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

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A FRIENDLY REST ROOM:

DEVELOPING TOILETS OF THE FUTURE

FOR DISABLED AND ELDERLY PEOPLE

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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.

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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

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All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without prior written permission from the publisher. ISBN 978-1-60750-751-2 (print)

ISBN 978-1-60750-752-9 (online)

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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 investiga-tions 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 es-tablish 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 difficul-ties; 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 ap-proach 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.

A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People J.F.M. Molenbroek et al. (Eds.)

IOS Press, 2011

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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 PopulaAc-tion 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 auton-omy, 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 eth-ics.

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 pro-ducers connected to the work performed during the length of the FRR project. We es-pecially 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 SoluInforma-tion 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.

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Last but not least, we would like to thank the hundreds of older or disabled partici-pants, many of them facing physical or mental difficulties, who were involved in all the studies mentioned. Especially considering this taboo surrounded topic, we admire tre-mendously 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: j.f.m.molenbroek@tudelft.nl

Dr. John MANTAS

Director of Health Informatics Laboratory, Professor of Health Informatics

Faculty of Nursing, University of Athens, Athens, Greece E-mail: jmantas@nurs.uoa.gr

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: rdebruin@ontwerpergonomie.nl

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Introduction

Johan F.M. MOLENBROEKa, John MANTASb and Renate DE BRUINa,c a_{Faculty of Industrial Design Engineering – Delft University of Technology,}

The Netherlands

b_{Laboratory of Health Informatics – Faculty of Nursing – University of Athens, Greece} c_{Erin 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 at-tention 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 dif-ferent 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 be-ings 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 de-velopment 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

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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 empiri-cal 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 con-trol 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 parame-ters 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 rehabilita-tion 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 com-petition 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 over-view of what has occurred in the last couple of years concerning the design and devel-opment 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, archi-tects, 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 eld-erly people can benefit from new technology in their homes with examples from prac-tice. 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

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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 prod-uct-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 digi-tal 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 dis-cussed, in Section 3 ‘FRR Case Studies and User Tests’ the focus lies on the user re-search 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 proto-types 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 ap-proach 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

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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 rou-tines. 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 de-signing, 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 de-velopment 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 squat-ting position is also favoured in ‘Alla Turca: Squatsquat-ting for Health and Hygiene’ by Oya Demirbilek and explains about the cultures – in this case specifically the Turkish cul-ture – that prefer the squat toilet. It shows many examples and closes with some mod-ern 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.

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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 independ-ence, 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.

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Section 1 General, Organizational and

Developmental Issues

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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

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Contact Information: Gertraud Dayé, Independent Expert; Adress: Kaiser-Franz-Josef-Kai 56, 8010 Graz, Austria; Tel: +43 316 678724; Mobile: +43 650 6787240; Email: gertraud.daye@aon.at

IOS Press, 2011

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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:

x Expanding participation of older persons in society and fostering social inclusion and independent living;

x Ensuring equal access to high quality health and social care; as well as x 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

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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:

x The FRR actually contributes to older persons’ independence, thus increasing their quality of life and respecting their dignity.

x 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.

x 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. x 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

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environments. The FRR could very well be a decisive element of such an age-friendly living environment.

x 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

G. Dayé / Meeting the Challenges of Demographic Change

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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: j.f.m.molenbroek@tudelft.nl

IOS Press, 2011

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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]:

x 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

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

x 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].

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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]

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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]:

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“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.

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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

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toilets are that comfortable for all of its users. Let’s consider the following groups and the standard public toilet environment;

x Wheel chair users (How to get on and off the toilet?)

x Rollator / Walker users (Where to park the walking aid and how to transfer to the toilet?)

x 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!) x People with a stoma (Where to place their hygienic aids?)

x People who suffer from arthritis (How to lock and unlock the door?)

x 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)

x 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

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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

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

A FRIENDLY REST ROOM:

DEVELOPING TOILETS OF THE FUTURE

FOR DISABLED AND ELDERLY PEOPLE

Assistive Technology Research Series

Volume 27

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

Foreword

Acknowledgements

Introduction

Contents

Section 1

General, Organizational and

Developmental Issues

Meeting the Challenges of Demographic

Change

Design for All: Not Excluded by Design