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

As part of its Fifth Framework Programme of Research and Technological Development, 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.

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.

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.

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.

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.

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’.

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.

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.

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.

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.

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 two-fold: 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.