explain why it is necessary to combine the creative design process with various usability evaluations, see Figure 1. Figure 1 presents the design process as a series of phases, with deliverables of the design phases available for usability assessment. Preferably design and research should run parallel, with ongoing feed of research information into the creative process.

1 Contact information: Theo Rooden; Tel: +31 (0)70 4458920; Email: [email protected] T. Rooden / Involvement of Users and Practitioners in Anticipating Future Usage 243

The earlier usability assessments can be made in the design process the better, as the opportunity for improvement by design is greater in the early phases. Various methods exist to assist designers with usability assessments. A distinction can be made between methods with, and those without user involvement. Methods without user involvement, also called usability inspection methods (see [1] for an overview), include heuristic evaluation, and cognitive walkthrough. At the core of user-involved usability assessments are observational studies, such as user trialling. During design processes users can be observed interacting with design models, such as drawings, foam models, and computer simulations.

Figure 1. Usage-centred design process, characterised by consecutive and iterative phases of creative design and usage research (derived from [3,4]).

This chapter deals with issues related to usability assessments with design models. The first topic is the design models themselves. The second topic is the methods of user trialling with design models. The third and final topic is the role of practitioners in usability assessments with design models. With each topic, recommendations for 244 T. Rooden / Involvement of Users and Practitioners in Anticipating Future Usage design practice are included. These recommendations are derived from PhD research by the author [2]. This PhD research contained empirical studies comparing user activities with various design models and actual products, and interpretation by practitioners.

2. Design Models

A design model (e.g. a set of drawings, a computer simulation, or working prototype) represents a design in some phase of development. Budget (both time and money) prevents some characteristics from being represented in the design model. And the design may not be detailed enough yet to have a full range of characteristics represented in material form. In observational studies, differences between the design itself and the design model may introduce 'artificial' ways of usage, and may prevent relevant ways of usage from being noticed. When building design models for usability assessment, it would be helpful to know which characteristics can be left out without penalty, and which characteristics should necessarily be represented in the design model. Although research has been aimed at developing guidelines for constructing design models for usability assessment, the studies were limited in scope and did not yield groundbreaking recommendations [5,6,7,8]. One claim is that aesthetic refinement of the design model does not matter [7]. Even this claim is disputable because only quantitative comparisons were made: Although various design models, differing only in the degree of aesthetic refinement, did not differ in the number of 'errors', nothing was said about possible differences in the nature of the errors in the various conditions. In depth qualitative research comparing user trials with various design models in our own research showed that basing conclusions on summative quantitative measures is misleading [2]. Although there may not be a set of general guidelines for constructing design models, our research has yielded some recommendations.

2.1. Represent Innovative Aspects of the Design

It is known that user activities are very much guided by previous experience with similar products and interactions. An implication is that characteristics of a design which are not represented in the design model may be filled in by participants in a user trial based on their previous experiences with similar products. This goes well as long as design solutions match expectations from previous experience. In building a design model, one should represent those characteristics which cannot easily be filled in by experience, or which will be filled in incorrectly. This is complicated by the fact that a variety of users may draw from a large variety of experiences. New, innovative or rare design solutions should at least be tested by having them represented in the design model. When the designed interaction does not follow from the product’s functioning and is without a logical rationale, it should also be represented in the design model.

2.2. Research Questions Are Guiding

It is obvious that research questions are guiding in decisions when building a design model. What is it that the design team want to know from usage research? When T. Rooden / Involvement of Users and Practitioners in Anticipating Future Usage 245 physical aspects are of relevance, a real size 3D-model seems essential. Usage of a product may be guided by certain features of the design. These (combinations of) characteristics may be identified by the term 'cues' or 'usecues' [11]. Some cues are explicitly designed into a product, like graphics and auditory signals. Other cues are designed into a product more intuitively, like the size of a button or the shape of an LCD, which have become implicit. When doubts exist about the quality of certain designed use cues, these specific cues should be represented and tested in user trials. A difficulty with this is that use cues through experience and familiarity with cultural conventions, both for designers and users. When doubts exist about the quality of certain designed usecues, these specific cues should be represented and tested in user trials. A difficulty with this is that usecues often do not work in isolation and that their quality can only be assessed in combination with other characteristics of the design.

2.3. Show All Sides of the Design

Particularly when making design models in the form of drawings, one should be aware that a necessarily chosen viewpoint hides a part of the design from the users in the trials. Recommendations include the preparation of additional drawings showing all sides of the design or making a 3D-model or a dynamic computer rendering. This shortcoming of drawings can also be compensated for by methodological precautions: In user trialling, users can be told about invisible information by the test leader. It requires a skillful test leader to decide at what moment to give away the information. It is probably best to intervene at the moment when users have made wrong assumptions about hidden information. A test leader is only able to do so when participants are thinking aloud, revealing some of their thoughts during usage. Having users think aloud is recommended anyway, as information about users’ thoughts and perceptions during usage is often helpful in linking usability problems to characteristics of the design. This is exactly the kind of information designers need to further improve the design.

2.4. Show Changes in Appearance during the Interaction

This is another recommendation mainly relevant for usability assessments with drawings. The interaction becomes more lifelike when changes are made visible and users and evaluators do not need to remember the status of the product. This can be achieved by preparing a series of drawings that are shown at the relevant moment, Figure 2. One requirement is that use actions need to be predictable to some extent in order to be able to prepare such drawings. Flexibility is required because of the known limitations to predicting user activities. Interaction on LCD-drawings can be simulated with little overlays or with computer simulations.

246 T. Rooden / Involvement of Users and Practitioners in Anticipating Future Usage

Figure 2. Video captures from a user trial with a series of drawings of a coffee-maker design. In the first picture, the participant indicates by gesturing and talking that she would remove the jug. She is then presented with a separate drawing of the jug and a drawing of the body of the machine without the jug. After having indicated that she would remove the top of the machine, she is presented (in the third picture) with a view of the interior.

2.5. Create Manipulable Models

When users interact with real products and 3D-models, actions can be observed and recorded for analysis, in particular on video-tape. When a design proposal is represented by drawings, a limitation for user trialling is that use actions cannot actually be performed. Information about actions will be meagre, unless actions are simulated by gesturing or by talking about intended actions. The information revealed about these actions in user trials may be limited. Some people may be more inclined to talk with their hands than others, and talking about manipulations has known limitations. Manipulations consist of skilled behaviour and most participants do not have an adequate vocabulary at hand. Manipulation can be encouraged when the drawings are real-size cut-out shapes, Figure 3. When manipulation is an important ingredient of the interaction, full scale 3D-models should be considered.

Figure 3. Cut-out drawings T. Rooden / Involvement of Users and Practitioners in Anticipating Future Usage 247

3. User Trialling with Design Models

User trials with design models differ from user trials with actual products. Design models bring along some degree of artificiality and cannot actually be used in a natural environment. Limitations of these user trials in capturing user activities should be understood. At the same time, some of the shortcomings and deficiencies of design models as such can be compensated by explaining their status and supplying additional information to participants in user trials.

3.1. Let Users Focus on Results

A difficulty with user trialling with non-functioning models is that users cannot actually focus on task performance, which may trigger activities not expected with real products. When using everyday products, such as an iron, the user's attention is probably directed at the task at hand or the performance, for instance removing wrinkles from a shirt. Having participants use a non-functioning design model in user trialling presents them with an unnatural situation. The product can no longer have this mediating role. In the case of the iron, the aim of user activities can not be to get rid of wrinkles in a shirt. Participants' approaches may become more consciously focused on the interaction itself, possibly leading to different, unrealistic activities. Some participants adopt a kind of expert role, in which they undertake to demonstrate and explain, instead of just operate the design model. With this explaining behaviour, the order of actions when operating design models may be less well-considered and trivial actions may be omitted when describing and demonstrating what one would do if it were a real product. This yields an incomplete picture. It is advised to make the interaction as real as possible, for instance by supplying participants with a realistic task, and by simulating results. In case of the iron, supply a setting with a real ironing board, and add a basket with a variety of garments. Additional information can be collected by user trialling with working prototypes or by observing usage of existing products with similar functionality.

3.2. Encourage Pointing and Gesturing

The problems of verbalising manipulations in user trialling with drawings may be solved by making drawings manipulable (see last recommendation in previous section), but also by encouraging participants to point at parts of the drawings and to show their intended manipulations by gesturing.

3.3. Collect Information Concurrently, Probe Actively

This recommendation is strongly related to user trialling as a design tool. Information about why users do what they do is crucial in informing designers. Formal methods of thinking aloud [9] do not accommodate for the elicitation of such information. Asking questions during a trial probably evokes more valuable information than retrospective interviews. It should be realised that active concurrent probing compromises possibilities of observing natural usage. In retrospective interviews, a video recording of the trial can be reviewed together with the participant to refresh his or her memory. 248 T. Rooden / Involvement of Users and Practitioners in Anticipating Future Usage

3.4. User Perspective

In our approach to the topic of design models, we regard the design model as the representation of a design proposal. It should be realised that users do not have this frame of reference, and they will build their own product based on the design model. In a user trial it is important to know how users fill in gaps of the design model, because only then it is possible to conclude whether the demonstrated ways of usage would occur when the participants are confronted with the finished design.

3.5. Complement User Trialling with Other Usability Assessment Methods

User trialling with design models captures only a part of possible user activities. It generally focuses on first time usage, and it often takes place in a neutral environment like a usability laboratory. Other methods may help to anticipate usability problems in a larger variety of use contexts, a variety of users, and a variety of tasks. Other methods include heuristic evaluation [10], and observation of usage of similar products.

4. Involving Expertise in Usability Assessments

In the previous section, the role of practitioners during user trials was already mentioned. His or her position can help improve the quality of the collected information. However, the role of practitioners is crucial in the analysis of the observations as well. The general approach in an analysis will be a systematic scrutiny of the data to extract usability problems and causes, preferably with guidance of a previously set definition of what constitutes a usability problem. With this approach it is still possible to include 'artificial' usability problems (i.e. problems which cannot occur with the real product), and relevant ways of usage and usability problems may not be noticed. Practitioners will be able to filter out usability problems that are artificially created by design models, and will at the same time anticipate usability problems which do not readily come to light in user trials with design models (see last recommendation in previous section). We had practitioners view recordings of user trials and had them extract usability problems [2]. Large inter-individual differences in the number of anticipated usability problems were shown. Knowing why certain practitioners outperformed others may inform the selection of practitioners for usability assessment and may reveal effective approaches for usability assessment. Our study suggests that the approaches adopted by practitioners (e.g. systematic approach, time investment) are more important than actual expertise, although the ability to empathise with a variety of users seems essential. It is advisable not to rely on a single analyst, but to combine findings from several analysts, preferably with various backgrounds.

5. Conclusions

This chapter presented a general overview of issues related to the application of design models in usage-centred design, together with recommendations for design practice. One might get the impression that user trialling with design models comes with too T. Rooden / Involvement of Users and Practitioners in Anticipating Future Usage 249 many difficulties to be carried out with confidence. This is not the case, our experiences are positive: in general participants bridge the gap between design model and intended product very well, supplying invaluable information in the user trials to be used as input in usage-centred design. Practitioners are encouraged to integrate usage observation with design models into their design processes, to reflect on the findings, to improve methods, and to tune these to their specific contexts. The recommendations presented in this chapter can be helpful in this process.

References

[1] Nielsen J, Mack RL. Usability inspection methods. New York: Wiley; 1994. [2] Rooden MJ. Design models for anticipating usage [PhD thesis]. Delft: Faculty of Industrial Design Engineering, Delft University of Technology; 2001. [3] Den Buurman R. Designing smart products; a user-centred approach. In: Seppala P, Luopajarvi T, Nygard CH, Mattila M, editors. Proceedings of the 13th Triennial Congress of the International Ergonomics Association; 1997; Tampere, Finland. Helsinki: Finnish Institute of Occupational Health; 1997, p2-3 – 2-5. [4] Marinissen AH. Ergonomic aspects in designing automotive displays with route guidance information. In: Grieco A, Molteni G, Piccoli B, Occhipinti E, editors. Selected papers of the Fourth International Scientific Conference Work with Display Units 94. Milan, Italy; 1995, p271-176. [5] Fay D, Hurwitz J, Teare S. The use of low-fidelity prototypes in user interface design. In: Proceedings of the 13th International Symposium Human Factors in Telecommunication; 1990 Sep 10-14; Torino, Italy. 1990, p23-31. [6] Prümper J, Heinbokel T, Kuting HJ. Virtuelle Prototypen als Werkzuege zur Benutzerzentrierten Productentwicklung. Zeitschrift für Arbeitswissenschaft. 1993; 3(47); 160-167. [In German]. [7] Wiklund ME, Thurrot C, Dumas JS. Does the fidelity of software prototypes affect the perception of usability? In: Proceedings of the Human Factors Society 36th Annual Meeting; 1992 Oct 12-16; Atlanta, Georgia/Innovations for Interactions. 1992, p399-403. [8] Virzi RA, Sokolov JL, Karis D. Usability problem identification using both low- and high-fidelity prototypes. In: CHI Conference Proceedings Human Factors in Computing Systems, 1996 April 13-18; Vancouver, British Columbia, Canada. 1996, p236-243 [9] Ericsson KA, Simon HA. Protocol Analysis: verbal reports as data. Cambridge: MIT Press; 1993. [10] Nielsen J. Usability Engineering. Boston: Academic Press; 1993. [11] Kanis H, Rooden MJ, Green WS. Usecues in the Delft design course. In: McCabe PT, Hanson MA, Robertson SA, editors. Contemporary Ergonomics. London: Taylor and Francis; 2000. p365-369. 250 A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-250 Key Dimensions of Client Satisfaction with Assistive Technology: A Cross-validation 1 of a Canadian Measure in The Netherlands

Louise DEMERSa , Roelof WESSELS† b, Rhoda WEISS-LAMBROUc, Bernadette SKAd and Luc P. DE WITTEb aCentre for Clinical Epidemiology and Community Studies – Sir Mortimer B. Davis Jewish General Hospital, Montreal, Canada bInstitute for Rehabilitation Research, Hoensbroek, The Netherlands cÉcole de réadaptation – Université de Montréal, Montreal, Canada dCentre de recherche de l'Institut universitaire de gériatrie de Montréal, Montreal, Canada

Abstract. The purpose of this study was to conduct a cross-validation of the bidimensional structure of a satisfaction measure with assistive technology. Data were drawn from a follow-up study of 243 subjects who had been administered the Dutch version of the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST). Ratings related to 12 satisfaction items were analysed. Factor analysis results showed that the underlying structure of satisfaction with assistive technology consists of two dimensions related to assistive technology, Device (eight items) and Services (four items), accounting for 40% of the common variance. This finding was consistent with a previous Canadian study and was interpreted as supporting the adequacy and stability of the QUEST measure of satisfaction. Although the structure is delineated, further studies are recommended to support its use in European countries.

Keywords. Assistive Technology, User Satisfaction, Validation, Factor Analysis, Outcome Assessment, Quest

1. Introduction

In this new era of evidence-based practice, satisfaction information is conferred considerable importance as a patient outcome and, as a result, measurement of the concept is gaining status [1,2,3]. It is common belief that satisfaction data can help clinicians, researchers, managers, and payers improve what they do, for example, by enabling services monitoring and creating positive attitudes among patients or clients [4]. According to Keith [2], satisfaction can be defined as an attitude about a service, a product, a service provider or a person's health status. This definition emphasises the diversity of purposes satisfaction outcomes may address.

1 This chapter has been published before as part of the doctoral thesis of Roelof Wessels ‘Ask the user : user perspective in the assessment of assistive technology’ and in the Journal of Rehabilitation Medicine 2001, 33: 187-191 and is reprinted here with his permission. L. Demers et al. /KeyDimensions of Client Satisfaction with Assistive Technology 251

Figure 1. Satisfaction with assistive technology model, inspired from Simon & Patrick [6]

In the field of assistive technology, user satisfaction is identified as one of five main outcomes categories, together with clinical results, functional status, quality of life, and costs [5]. Although the use of these outcomes is strongly advocated, satisfaction assessment tools are scarce, due in part, to a vacuum in the theoretical knowledge concerning the phenomenon under study. Indeed, satisfaction determinants are vague and indefinite and this situation is prejudicial for the measurement of the concept, frequently making it totally arbitrary. Despite important conceptual limitations, it is useful in the context of this study to represent the relations between the variables involved in the experience of assistive technology within a general frame of reference. The linear satisfaction theoretical model depicted in Figure 1 was inspired by Simon & Patrick`s work [6] in rehabilitation. Expressed satisfaction, which appears in the corner box, may be conceived as a reaction to assistive technology provision and, therefore, as a dependent variable. Satisfaction can also trigger a subsequent action or behaviour, whereby it is approached as an independent variable. According to this model, the core concept under study can be broken down into several dimensions, all of which contribute to the user perception. This multidimensional approach is strongly supported by empirical work in the field of rehabilitation [7,8] as well as in other health domains [9,10]. To date however, there is little agreement about the conceptual structure of satisfaction measures with assistive technology. A first step in the definition of key satisfaction dimensions with assistive technology was recently taken in the context of the development of the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST) tool [11]. This outcome measurement instrument was designed to measure satisfaction with assistive technology devices in a structured and standardised way. Although its experimental version consisted of 24 variables, an item analysis subsequently reduced this number 252 L. Demers et al. /KeyDimensions of Client Satisfaction with Assistive Technology by half [12]. As part of the same methodological study, the 12 selected items were submitted to factor analysis. Results suggested that the underlying structure of satisfaction consists of two key dimensions respectively related to assistive technology Device and Services. As shown in Figure 2, the Device dimension embraced eight items related to salient characteristics of the assistive technology whereas the Services dimension encompassed four intercorrelated items. The fit of the proposed measurement model was judged as reasonably good, with an acceptable amount of explained total item variance totalling 48.4% [12]. Several studies [13,14,15] have been published which support the bidimensional approach of assistive technology, thus strengthening its validity. From a methodological perspective however, there are two issues that challenge the stability of this conceptual structure. Both stem from the fact that the data used were obtained from a single sample of subjects. The first criticism is that all satisfaction ratings were drawn from seating and mobility aids as well as lower limb prostheses [12]. Logically, it can be argued that different patterns of inter-correlated items might have emerged with other types of devices. The second criticism concerns the cross-cultural application of the satisfaction structure proposed, since it was based on a single North American setting, that of Montreal. Provision of assistive technology is likely to vary substantially across countries, not to mention continents. Both limitations need to be addressed in order to give credibility to the proposed structure and support its adequacy The goal of the present study was to conduct a cross-validation of the bidimensional structure of satisfaction with assistive technology, using a sample of subjects that differed from the original research with respect to cultural setting and types of devices.

Figure 2. Key dimensions of satisfaction with assistive technology

L. Demers et al. /KeyDimensions of Client Satisfaction with Assistive Technology 253

2. Methods

2.1. Subjects

Data were obtained from a previous Dutch follow-up study involving 375 subjects [16]. The devices used by these people included toilet adaptations, shower seats and chairs, wheelchairs, adapted beds, stairlifts, home adaptations and adapted beds. A large proportion of this sample (82%) was recruited from the TNO-PG, a Dutch organisation for applied scientific research located in Leiden. These subjects had been provided with an assistive technology device in the past and were taking part in a larger questionnaire survey. The remaining 18% of the sample were selected from the Institute for Rehabilitation Research (iRv) in Hoensbroek, which houses an assistive technology service delivery centre. A follow-up evaluation was implemented three months after the clients had received a new device. In both of these regions, subjects were visited in their home. No formal training of the evaluators was provided and a large number of them (total of n=31) were involved in the data collection. Prior to conducting the analysis, the dataset was inspected to ensure it was suitable for the intended purpose. Data were screened with regards to age of subjects (children were excluded from sample), aberrant data (zero variability), missing data and non-applicable responses (individuals who responded to less than 50% of the questions were excluded).

2.2. Items

All subjects were administered the Dutch version of the experimental QUEST, the D- QUEST [17]. The translation was based on a set of standardised procedures as discussed in two articles [16, 18]. The consistency of viewpoints between the authors of the tool, the researchers from the iRv and several Dutch occupational therapists was a strong contributing factor for obtaining conceptual equivalence between the English and Dutch versions. It also permitted the adaptation of the instrument to the specific context of assistive technology provision and use in the Netherlands. The D-QUEST was administered in full. However in this study, satisfaction ratings with 12 items selected from the previous item analysis of the QUEST [12] were included in the analysis. These target items are listed in Table 1, together with their definition. Each item was scored with a 5-point satisfaction scale, with a score of 1 denoting “not satisfied at all”, 2 “not very satisfied”, 3 “more or less satisfied”, 4 “quite satisfied”, and 5 indicating “very satisfied”. In terms of psychometric properties, they were found to be reliable with respect to test retest stability and interrater reproducibility, with weighted kappa values respectively ranging from 0.51 to 0.74, and from 0.35 to 0.72 [19]. With respect to content validity, all 12 items were considered of primary importance for assessing satisfaction according to 50% and more assistive technology experts (n=12) recruited in the United States, the Netherlands and Canada [18]. Moreover, these items were rated as highly important (mean scores of 4.00 to 4.85 on a 5-point importance scale) by 158 Canadian users of assistive technology [12].

2.3. Procedures

Factor analysis is an analytical technique that permits the reduction of a certain number of interrelated variables to a smaller number of latent hidden dimensions [20]. In test development and cross-validation, it reveals the pattern of shared variation within a set 254 L. Demers et al. /KeyDimensions of Client Satisfaction with Assistive Technology of items. Principal Axis Factoring (PAF) is the most widely used method of factor extraction for explaining common variance [20] and it was used in this study. Principal Components Analysis (PCA) which is designed to extract total (not common) variance, is automatically produced as a preliminary step to PAF. The statistic pertaining to total variance was examined. Because the QUEST provided subjects with the option of scoring items as non- applicable, there was a large proportion of missing data (24%). The percentage of missing responses per item is given in Table 1. Therefore, in order to avoid a significant reduction of the sample size, a pairwise strategy was used to compute the matrix of inter-item correlation coefficients. Accordingly, all valid responses were analysed. To obtain a simple structure, items loading (correlating) high on one factor and low on the remaining factors were needed. Loading values may vary from 0.000 to 1.000. Meaningful item loadings for each factor were examined after both orthogonal (varimax) and oblique (oblimin) rotations. In one case, the factors are independent, whereas in the second case, they are allowed to correlate. The results were similar, but orthogonal rotation was retained because it was easier to interpret.

Table 1. QUEST items, definitions and percentage of missing data (ATD = Assistive Technology Device).

% of missing No Item Definition data 1. Comfort Physical and psychological well-being associated with use 5.8 of ATD. 2. Dimensions Convenience of the device's size (height, width, length). 6.2 3. Professional services Quality of information on ATD provided, accessibility and 18.1 competence of professionals. 4. Follow-up services Ongoing support services for ATD. 42.0 5. Simplicity of use Ease in using the ATD. 2.5 6. Effectiveness Goal achievement with the ATD. 7.4 7. Repairs and servicing Ease in having the ATD repaired and serviced. 48.6 8. Durability Robustness and sturdiness of the ATD. 9.9 9. Adjustments Simplicity in setting/fixing the components of ATD. 42.4 10. Safety Degree to which the ATD is safe, secure and harmless. 6.6 11. Service delivery Ease in acquiring the ATD including length of time. 14.8 12. Weight Ease in lifting and/or moving the ATD. 62.1

3. Results

Factor analysis was performed on a matrix of correlations between item scores obtained from 243 subjects (67.5% of the original sample). This sample size exceeded the recommendation of having at least 10 times as many subjects as variables [21]. Both L. Demers et al. /KeyDimensions of Client Satisfaction with Assistive Technology 255 the Bartlett Test of Sphericity (p<0.000) and the Kaiser-Meyer-Olkin Measure of Sampling Adequacy (KMO) (0.76) demonstrated that the data were appropriate for the planned analysis. The results yielded two factors accounting for 40% of the total common variance among the 12 items. Based on PCA, the total item variance explained by this solution attained 49%. Consistent with common practice, each factor

Table 2. Dutch and Canadian results of factor analysis (after orthogonal rotation) of 12 QUEST satisfaction items.

Factor 1 Factor 2 Item Communalities Device Services Dutch (n=253) 1. Comfort 0.764 0.611 2. Dimensions 0.611 0.399 5. Simplicity of use 0.766 0.609 6. Effectiveness 0.585 0.377 0.484 8. Durability 0.339 0.395 0.271 9. Adjustments 0.629 0.402 10. Safety 0.467 0.305 12. Weight 0.474 0.316 0.325 3. Professional service 0.503 0.333 4. Follow-up services 0.651 0.434 7. Repairs/servicing 0.685 0.475 11. Service delivery 0.312 0.108

Canadian (n=150) 1. Comfort 0.420 0.193 2. Dimensions 0.608 0.381 5. Simplicity of use 0.661 0.485 6. Effectiveness 0.589 0.346 0.466 8. Durability 0.361 0.419 0.306 9. Adjustments 0.658 0.449 10. Safety 0.396 0.224 12. Weight 0.577 0.338 3. Professional service 0.689 0.509 4. Follow-up services 0.823 0.696 7. Repairs/servicing 0.689 0.487 11. Service delivery 0.394 0.180 256 L. Demers et al. /KeyDimensions of Client Satisfaction with Assistive Technology was interpreted according to the variables (QUEST items) that 'loaded' or were mostly highly correlated. The factor structure matrix shown in Table 2 represents the loadings of the 12 items with the factors. The communalities, or the proportion of variance that is accounted for by this solution, are reported in the right-hand column. Small portions of durability (#8), and service delivery (#11) variances were explained (0.271 and 0.108 respectively). For this analysis, a conservative threshold for meaningful loadings at 0.30 was employed [20]. Results revealed that most items are high on one factor and low on the other, thus contributing positively to a simple resulting structure. Three items, however, performed slightly differently. Items effectiveness (#6) and weight (#12) loaded on both factors but more substantially with Factor 1. Item durability (#8) loaded moderately on the two factors, however, somewhat more with Factor 2. The largest factor was consistent with a Device dimension and accounted for 24.6% of the explained common item variance. It was characterised by high loadings of all technical and 'user-interface' features of the assistive technology. Indeed, comfort (#1), dimensions (#2), simplicity of use (#5), effectiveness (#6), adjustments (#9), safety (#10), and weight (#12) all loaded high on this factor. Despite its dual allegiance, it was reasonable to also assign durability (#8) to Factor 1 because it is usually considered as a technical characteristic of a device. The second factor, Services, accounted for 15.1% of the explained common variance. It was defined by high loadings of consumer service aspects of assistive technology. The items involved included professional services (#3), follow-up services (#4), repairs/servicing (#7) and service delivery (#11). As noted previously, items effectiveness (#6), durability (#8), and weight (#12) also moderately correlated with Factor 2, despite their stronger affiliation with Factor 1. Table 2 also reproduces the Canadian factor analysis in order to make comparison of results.

4. Discussion and Conclusions

To gain confidence in outcome assessments and increase knowledge of user perception and satisfaction, it is essential to build theoretical backgrounds that support the proposed approaches. Based on a previous study of the QUEST tool, it was hypothesised that satisfaction with assistive technology should be considered as a bidimensional construct, encompassing satisfaction with the Device and Services. To test the validity of this proposition, a different sample of subjects from that on which the items were originally selected. By conducting the same analyses as in the original study, we are quite confident that the results of this replication study were not due to some methodological scheme. The existence of the Device and Services components for the assessment of satisfaction with assistive technology was confirmed by the fact that the same factorial structure emerged from this study data. Indeed, the first factor embraced 8 items: comfort, dimensions, simplicity of use, effectiveness, durability, adjustments, safety, and weight. On the basis of content validity, it is reasonable to include durability in the device dimension. However, because of its allegiance to both factors, the position of this item is rather weak and should be considered in future studies. It is important to note that, despite some minor differences in loadings and communalities values, the same pooling of items had been obtained in the previous study from Demers et al. [12]. L. Demers et al. /KeyDimensions of Client Satisfaction with Assistive Technology 257

From a theoretical perspective, this finding is consistent with those who view technology quality as a top priority in device selection [13], use [22], and evaluation [14,15,23]. Similarly, the second factor regrouped the four items most closely associated with Services aspects of assistive technology provision: professional services, follow-up services, repairs/servicing, and service delivery, with loadings and communality values very close to those published originally [12]. Based on the literature reviewed, defining these two key dimensions of satisfaction with assistive technology appears sound. Although it is the first time that such a conceptual structure is empirically supported for satisfaction, theoretical reflections of authors concerned with use, delivery and evaluation of assistive technology distinguish the same dimensions and view the concept in a similar way. This has been highlighted by Bain [15] who, in her systematic evaluative approach, suggested that assistive technology is comprised of devices and service delivery. Similarly, Kohn et al. [14] explicitly referred to two areas of practice: the provision of services, and the devices themselves. Vanderheiden [13] also emphasized that the proper choice of advanced technology and effective delivery were the essential conditions for successful assistive technology provision. The data set used for this study was diametrically different from the original study. Indeed, subjects were assessed in the context of a clinical follow-up, with few standardised procedures. Compared with the strict management of a research protocol, it is not surprising to see more interviewers involved, varying degrees of training and a variety in the types of devices. In addition, although Canada and the Netherlands' health and social services systems may, due to common western values, resemble each other in some ways, delivery of assistive technology in the two countries is clearly distinct. Examples of differences include private/public funding, training, follow-up, and availability of devices, all of which may influence the users' perception. By revealing an identical factorial solution, this study provides a strong support for the adequacy and stability of the measure of satisfaction. One benefit of this study is to confirm that measurement of satisfaction with assistive technology should be divided in two components, related to the device and the services characteristics of assistive technology. In conclusion, future studies will need to be conducted to support the applicability of the QUEST tool in the European countries.

Acknowledgements

This paper is based on the doctoral thesis of Louise Demers. The authors gratefully acknowledge the financial support provided by the Foundation of Quality and Usability Research of Technical Aids in the Netherlands and the Fonds pour la recherche en santé du Québec in Canada. Special thanks are extended to the assistive technology users and to the personnel of TNO-PG for sharing with us their data.

Obituary

Dr.Roelof Wessels studied industrial design engineering in Delft and thereafter worked as scientific researcher at the Institute for Rehabilitation Research in Hoensbroeck. Although suffering from Multiple Sclerosis that gave him some limitations, he was always optimistic and energetic. Unfortunately he passed away at 16 November 2007 at the age of 39 years old. He is survived by his wife and his children. 258 L. Demers et al. /KeyDimensions of Client Satisfaction with Assistive Technology

References

[1] Robertson SC, Colborn AP. Outcomes research for rehabilitation issues and solutions. Journal of Rehabilitation Outcomes Measurement 1997; 1:15-23. [2] Keith RA. Patient satisfaction and rehabilitation services. Archives of Physical Medicine and Rehabilitation 1998; 79:1122-1128. [3] Osborn CE. Developing instruments for assessment of patient outcomes. Journal of Rehabilitation Outcomes Measurement 1998; 2:18-25. [4] Scherer MJ, Vitaliti LT. A functional approach to technological factors and their assessment in rehabilitation. In: Dittmar SS, Gresham GE, editors. Functional assessment and outcome measures for the rehabilitation health professional. Gaithersburg: Aspen, 1997: 69-88. [5] DeRuyter F. Evaluating outcomes in assistive technology: Do we understand the commitment? Assistive Technology 1995; 7:3-16. [6] Simon SE, Patrick A. Understanding and assessing consumer satisfaction in rehabilitation. Journal of Rehabilitation Outcomes Measurement 1997; 1(5):1-14. [7] McComas J, Kosseim M, Macintosh D. Client-centred approach to develop a seating clinic satisfaction questionnaire: a qualitative study. The American Journal of Occupational Therapy 1995; 49:980-985. [8] Wilson KG, Crupi CD, Greene G, Dehoux E, Korol KT. Consumer satisfaction with a rehabilitation mobile outreach program. Archives of Physical Medicine and Rehabilitation 1995; 76:899-904. [9] Fitzpatrick R. Surveys of patient satisfaction: I - Important general considerations. British Medical Journal 1991; 302:887-889. [10] Steiber SR, Krowinski WJ. Measuring and managing patient satisfaction. Chigago: American Hospital Publications, 1990. [11] Demers L, Weiss-Lambrou R, Ska B. Development of the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST). Assistive Technology 1996; 8:3-13. [12] Demers L, Weiss-Lambrou R, Ska B. Item analysis of the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST). Assistive Technology 2001; 12(2). [13] Vanderheiden GC. Service delivery mechanisms in rehabilitation technology. The American Journal of Occupational Therapy 1987; 41:703-710. [14] Kohn J, Mortola P, LeBlanc M. Clinical trials and quality control: Checkpoints in the provision of assistive technology. Assistive Technology 1991; 3:67-74. [15] Bain BK. Assistive technology in occupational therapy. In: Neistadt ME, Crepeau EB, eds. Williard and Spackman's occupational therapy. Philadelphia: Lippincott, 1997: 498-513. [16] Wessels RD, De Witte LP, Weiss-Lambrou R, Demers L, Wijlhuizen G. A Dutch version of QUEST (D-QUEST) applied as a routine follow-up within the service delivery process. In: Placiencia Porrero I, Ballabio E, editors. Improving the quality of life for the European Citizen. Amsterdam: IOS Press, 1998: 420-424. [17] Wessels R, De Witte L, Knopps HThP. D-QUEST. Hoesbroek: Institute for Rehabilitation Research (iRv), PO 192, 6430 AD Hoesbroek, the Netherlands, 2000. [18] Demers L, Wessels R, Weiss-Lambrou R, Ska R, De Witte L. An international content validation of the Quebec User Evaluation of Satisfaction with assistive Technology. Occupational Therapy International 1999; 6:159-175. [19] Demers L, Ska B, Giroux F, Weiss-Lambrou R. Stability and reproducibility of the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST). Journal of Rehabilitation Outcomes Measurement 1999; 3(4):42-52. [20] Pedhazur EJ, Schmelkin LP. Measurement, design, and analysis: An integrated approach. Hillsdale: Lawrence Erlbaum Associates, 1991. [21] Nunally JC. Psychometric theory. 2 ed. NewYork: McGraw-Hill, 1978. [22] Galvin JC, Scherer MJ. Evaluating, selecting, and using appropriate assistive technology. Gaitherburg: Aspen, 1996. [23] Eblen C. Issues involved in the evaluation of assistive devices. Topics in Geriatric Rehabilitation 1992; 8(2):6-11.

A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People 259 J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-259 Plea for Use of Lowered Toilet for All

Pamela MUSCH1, Maarten DEN HARTOG Studio DenHartogMusch, Arnhem, The Netherlands

Abstract. The posture of squatting is biomechanically considered a healthier posture than the western toilet posture. For the western population, squatting proves to be a difficult and uncomfortable experience. By lowering the seat and combining it with point and foot support, a more comfortable squatting posture is created. In this article the lower point support posture is analysed and visualised in anatomical and ergonomic sense. Furthermore, the expectation is expressed that the lower point- supported toilet concept will prevent problems with constipation, safety and hygiene. It is probable that after experienced use the (more flexible) elderly user will be able to use the toilet longer and more independently, albeit with some special adaptations. A plea for further research on and investigation into the preventive function of a lower point-supported toilet concept is expressed. Some solutions for further development are discussed in order to improve this toilet concept for the elderly user. The lower point-supported toilet concept presented in this article should be tested and developed further and should be regarded as a first step towards a preventive and healthy toilet for every adult, the elderly included.

Keywords. Squatting, Elderly, Toilet, Pelvic Floor Muscle, Constipation, Support

1. Introduction

The increasing population of elderly people and the risks of dizziness and falling that come with age demand a safe and responsible design of toilets. For the elderly toilet user preventive measures are advertised widely: toilet seats with increased height and bathrooms with impressive adjustment functions. One cannot deny the fact of the actual ‘seating’ thus being made more comfortable, but considering almost any other aspect of toilet use (hygiene, increased problems of constipation, balance problems), these solutions overshoot the mark. They merely lead to an increased probability of constipation, to unhygienic situations and unnecessary tumbling risks. Tumbling risk occurs because of the loss of foot contact with the floor or because of the often inadequately placed support, most likely in the situation of toilet users with shorter arms and legs. Snijders, Molenbroek and Plante already described the disadvantages of elevated toilet seats [3] and argued for rethinking the almost automatic installation of such toilets for elderly people. This article shows that a lower point-supported posture for toilet use may even be a better solution to solve the above mentioned problems. In literature [2] the squatting posture appears to be the most natural one in which unobstructed and hygienic toilet use is possible. The deeper the squatting, the less

1 Contact Information: Studio DenHartogMusch; Address: Wichard van Pontlaan 201, 6824 GJ Arnhem, The Netherlands; Tel: +31 (0)26 3882637; Fax: +31 (0)26 3882639; E-mail: [email protected] 260 P. Musch and M. den Hartog / Plea for Use of Lowered Toilet for All obstruction of the bowels. Because the feet are in good contact with the floor, the risk of tumbling is decreased, which makes the squatting posture a safe option. Of course, for the elderly toilet user, the squatting posture is unquestionably more difficult to realize than sitting down on an elevated toilet seat. This is also true for the younger toilet user: squatting definitely takes more effort and causes more strain than regular sitting on a toilet. This, of course, raises the necessary questions concerning the idea of a lower point-supported toilet, especially in relation to the elderly. Besides this, the use of conventional squatting toilets meets with many psychological barriers in the western society. Objections are of a both physical and psychological nature [2]:

Squatting is regarded as unhygienic, clothes get dirty easily Squatting is not at all easy and ‘directing’ is difficult Keeping balance is difficult Large strains occur on leg muscles and knee joints, especially when squatting longer

In this applied research the central question was how to find a proper way to create a (kind of) squatting toilet posture that provides a more comfortable experience than the native squatting posture. This resulted in a lower point-supported toilet concept. Secondly, possibilities to improve hygiene and user comfort (clothes, cleaning buttocks) in comparison to the conventional squatting toilet were examined. In conclusion, adaptations to the lower point-supported toilet concept for the elderly user were looked into. The argumentation in this article leads to the conviction that the (preventive) use of a lower point-supported toilet offers a healthy, hygienic and safe solution for users up to old age.

2. Methods

The described explorative study contains a literature study of the squatting posture and a physical (interactive) study of the lower point-supported sitting (with a mock-up and a questionnaire). These formed the basis for a design study in which a lower point- supported toilet concept was created.

2.1. Study of the Squatting Posture

The posture of the conventional squatting toilet (with a ‘hole’ in the ground) is very similar to the native squatting posture in some Asian countries, for example Indonesia. In literature, this posture is considered to be a better posture than the posture of the western toilet with its seat at an average height of 42 cm [1]. P. Musch and M. den Hartog / Plea for Use of Lowered Toilet for All 261

Figure 1. Various squatting postures, lower point-supported seating and regular seating Native unstrained squatting posture (A), western or inexperienced squatting (B), squatting with foot support (C), squatting with foot support and point support (D), regular sitting (E)

When squatting, the bowels are stimulated, the muscles around the pelvic floor are not strained, and the buttocks are spread which is far more hygienic (reduction of the need for cleaning). The native squatting posture (with feet flat on the ground, see Figure 1A) is a comfortable posture, but it requires flexible ankles, hips and knees. Whether because of lack of flexibility in these joints or because of insufficient length of ligaments, it is not known, but certain is that most of the western population can hardly attain this posture. The differences between Asian and western populations can be attributed to a combination of inexperience and a different structure of joints and muscles. The (inexperienced) western squatting posture looks like Figure 1B. This posture leads to a lot of strain on the calves, and the knees are relatively heavily loaded. Many people find it difficult to get up out of this posture, particularly because of balancing problems. For going into and getting up from the squatting position, the whole body has to cooperate. By far the largest contribution to the total effort is delivered by the legs.

2.2. Squatting Less Deep, a Logical Solution

The dexterity with which people can go into a squatting position depends on the length, size and flexibility of their joints, and also on practice, therefore it can vary considerably per person. If we examine the native squatting posture (Figure 1A), by measuring diverse people in this posture, and by using Boschmallen (P5 woman/P95 man), the distance of the buttocks to the ground varies from 150 – 205 mm. A wedge support at an angle of 15o under the heels makes squatting more comfortable (Figure 1C). In this particular squatting posture, the buttocks are a little higher, and the distance of the buttocks to the ground varies between 230 and 280 mm [4]. Squatting with the use of a foot support makes both getting up from and going down into the squatting posture easier and also enables better balance. Even more comfortable than 262 P. Musch and M. den Hartog / Plea for Use of Lowered Toilet for All squatting with a foot support is the lower point-supported posture (Figure 1D), in which a large part of the body weight is transferred to the point supports (see also Figure 2). Their height is 25.5 mm, which is an average height and 16.5 mm lower than the average toilet height of 42 cm. For illustration, the regular sitting posture is shown (Figure 1E).

2.3. Lowered Sitting Posture Ideal for Toilet

If we examine the various squatting postures (Figure 1A, 1B and 1C) and compare them to the regular sitting posture (Figure 1E), it appears that the sitting posture in respect to the stool has a disadvantage: the anteflexion of the hip joint will not be large enough to tilt the pelvis when spreading the legs, thus more or less obstructing the ‘transit’ of the faeces [3]. The sitting posture compared to the native squatting posture (Figure 1A), however, does have the advantage that leg muscles and knee joints are strained less as the swells carry the major part of the body weight (60/70% is carried by the seat, see also Figure 2). This advantage is quite similar in the situation of the lower point-supported posture (point support, see Figure 2B), where the support takes between 40 and 50% of the body weight off of the legs. Considering this aspect, the lower point-supported posture offers almost the same advantages as a regular toilet seat, on top of its other advantages in comparison to elevated toilets (low risk of tumbling, better transit of faeces, lower risk of constipation).

2.4. Further Studies

The forces in the lower point-supported sitting posture (Figure 2 middle) are carried by the ligaments and the muscles. The actual distribution of these forces and torques on every component (bone, tissue, muscles) theoretically has been determined, however has not been confirmed yet by measurements in practice. With these measurement data a more accurate validation of the profits of the lower point-supported sitting posture can be made.

Buttock support 60-70% Point support 40-50%

Figure 2. Forces in different toilet sitting postures P. Musch and M. den Hartog / Plea for Use of Lowered Toilet for All 263

3. Lowered Sitting As a Training for the Stool?

It has not been proven, but it seems logical to suppose that regular use of a point- supported lower toilet starting at young age will develop better muscle condition and flexibility for the user. Together with better posture (of the pelvis) this could help decrease potential constipation problems or maybe even prevent them in old age. As the elderly population is not ‘trained’ in this respect, it is expected that inexperienced use of a lower point-supported toilet will most certainly cause problems. Solutions can be found in aids that help to start and support the movement at a higher level, and those that support the user during the downward movement into the lower supported position, including adequate aids to help the user get up again. A ‘sit-stand’ support will function in a similar way as current solutions for ‘sit-stand’ aids, only differing at the end position which is significantly lower than usual. By the way, every centimeter lower is already an improvement compared to the current toilet elevators. It is known [5] that a passive stimulation of muscles indirectly causes a training effect on those muscles working in the opposite direction. This also works for the use of the ‘squatting’ muscles during a supported movement, both for the movement of the actual ‘squatting’ and for the movement of getting up from out of the lower point- supported posture. We therefore may postulate the assumption that the lower point- supported toilet posture can be regarded as training for these muscles, with a matching expectation of positive side effects on potential constipation.

3.1. More Stability When Sitting Lower

The gravity centre of an upright sitting person on a regular toilet is about 20 cm behind the feet. (see Figure 3C). The exact distance depends on the body size of the user and on the actual posture of the user. Sitting down on a toilet seat requires a backward horizontal gravity centre displacement of about 20 cm, some 2/3 of the seat depth. To get up without using the arms, the user has to ‘throw’ the upper body forwards, which creates a momentum that brings the gravity centre above the feet again. Frequently, elderly toilet users are either not able to or do not dare to deliver this momentum. In that case the elderly toilet user will either choose to slide to the front of the seat, or will reach out for a support. Both choices create a risk of tumbling. In the Figure 3, a P50 woman is shown in four postures: lower point-supported sitting, squatting on a platform with a slope of 15o, sitting on an average toilet seat (42 cm height) and finally standing upright. The gravity centres in all postures are marked indicatively with a black dot. When sitting on a lower point-supported construction, the distance between the gravity centre and the feet is about 8 cm. Standing up from this lower point-supported posture is safer as it requires only leaning forward, thus bringing the gravity centre above the feet. Additionally, the fact that the legs are in good contact with the floor creates a very stable situation. To get up again there is no need to slide or reach forward, the user just has to stretch his legs. Only in situations where a toilet user (who is able to go into this lowered position) lacks muscle strength or stability, extra support will be necessary.

264 P. Musch and M. den Hartog / Plea for Use of Lowered Toilet for All

Figure 3. P50 woman on point-supported seat, squatting on a sloping platform 15o, sitting on toilet (42 cm) and standing upright. The black dot indicates the gravity centre.

3.2. Lower Point Support More Hygienic

In regular every day female toilet use the cleaning is practically realized by sliding forward and backward on the toilet seat. Men will probably prefer to stand up in order to clean, thus avoiding undesirable ‘skin-seat’ contact. The situation with increased toilet seat height creates difficulties for the elderly lady in this respect, since the opening quite often is significantly smaller. For small women with shorter legs situated at increased height, not being able to reach the floor, an unhygienic smearing of the seat can be the result. On a regular toilet seat, skin contact with the seat is normal. The lower point- supported toilet concept reduces this skin contact to the point-support. In theory, the lower point-supported toilet concept shows an advantage with respect to hygiene. Since the faeces pass at close distance to the point support, the design of this support will have to be determined very precisely to enable the user to take place in exactly the right position and to create the conditions for hygienic use. Similar to the squatting posture, the lower point-supported posture causes the buttocks to be more spread open, thus reducing the need for cleaning. For this reason the lower point-supported posture can more easily be combined with integrated hydration/dry systems because these systems will work more effectively. Hydration/dry systems also match the cultures in which the use of toilet paper is considered unhygienic. Without a hydration system, it is necessary to clean buttocks at the lower position, because when cleaning after getting up, the buttocks automatically join, with increased need for cleaning as a result. For the elderly user this raises the question whether it is possible to comfortably clean in the lower point-supported position. At the same time one should question the stability of elderly persons sitting on a seat far too high for the legs to reach the floor, wanting to clean and not being able to do so without holding oneself with one hand or having to stand on the floor first, which causes a dirty toilet seat. A slightly more uncomfortable lower point-supported posture with both feet firmly on the ground might be preferred purely from a safety and hygiene point of view. P. Musch and M. den Hartog / Plea for Use of Lowered Toilet for All 265

3.3. ‘Pressing’ Easier in Squatting Posture

In literature [2] it is indicated that the squatting posture shows a relaxation of the muscles of the pelvic floor, so that the bowels are not obstructed during discharge. It is also mentioned that squatting enables a better possibility to press with the abdominal muscles [4]. The posture of the lower seat with point support seems to provide almost the same stimulating conditions for the pelvis to rotate and for the legs to spread, thus creating a situation for the upper legs to push back. This will result in a preventive advantage with respect to constipation problems.

4. Ergonomics of the Lower Sitting Posture

With a regular toilet seat the user’s weight is spread over the whole surface of the toilet seat. In the situation of the lower point-supported posture, more body weight is concentrated on a significantly smaller surface. This requires specific dimensions for the shape and comfort of the design of the point support. It also means that the legs will be actively used for balance. On average, adult buttock bones are some 25 mm wide and some 40-50 mm long, and the distance in between varies from 120 to160 mm [2]. With female buttocks, this in between distance is on average some 20 mm wider than with male buttocks. For optimal comfort the buttock bones will have to be supported fully yet allowing for hygienic toilet use. The ideal point support opening therefore should lie somewhere between 75 and 90 mm. This demands a clever design, especially with respect to the space needed for cleaning both at the front and at the back side of the point support. Broad openings at the front and back side of the toilet seem a logical solution, since the user of the lower point-supported toilet will not be able to slide on the seat as usual. Finally it is important that the toilet offers enough space to place the feet as close to the gravity centre of the body as possible.

Figure 4. ADAPS study: Use of mockup by P5 woman and P95 man

266 P. Musch and M. den Hartog / Plea for Use of Lowered Toilet for All

4.1. Ergonomic Demands for Lowered Sitting with Point Support

The above-mentioned translation of the squatting posture anthropometry into a lower point-supported posture was first put into a geometric substructure. The research was at first focused on the able-bodied adult user up to an age of 55 years. The goal of the study was the development of a preventive toilet concept with an integrated point support to be used by everybody. Later it was decided to examine the concept for use by the elderly user as well. The geometric substructure was qualitatively examined by making use of the ADAPS programme (see Figure 4), after which a foam mock-up (see Figure 5) was built that was tested by 20 people (wearing clothes). In the foam mock-up the point support is integrated at an average (free squatting) height (Figure 1C) of 25.5 cm, combined with a foot support in the form of a wedge with an angle of 15o. The ADAPS study above did not make use of this foot support. The support of 15o under the feet provides the user with some extra comfort and makes it more easy to go into the lower sitting posture [4].

4.2. Testing the Lower Sitting Concept

A group of twenty test subjects with an average age of 27 years examined the lower point-supported sitting posture of the mock-up. On a questionnaire comments were given on the mock-up, on the movement necessary to go into lower supported sitting, on the comfort of the height itself, on the overall dimensions (space for cleaning), and on the appeal of the concept in general. The responses were used to improve the mock- up and to translate the mock-up geometry into a dimensioned and materialised global product design. In Figure 6 a ‘translation’ is shown of the geometric substructure into a contemporary looking lower point-supported toilet concept.

5. Increasing Elderly Population

This study was concluded in 1996, a period in which it seemed far too early to publish the innovative toilet concept. But today in 2008, the time seems right for the insight that elderly people are (preventively) helped by a lower point-supported toilet. The main advantages of this concept are lower risk of falling, less constipation problems, and increased hygiene. All of this leads, in the long run, to a prolonged independent use of the toilet in old age. This vision, however, does require some adaptations of the concept shown in Figure 6.

5.1. Solutions for Adapting the Concept to the Elderly User

Though the pictures of squatting elderly people in Figure 7 do justify some optimism, elderly users in general will have trouble to go into a lower sitting posture, if they ever reach that posture at all. (In this respect we focus on the elderly that are still ‘flexible’.) To support the elderly user during the movement of going down and getting up from the lower point-supported sitting posture, the toilet can be provided with a seat lifter and a support bar, preferably in front of the toilet [3]. Figure 8 indicatively shows a possible position for such a support bar for a P95 P. Musch and M. den Hartog / Plea for Use of Lowered Toilet for All 267

Figure 5. Dimensions of the mock-up 268 P. Musch and M. den Hartog / Plea for Use of Lowered Toilet for All

Figure 6. Materialized concept for lower point-supported toilet (front, side and scaled top view) © Studio DenHartogMusch, Arnhem 1996.

Figure 7. Squatting of a healthy elderly person (male, 75 years, 1.78 m, no support, feet flat with shoes, distance buttock to floor 25 cm; and female, 72 years, support, shoes, distance buttock to floor 23 cm, heels up).

male and a P5 female. Adaptations like the ones indicated here will probably be appropriate to adapt the concept of lower point-supported toilet to the elderly user, but the only way to examine this is by doing more research.

P. Musch and M. den Hartog / Plea for Use of Lowered Toilet for All 269

6. Conclusions

In the situation of lower point-supported sitting the gravity centre is closer to the feet, so the forces necessary to stand up can more easily be delivered by the legs. In comparison to the situation on a regular toilet seat, this leads to a significant reduction of the arm force needed in the case of a small person, since both feet already touch the ground. From this viewpoint, the lower point-supported toilet offers a more stable situation and therefore justifies the expectation that it will offer a safer condition than the current elevated toilet seats. Further investigation is needed to provide proof for this statement. Though still a lot of research has to be done to determine the definitive dimensions of the lower point-supported toilet and its additional supporting devices for the elderly user, there are strong indications that -despite the challenging movement of squatting for the elderly person- the concept of the lower point-supported toilet has serious user comfort to offer and may prevent many problems of hygiene, constipation and unsafety with conventional toilet seats.

Figure 8. (Above) indicatively supported lower sitting with sit-stand-up aid and support bar in front of P95 male, (below) indicatively supported lower sitting with sit-stand-up aid and support bar in front of P5 female

270 P. Musch and M. den Hartog / Plea for Use of Lowered Toilet for All

References

[1] Sikirov D. Comparison of straining during defecation in three positions; results and implications for human health. Digestive Diseases and Sciences 2003; 48(8); 1201-1205. [2] Hoekstra G. Toegepast onderzoek naar houding en antropometrie bij hurkend toiletteren. [Intern report, in Dutch]; Studio DenHartogMusch. Delft: Delft University of Technology, Faculty of Industrial Design Engineering;1995. [3] Snijders CJ, Molenbroek JFM, Plante RA. Biomechanical Aspects of Defecation with Implications for the Height of the Toilet. This volume. [4] Sonneveld M. Baarsteun voor verticaal baren [Master thesis, in Dutch] Delft University of Technology, Faculty of Industrial Design Engineering; 1989. [5] Hill AV. The heat of shortening and the dynamic constants of muscle. Proceedings of the Royal Society of Medicine 1938; B126: 136-95. A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People 271 J.F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved. doi:10.3233/978-1-60750-752-9-271 Alla Turca: Squatting for Health and Hygiene

Oya DEMIRBILEK1 University of New South Wales, Sydney, Australia

Abstract. This paper describes the traditional alla turca Turkish toilet, or squat toilet, as well as its more modern sitting version, and the hygiene etiquette in using the toilet, including the pros and cons of the squatting posture and the squat toilet. This is complemented with modern design solutions for these two types of toilets.

Keywords. Defecation, Constipation, Toilet, Height, Elderly, Pelvic Floor Muscle, Low Back Pain

1. Introduction

In most Muslim countries, squat toilets are the norm. These toilets, used by almost two thirds of the world population, may seem archaic and “undignified” to most Westerners, but they have been proven as being much healthier and more hygienic than the sitting ones [1]. There are several types of squat toilets (also known as Eastern, alla turca, Turkish, or Natural-Position toilet). These all consist essentially of a hole in the ground and places for the feet, with one exception, the "pedestal" squat toilet, which is as high as a standard sitting toilet. Old Turkish squat toilets, as well as the ones found in remote areas in the countryside, have a water tap and/or a container of water for washing the intimate parts with the left hand, and if available, toilet papers (see Figure 1). During the Ottoman period, squat toilets were in private rooms generally located outside of homes for hygienic reasons. This changed with the development and improvement of drainage and sewage systems and these toilets took their place inside the home, in a section called eyvan [2]. Figure 2 shows the basic types of Turkish squat toilets from the Ottoman period. In urban Turkish homes, many toilets have ‘evolved’ to the sitting types (also known as alla franca, Flush Toilets or Western Toilets) for most buildings. This was considered as modernisation and many families have opted to the sitting posture, finding it more comfortable and aesthetic, and more Western looking. The hygiene and health aspects of the squat toilet have slowly been ignored. Even after the introduction of toilet paper, water still remained as a cleansing agent, and has also been incorporated to sitting toilets (see Figure 7), in the form of a nozzle that comes out from underneath the toilet seat, from the back and squirts a jet of water. This is now a common feature in most households.

1 Contact Information: Oya Demirbilek; Email: [email protected] 272 O. Demirbilek / Alla Turca: Squatting for Health and Hygiene

One could possibly also squat over standard Western sitting toilets, after raising the toilet lid, but this requires extra care, as they are not specifically designed for this purpose. Some retrofitting apparatus and designs are available to facilitate this task. Please see Figures 10 and 11 for such examples.

2. Hygiene Etiquette in Using a Turkish Toilet

In relation to the grooming activities following the use of a toilet, Gallagher [3] separates the users in two categories “the wipers and the washers”. The Turkish culture belongs mainly to the washers’ category. Muslims, Japanese and continental Europeans are all ‘washers’, mostly using a bidet after passing motion. For the Muslims, this is also a religious requirement, while for the others; washing gives them a greater sense of hygiene. In the Muslim faith, this washing is concerned with cleanliness and purity of body and soul, and can be applied to both sitting and squatting toilet postures. This comes from the fact that the Islamic culture gives an important role to water in praying, to purify the body and the soul. “In the Islamic garden, the water is the mirror of the Heavens and the symbol of life [4]” says Ayşe Birsel, designer of Zoê, the Toto washlet (see Figure 7).

Figure 1. A typical Turkish squat toilet with a water tap on the right, a toilet paper roll holder and a wall mounted flush button. O. Demirbilek / Alla Turca: Squatting for Health and Hygiene 273

Figure 2. Ottoman squat toilets [2]

The Islamic faith has a long list of prescriptive rules regarding personal hygiene when it comes to the use of the toilet. This set of rules is known as Qadaahul Haajah. It is important to understand that these rules have been established well before the invention of toilet seats and toilet paper. Leaving the religious concerns aside, some of the rules for the hygienic etiquette of using a squat Turkish toilet are as follows [5]:

One should squat keeping thighs wide apart applying the stress on the left foot. After relieving oneself it is essential to perform Istinja (washing with water) of the intimate parts with the left hand and water. This has been updated by religious leaders as: "At the beginning of Istinja, it is preferable to use toilet paper three times”. After this process the hands should also be washed thoroughly.

274 O. Demirbilek / Alla Turca: Squatting for Health and Hygiene

Figure 3. Puborectalis muscle in the sitting and squatting posture [15,16]

3. Advantages of the Squat Toilet

The use of a squat toilet is said to have many health advantages from a physiological point of view [6,7,8,9,10,11,12,13]. First of all, it is considered hygienic, as it does not involve any contact between the user and a potentially unsanitary surface. There is also no potential splashing as there is no water in the bowl. Ergonomically, the squatting posture provides a natural body posture and is healthier than the sitting one, as it provides for the alignment of the rectum and the anus in a near vertical position. This is facilitating the complete evacuation of bodily waste. Furthermore, elimination of waste in this posture protects the nerves controlling the prostate, bladder and uterus from being stretched and damaged. Squatting also relaxes the puborectalis muscle and straightens the bend to allow waste to be evacuated easily (see Figure 3). It is also said that squatting helps in reducing the occurrence of diseases of the digestive system, such as constipation and hemorrhoids [14,15] and other colorectal disorders (such as colitis, diverticulosis and appendicitis). For pregnant women, the squatting posture is also said to be better as it does not apply pressure on the uterus, and daily squatting is reported to help prepare for a more natural delivery [12]. One other big advantage of squat toilets is that they are very easy to clean. They also consume less water per flush than western toilets and hence are more environmentally friendly.

4. Disadvantages of the Squat Toilet

From an ergonomic point of view, squat toilets are more difficult to use, requiring careful balancing skills. This is particularly important for people with knee joint problems, limited mobility or recovering from leg injuries. Elderly people may find it very hard to squat and rise back, if they are not used to it. For the large majority of the Muslim population, especially those practicing the religion with a regime of five O. Demirbilek / Alla Turca: Squatting for Health and Hygiene 275 prayers a day (involving a lot of kneeling down and rising up), squatting would not be a problem. Another big disadvantage is that squat toilets may often smell bad, as their traps design does not allow for a complete flush. The sitting toilet, due to its bowl design that traps most of the odor under water and to the fact that it is completely flushed after each use, does not retain any odor. Yet another disadvantage related to hygiene pointed out by Genç [2] is that the footrest may get dirty and cause the transfer of microbes around. This may not be such a big problem for domestic toilets as most people in Eastern and Asian countries take their shoes off inside their home, and some also have special slippers for using the squat toilet. On the other hand, this is a problem in public restrooms [2]. Finally, squat toilets may also allow splatter to occur on one's own legs and feet, not to mention the potential to lose back pocket belongings into the hole.

5. Modern Toilet Designs

Modern versions of Turkish toilet designs have been created during the years and the following section will discuss examples of these.

5.1. Squat Toilets

Although it is difficult to find examples of modern squat toilets, there are few designers reinterpreting the squat toilet. Two re-designs of the traditional Turkish squat toilet can be seen in Figures 4 and 5, both designed by Inci Mutlu and Gamze Akay for VitrA. In Sun (Figure 5), the foot grid, usually in the shape of two “elephant feet” has been extended all around the recess and the hole. The Water Room (Figure 6) was designed by Ayşe Birsel. This design is inspired by the beauty of water in nature, and incorporates a minimalist squat toilet which consists of a recess and a hole, with a bar to hold while rising up and a soft rock to lean

Figure 4. Squat Toilet by Gamze Turkoğlu Akay and Figure 5. Sun – Turkish squat toilet [18] İnci Mutlu for Eczacıbaşı VitrA [17]

276 O. Demirbilek / Alla Turca: Squatting for Health and Hygiene

Figure 6. The Water Room incorporating a squat toilet

against (encircled on the left of the image). The water room was awarded first prize at the “Design the Future competition” in Japan, in 1989, and an “ID Magazine Award for Concepts” in 1990.

5.2. Sitting Toilet with Imbedded Washing Pipe

As mentioned earlier, most seated type Turkish toilets have a washing copper pipe incorporated. A modern version is Zoê (Figure 7) designed by Ayşe Birsel for the Japanese company Toto.

Figure 7. Zoê Washlet O. Demirbilek / Alla Turca: Squatting for Health and Hygiene 277

Figure 8. Flo Figure 9. Pinz Ideation 2-in-1 [19]

5.3. Hybrid Toilets, Squatting/Sitting Versions

Flo (Figure 8) was designed by a team of staff and graduate students at Arizona State University, with the aim to design a sustainable, transgenerational toilet that would be usable by toddlers as well as by their grandparents [13]. Figure 9 shows Pinz, incorporating dual use of sit and squat toilet [19]. The benefits of Pinz are cited as follows: 1) Non-splashing, as the water level is close to he body; 2) Water saving with a pressurized cistern located next to the siphon jet; 3) No blockage with a large trap way (8 cm internal diameter); 4) Safe, as unlike Turkish toilets, this one is above the floor level with a rim around, avoiding slipping into the pan; 5) Hoods on both ends to contain urine spray, like Japanese squat toilets; 6) Easy installation, simply bolted onto the floor, like a normal toilet; and finally, 7) Choice of wet or dry landing.

5.4. Retrofit Squatting Devices for Sitting Toilets

Figure 10 and 11 below show two different temporary retrofit squatting devices easy to install. The first one, NaturesPlatform™, provides a platform over an existing seated toilet, enabling the user to squat. This device is manufactured in the UK. The second one, Lillipad also allows for a semi-squat position for those with limited flexibility, by raising the feet onto the front step while sitting on the toilet and leaning forwards. A more permanent example, the Toilet Transformer, Westernises and converts old-style Japanese squat toilets into the 21st century (see Figure 12).

278 O. Demirbilek / Alla Turca: Squatting for Health and Hygiene

Figure 10. NaturesPlatform™, Nature's Platform toilet converter (http://www.naturesplatform.com/)

Figure 11. Lillipad: retrofit squatting device for seated toilets [20]

6. Conclusion

Squat toilets have been designed and used in India, the Far East, Asia and Anatolia since ancient times. The instinctive squatting posture may well have inspired the design of the first squat toilets [2]. This posture has advantages and disadvantages. The main advantages can be summarized as follows: considered hygienic, this posture provides a natural body posture that allows better relaxation during body waste evacuation, which prevents diseases in the small intestines. Furthermore, it is eco-friendly as it uses less water. The disadvantages can be summarised as follows: this posture may not be comfortable for all, especially for the disabled and for elderly people with arthritis in the knee. Another disadvantage is that, in heavily used public restrooms, the footrests may hold dirt and bacteria that could be spread around by users [2]. O. Demirbilek / Alla Turca: Squatting for Health and Hygiene 279

Despite health and hygiene advantages, the Turkish squat toilet is getting less popular as days go by. The comfort of the sitting posture and the wide range of beautiful sitting toilet designs seem to shadow the advantages of the squat posture. The squat toilet is in desperate need of reinterpretation and innovation by talented designers to return into peoples’ daily life. Finally, increased concerns about the environment and irresponsible use of natural resources may well bring squat toilets back as a healthy and sustainable alternative to flushed sitting toilets.

Figure 12. Toilet transformer [21]

References

[1] Nature's Platform. Health Benefits of the Natural Squatting Position. [Internet]. 2006 [cited 2009 October 6]. Available from: http://www.naturesplatform.com/health_benefits.html [2] Genç M. The Evolution of Toilets and its Current State [Master Thesis]. Ankara: Middle East Technical University; 2009. [3] Gallagher W. Bath and Body Works. The Wilson Quarterly. 2008 Winter; 32(1):89 [4] Birsel A. On My Way to Water [Internet]. 2002 [cited 2002 May 5]. Available from: http://www.core77.com/Reactor/ayse/bio.html [5] QuantumFoam. Islamic Toilet Etiquette, QuantumFoam's Diary [Internet]. 2009 [cited 2009 October 10]. Available from: http://www.kuro5hin.org/ story/2009/2/20/15517/5559 [6] Aaron H. Our Common Ailment. New York: Dodge; 1938. [7] Bokus HL. Gastroenterology. Philadelphia: Saunders; 1944. [8] Hornibrook F. The Case for the Health Closet. The Architects Journal. 1963(July 31): p.221-232. [9] Davenport HW. Handbook of physiology, 4 (2nd ed.). Chicago: Appleton-Century-Crofts; 1966. 280 O. Demirbilek / Alla Turca: Squatting for Health and Hygiene

[10] Kira A. The Bathroom. New York: Penguin; 1976 [11] Heller J, Henkin W. Body Wise. New York: J.P Tarcher Inc/St Martin's Press; 1986. [12] Balaskas J. New Active Birth. London: Thorsons; 1991. [13] Christensen T, Takamura J, Shin D, Bacalzo D. Go With The Flo: A report on a collaborative toilet design project that utilized a transdisciplinary approach. International Conference in Lisbon. IADE Design Research Society; 2006. [14] Dimmer C, Martin B, Reeves N, Sullivan F. Squatting for the Prevention of Hemorrhoids? Townsend Letter for Doctors & Patients. 1996;159:66–70. Available from: http://www.uow.edu.au/arts/sts/bmartin/pubs/96tldp.html. [15] Natures Platform. A Clinical Study of Sitting vs. Squatting. 2002 [cited 2009 October 12]. Available from: http://www.naturesplatform.co.uk/site/clinical_study_of_sitting_squatting.php [16] Toilet related ailments .com. Colon Cancer - Why Is It So Common In the West, But Not In Other Places? [Internet] 2009 [cited October 8]. Available from: http://www.toilet-related- ailments.com/colon-cancer.html [17] Özcan CA. H20 Not Water Everywhere Cultures Evolutionary Design Practices. The 6th International Conference of the European Academy of Design. Bremen; 2006. [18] VitrA Bathroom Culture. 2008 [cited 2009 Dec 3]. Available from: http://enexp.vitra.com.tr/ design_culture/overview.aspx [19] Pinz Ideation. 2009 [cited 2009 Oct 7]. Available from: http://www.pinz.com.sg [20] Lillipad. 2009 [cited 2009 October 8]. Available from: http://lillipad.co.nz/ [21] Toilet Transformer: zaps old-style Japanese squatters into the 21st century. 2007 [cited 2009 Dec 5]. Available from: http://www.digitalworldtokyo.com/index.php/digital_tokyo/articles/toilet_ transformer_zaps_old_style_japanese_squatters_into_the_21st_century/

Subject Index

ADL 127, 166 knowledge base 94 ageing 3 knowledge management 94 ambient intelligence 151 laboratory testing 141 anthropometry 228 low back pain 207, 271 applied ergonomics 35 multiple sclerosis 166 assisted transfer 151 observational study 127, 141 assistive devices 183 older persons 151, 166 assistive environments 217 outcome assessment 250 assistive technology 35, 49, 60, 69, peer review 49 101, 112, 250 pelvic floor muscle 207, 259, 271 autonomy 166 personal hygiene 194 body support 194 potentially vulnerable users 49 care 19 quantitative research 69 co-operative work 94 quest 250 comfort 19 RFID 151, 166 computer based interviews 80 research ethics 60 computer security 27 rest room 35, 101 confidentiality 27 safety 19 constipation 207, 259, 271 security 19 cultural differences 35 seniors 194 day care 166 slips 183 defecation 207, 271 smart home 112 demography 3 smart toilet 112 design 112 squatting 259 design evaluation 217 support 183, 259 design for all 7 toilet 35, 60, 69, 80, 101, 127, 141, design process 217 151, 166, 183, 194, 207, 259, 271 disabilities 127 toilet environment 228 disabled 35, 228 triangulation 60 elderly 35, 101, 127, 141, 207, trips and falls 183 228, 259, 271 universal design 7 ethical guidance 49 usability 242 ethics 35, 49 user centred design 242 experiences 19 user involvement 49, 60 factor analysis 250 user needs 60, 69 health data 27 user preferences 194 height 207, 271 user satisfaction 250 home automation 19 user test 194 human computer interface 101 user trialling 242 inclusive design 7, 35, 183 user-driven research 3, 60, 69 information gathering 80 validation 250 information systems 27 virtual reality 80 international survey 69 well-being 217 This page intentionally left blank A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People 283 J .F.M. Molenbroek et al. (Eds.) IOS Press, 2011 © 2011 The authors. All rights reserved.

Author Index

Alm, N. 80, 101 Liaskos, J. 27, 94, 141 Ambrose, I. v Magnusson, C. 101 Boess, S.U. 217 Mantas, J. vii, ix, 27, 94 Buzink, S.N. 183, 194 Mayer, P. 101, 151, 166 Charalampidou, M. 94 Menezello, T. 127 Dayé, G. 3 Molenbroek, J.F.M. vii, ix, 7, 35, Dayé, C. 60, 69, 166 112, 183, 194, 207, 228 de Bruin, R. vii, ix, 7, 35, 112, 183, Morrison, K. 80 228 Musch, P. 259 de Witte, L.P. 250 Panek, P. 101, 151, 166 Dekker, D. 112, 194 Plante, R.A. 207 Demers, L. 250 Rauhala, M. 49 Demirbilek, O. 271 Rist, A. 112 den Hartog, M. 259 Rooden, T. 242 Edelmayer, G. 101, 151, 166 Schlathau, R. 166 Egger de Campo, M. 60, 166 Ska, B. 250 Gentile, N. 166 Snijders, C.J. 207 Gregor, P. 80 Sourtzi, P. 127, 141 Groothuizen, T.J.J. 7, 112, 183 van Berlo, A. 19 Haagsman, E.M. 183 van Weeren, M.H. 80, 112 Hands, K. 80 Weiss-Lambrou, R. 250 Hine, N. 80 Wessels, R. 250 Joel, S. 80 Zagler, W.L. 151 Knall, G. 141 This page intentionally left blank This page intentionally left blank This page intentionally left blank