Jo-Anne Bichard & Gail Knight
Helen Hamlyn Centre for Design, Royal College of Art
The design and provision of toilet facilities for people with disabilities has been covered in great depth by research (see Feeney, 2003), that in the UK, helped develop the ‘British Standard BS8300: Design of buildings and their approaches to meet the needs of disabled people’ and ‘Approved Document M of the Building Regulations’. However, research undertaken by Hanson et al (2007) has found that many older people do not think they are ‘entitled’ to use the accessible (disabled) toilet and therefore feel their needs are not being met, both in design and provision of lavatory facilities they may need when ‘away from home’. [1,2]
Current research being undertaken at the Royal College of Art Helen Hamlyn Centre (RCAHHC) is aiming to address the issue of older peoples access to ‘away from home’ toilet facilities. The research is focusing on the environmental barriers our ageing society faces when attempting to access a toilet away from home. Access to toilet facilities is one of the primary issues faced by many people who manage continence conditions, either as a temporary situation or more long-term chronic health concern. Examination of the issue of continence is being carried out by the RCAHHC in conjunction with a consortium of other researchers  on a project called ‘Tackling Ageing Continence through Theory Tools and Technology’ (TACT3). This is a three-year study that is specifically focused on age related continence, and is funded by the New Dynamics of Ageing (http://www.newdynamics.group.shef.ac.uk/) a unique collaborative research programme that is investigating the needs and issues of an ageing population and funded by all five of the UK’s research councils.
This posting specifically discusses the work package ‘Challenging Environmental Barriers to Continence’. It highlights current innovations in the design of non-domestic lavatory facilities and interventions, as well as demonstrates how these may not be suitable for an ageing population. The provision of toilets used by members of the public will be presented as a case study of how design needs to negotiate the physical and cognitive needs of a population to meet needs across the life course.
Toilet Provision for an Ageing Population
Besides dementia, which will be discussed in more detail in the next section, nothing is more feared by many older people than incontinence. Whilst the condition is not directly a consequence of ageing, urinary incontinence affects between 30-60% of women over the age of 40, and around 15-30% of men. Studies have shown that whilst urinary function does diminish with age, this can be exasperated by medication taken to counteract other chronic illnesses associated with the ageing process including; heart failure, some forms of cancer, Parkinson’s and Alzheimer’s disease. Even for many older people who are not managing health conditions, the general effects of ageing on the body may result in the need to use the lavatory urgently and with more frequency. Ageing amongst the oldest old, those aged eighty, ninety and even centenarians, may make physical mobility more difficult and affects continence simply because an older person may find it harder to transfer on and off the WC pan or even reach lavatory facilities in time.
After climate change, the second most pressing issue for many of today’s societies is the global ageing population. It is currently estimated by the World Health Organisation that there are 6000 million people in the world aged 60 and over, and this figure is predicted to double by 2025 (WHO 2004). In the European Union it is estimated that 20% of the population are aged 60 and over, and like the global phenomenon this figure is also expected to double.
With a global ageing population, the issue of accessing appropriate lavatory facilities will be seen to be more pressing for independent living, well being and quality of life issues for older people. In 2007 it was estimated that half of the global population now lives in cities. The course of the twentieth century saw the mega city, with populations over 10 million people, extend from two to twenty. It is estimated that by 2030, 3 out of 5 people in the world will live in a city (WHO, 2007). With the growing ageing population and the move to more urban centres, The World Health Organisation has identified the provision of public toilets as essential to its ‘Age Friendly Cities’ programme.
Due to difficulties accessing toilets when away from home, many older people have been known to limit the time and the distances they leave their homes for. Yet, in contrast to a growing ageing population in the UK, the charity Help The Aged (2007) has found that the number of available public toilet facilities has dramatically declined.
In the United Kingdom, local authorities generally operate public toilet facilities. Provision is discretionary and there is no legislative enforcement that ensures an area has public toilet provision. Estimates suggest that current toilet provision operated by local authorities has dropped from approximately 10,000 in 1999 (Audit Commission, 1999) to 4423 in 2008 (Value Office Agency, 2008). With the UK population estimated by the World Bank to currently stand at 61,399,118, there is approximately one public toilet for every 13,882 people.
Help the Aged’s research has found that the reduction in provision especially at the local neighbourhood level can severely limit people’s activity’s of daily living such as going to the shops for food. Such restriction on movement can result in social isolation and avoidance of travelling to visit family and friends and going to work. The larger consequence of such access concerns has been found to be greater instances of low self-esteem, depression and loneliness, all of which draw on the resources of the local health authorities and social services.
We therefore have a need for facilities to be placed in the built environment that can be accessed by all but especially an ageing population. Yet for successful toileting a number of supporting interventions need to also be considered as part of the wider spectrum of toilet provision.
Figure 1. An Automatic Public Convenience (APC)
Design Innovation for Toilet Provision.
Despite the closure of many of the UK’s public toilets, there have been a number of innovative designs that attempt to address the issue of toilet provision with innovative and technology inspired designs. The Automatic Public Convenience (APC) also known as the ‘Superloo’ or ‘Tardis’ (Fig. 1) began appearing on UK streets in the early 1990’s, but has not found favour with the toileting needs of the public (Bichard & Hanson, 2009). Previous research undertaken by Hanson et al (2007) found that many people would prefer to travel to the top floor of a department store then use an Automatic Public Convenience. In addition, their case studies of provision found that women over the age of 65 would not use this type of toilet provision. One user commented that the reason they avoided this form of provision was because it was too unfamiliar and perceived as complicated:
“I don’t know how to use one (APC)… I’m not standing outside reading instructions on how to use a toilet”.
A more recent innovation has seen the needs of evening toilet provision addressed by the ‘Urilift’ (Fig. 2a, 2b). This ‘pop-up’ urinal is raised by remote control at dusk and set back in the ground at dawn. Designed primarily to counteract the effects of street urination (both the unsightly behaviour associated with this practice and the environmental distress caused by uric acid in urine), the Urilift has become a popular option amongst local authorities seeking to address the need for evening toilet provision. Noticeably the Urilift (and other temporary urinal solutions) only addresses the needs of the male population, and within this sector is not a toileting solution for men who have Paruresis (shy bladder syndrome); men who observe faith and hygiene practices with regards to toileting, and older men who find such urinals still somewhat exposed.
Figures 2a, 2b: ‘Urilift’
A more recent design incorporates a urinal into a ‘wheelie bin’ (Bischof, 2009) and like most recent design solutions; this only meets the need of one small segment of the population (Fig. 3). In addition, such design interventions do nothing to challenge and discourage street urination. Indeed, it can be argued that such solutions continue to indulge the practice of street urination, which in general is considered anti-social behaviour.
Given that these current innovations do not meet the wider public preference and therefore needs, especially those of the ageing population, the researchers at the RCAHHC are investigating how provision can be best maximised to offer toileting facilities that are well designed for hygiene, access, comfort and dignity, and that will be welcomed by the majority of users.
Figure 3: Wheelie Bin Urinal (Bischof, 2009).
Thinking about the needs of an ageing society
Whilst not exclusively a consequence of ageing, many older people do develop some form of cognitive impairment, and it is currently estimated that over 800,000 people in the UK have some degree of cognitive impairment associated with dementia. This number is expected to rise to over one million in the next 30 years (Matthews et al 2005).
Dementia is a degenerative impairment, and therefore the cognitive functions of people with dementia are unlikely to improve. Current and future medical advances are likely to increase the survival of older people, and thus it can be surmised that the populations of people with cognitive impairments are likely to increase. Globally, over 35 million people are currently estimated to have dementia, and 4.6 million new cases are diagnosed each year. There is a myth that diseases like Alzheimer’s are only associated with living in developed economies with the rate of dementia expected to double between 2001 and 2040. Yet 60 percent of people with dementia live in developing countries and it is forecast to increase by more than 300 percent in India and China (Ferri et al, 2005).
The Second Nature of Toileting
For many people, the act of using the toilet does not require much thought regarding of the use of the space and it’s supporting products. After the initial conscious cue for the need to excrete, the use of the lavatory environment from opening to closing the door, sitting on, or standing in front of the WC pan, flushing after we leave the cubicle and washing our hands at the end of the toileting ritual can be considered mostly an unconscious activity, in many ways ‘second nature’ (Bichard et, al 2005).
Yet such instinctual behaviour may become more conscious through the ageing process. Freund (2001) has noted that age associated impairments may shift how an individuals experience of their body. Stiffness, loss of strength and aches and pains may become more acute, making routine and everyday activities increasingly difficult and therefore more noticeable. This may lead to a once familiar friendly space becoming associated with pain and anxiety. Hence it is suggested that the use of space with ease is not an issue in the context of mechanistic ergonomics, but one of an ‘embodied relationship to the physical artifacts and environments’ (Freund 2001:699). In the case of using toilets when away from home, the unconscious and second nature of toileting may become conscious and fraught with difficulty due to the lack of available facilities with familiar products and associations. These might in turn, be primarily based on familiarity with the design of the domestic toilet facility. For people with cognitive impairments the familiarity with domestic designs such as the shape and operation of the flush handle can act as a signal for the ‘embodied relationship’ such as flushing the toilet after use, and therefore action the appropriate behaviour within the space. Such deviation in design of such essential facilities within the built environment may confuse some users and result in a familiar space and wider environment becoming unfamiliar and possibly threatening, and therefore avoided.
Challenging Environmental Barriers to Toilet Access for Older People.
To address the toileting needs of the ageing population, the first year of the TACT3 research has been talking to users to understand their experience of using toilets when away from home. In year two of the research we will take the user insights and requirements to those who manage toilet provision to understand what barriers they experience in providing facilities that users want. Finally, in year three, the research will consolidate the users and providers perspectives and experiences into design briefs that will aim to address the needs of both users and providers.
Initially user consultation was only to be with members of the public aged 50 and over. However at the first ‘expert forum’ with members of the New Dynamic of Ageing’s ‘Older Peoples Reference Group’ the researchers were advised to include the perspectives of all ages in the research, as access to toilets is a lifelong concern. Subsequently, the researchers constructed a methodology that would include the toileting needs of those aged 1-101i.
A Life Course Methodology
A life course framework has become a major methodological perspective in epidemiology and Public Health studies, as well as in wider notions of health and well being (Ben-Shlomo and Kuh; 2002). In contrast to more conventional epidemiological studies that recruit subjects in mid-life, a life course perspective offers a multi-disciplined approach that can illustrate how biological, behavioral and psychosocial pathways can ‘operate across an individuals life course, as well as across generations to influence the development of chronic diseases’ (Ibid, 2002;285). Life course approaches have also been adopted by sociologists’ to examine sociohistorical and biocultural contexts as well as biological anthropologists to explore disease consequences and has been presented as a powerful tool to test social interventions (ibid, 2002;291). Thus it can be surmised that the life course approach is based on biological and social factors that influence disease experienced in adulthood through factors that are independent, cumulative and interactive.
Whilst the connections between urban design and public health are not new, Northridge et al (2003) propose that there has been a demise in considering the links between urban design, especially planning, and public health, and urge for a re-establishment of the historic link between the built environment and public health, especially when considering the impact of mega cities.
Considering a life course approach in the inclusive design of public toilets offers a number of challenges. The research does not set out to create links between provision and continence, rather it is assessing how the design of the toilet cubicle maybe a barrier to use throughout the life course. For example, young children may have difficulty getting onto the WC pan, whilst older people may experience difficulties getting off the WC pan. By identifying issues that are experienced across age groups, the research aims to pin point areas where new design briefs may offer interventions that are suitable across generations and can therefore be considered to be more suitable for the life course of the population.
Identifying User Preferences
Currently over 100 Telephone and face-to-face interviews have been conducted with members of the public and providers of public toilets. In addition to personal details such as age and gender, each interviewee is asked to identify the type of area they would primarily require toilets in (home or work). The area types are identified as urban, suburb, town or rural. This last question helps the research to identify how provision can sometimes be a ‘postcode lottery’ in which locality determines the adequacy of provision, and what alternative solutions might be preferable. More importantly, as a user-centred inclusive design project the researchers will focus the design solutions on the areas of importance that users cited. We therefore asked interviewees to identify three main issues of concern that they felt should be addressed by the research. Interviews have been analysed by reference to re-occurring themes and the current issues that have emerged across age groups and genders are hygiene, information and cubicle design.
One user summed up the issue of hygiene as:
“Your confidence in the cleanliness comes from what it looks like on the outside and if you can see an attendant… if you can’t see those things then your confidence level starts dropping and you just don’t want to go in there”.
The importance of hygiene for the majority of users made it apparent that it is a central aspect of the design is for the toilet facility, in that it has to be accessible, not only to the user but to those who maintain the cleanliness and management of the facility. Therefore ensuring that the cubicle can be physically accessed by users, and those who maintain the facilities, such as cleaning and maintenance professionals, can be considered an essential element of the design brief.
The second key issue for research participants was the information used to not only find a toilet facility, but to ensure a hygienic level of provision. One participant commented:
“You can look at a map of the town, it might tell you where the toilets are but its not going to tell you what they’re like”
Many research participants commented that signs often do not include distances to the facilities or are often out of date resulting in finding the toilet facilities closed or gone altogether. The research is therefore including design briefs for directional and maintenance information.
Hygienic consideration of a number of supporting products has also emerged. One user commented:
“like it where you don’t touch the taps, its all sensored, that is a good idea, especially now people are so aware of cleanliness, like the dryers and the taps, sometimes as well the flush, so now the only thing you really need to touch is the locks on the doors”.
In contrast another user commented:
“What’s important to me is the ease of using one (toilet). For example there is one that is atrocious to use, you don’t know how to get in, you don’t know how to get out of it. You have to read a few things to know how to work the functions of what works automatically, which one to push, which colour to push, although they forget that people can also be colour blind”.
Here we see the tension between user acceptability of technological innovations and user resistance to the unfamiliar within the space of the toilet. These design issues are not new and have been identified by previous research in regards to access for people with cognitive disabilities and age related degenerative cognition (Hanson et al, 2007).
Research participants have identified a series of essential design interventions that are needed to support not only age positive toilet provision, but that can also extend across the populations life course. However, a number of design solutions have considered these issues but have proved not to be user friendly. In the rest of this posting, we attempt to illustrate how some technological interventions can be considered to have hindered rather then helped toilet access and use.
Information: Way Finding and Signage
For many people but especially older people who may need to find toilets urgently and people with dementia who may experience confusion, remaining continent is a major element of maintaining independence. As such, in the design of care centres and care homes, the maintenance of independent toileting has been an important aspect for interior design guidelines. It is recognised that an essential aspect of this is through making toilet facilities easy to locate and identify. Yet, as Greed (2003) has noted, such design consideration has not been extended to the built environment, and what remains of public toilet provision in the UK is sometimes positioned in segregated ‘out of the way’ locations that are difficult to find, and in some instances can feel threatening to potential users.
Previous research of care home design identified that adequate signage using a singular word such as “toilet” or a graphic of a familiar household toilet, increased usage. In the UK the current sign for the accessible toilet is a pictogram of a person using a wheelchair. Older people have reported that they would not consider using the ‘disabled’ facilities, even though the use of grab rails and accessible hand washing facilities such as levered taps may make toileting more comfortable. In addition, a person with dementia may not be easily recognise the ‘wheelchair’ symbol as an indication of an appropriate facility for them to use. Signs representing the appropriate gender often signify standard facilities. However, it is increasingly common for smaller businesses to provide as their only toilet facility a ‘universal accessible toilet’ to be used by both sexes and signified by the wheelchair pictogram. In addition, many UK public toilets are known and signposted by varied terms these include “WC” “Public Conveniences” and “Lavatories”. The lack of cohesion concerning the name of facilities could further confuse the person with dementia as well as users who are unfamiliar with the English language. Clear signage of toilet facilities would help all users, but would be significantly helpful for those who need to find toilet facilities quickly as well as people with dementia and learning disabilities who may experience difficulties with way finding.
Supporting Products: Door Locks
For the comfort, safety and dignity of most public toilet users, the first and possibly most important aspect of using the toilet will be to close and lock the door once they have entered the toilet cubicle. In recent cubicle door lock designs, especially those on ‘accessible’ trains, a three-stage electronic operation has been introduced (Fig. 4). Whilst removing the need for physical strength and manual dexterity to open a door, this mechanism involves pushing buttons in sequence to close lock and then open the door. This first two-stage operation (push button to close, push separate button to lock) effectively separates two closely related operations. To open the door a third separate button is pushed. Although instructions for the operation of the door lock are clear (and also provided in Braille), the need to pause and read in order to lock requires a degree of cognition and therefore such cognitive requirement to operate the door lock may cause difficulties for people with cognitive impairments as well as non-English speakers, and could lead to embarrassing and distressing situations.
Figure 4: Automatic Door Lock
Supporting Products: The Toilet Flush
There are a number of varied design options for toilet flushes. Carers of users such as children with autism and people with learning disabilities, have noted that the act of flushing can be considered the ‘reward’ for successful toileting, with the reward involving the twofold action of flushing as much as the consequence of the act (Bichard et al, 2005). More recent technological innovations such as Sensor-flushes actively remove the need to touch, pull or push the flush. Sensor-flushes operate by waving hands across the sensor. Yet, for people with cognitive impairments, the replacement of ‘hands on’ flush mechanism such as a handle, button, lever or pulley, with a hands free sensor application, may remove a familiar aspect of the toileting ritual and therefore may cause distress to a person who can not understand why they can not actively flush the toilet, and for some users receive the ‘reward’ for good toileting behaviour.
These examples have been used to illustrate how, in the case of toilet provision in public space, a technological approach may not be of benefit to the needs of all those who make up the potential users.
For many people abut especially people with cognitive impairments many aspects of the toilet may act as a cue for appropriate behaviour. The familiarity of a sign, the door lock and the handle of a flush, may all act as objects that focus the user on the use of the toilet. The replacement of such familiar objects with hi-tech solutions may effectively distract or confuse those with impaired cognition, and lead to an avoidance of perceived unfamiliar and unfriendly spaces.
There is a need for designers to understand precisely how each of the fixtures and fittings in WC cubicle may differ in use between a range of users of varying ages and abilities. This is a particular challenge for designers of Automatic Public Convenience’s (APC’s), but even in the familiar standard toilet block, the numerous technological ‘advances’ in fixtures and fittings, coupled to the ‘technisation’ (Freund, 2001:699) of the routine of using a public toilet facility may prove too complex for many users, especially for those with cognitive impairments.
Kitchin and Law (2001) have used the term ‘the bladders leash’ to describe how the mobility of people with disabilities is restricted in the urban environment by the absence of accessible public toilets in city centres. In addition, parents with young children and older people have reported that they too are limiting the amount of time they are away from home explicitly due to the lack of available toilet facilities.
The design of toilets used when away from home superficially presents itself as a technological affair in which successful design can be seen in getting a specification right (Hanson et al, 2007). Without understanding how the WC cubicle is actually used, by the wide range of prospective users, there will continue to be costly design responses that may exclude rather then include users, and do so from child to adulthood and into extended age.
For users under the age of 16, consent was sought from parents and/or guardians. For older people who are in care settings consent was sought from family members and/or carers.
There is currently a number of smart phone applications for finding toilets that include the opportunity to comment on the condition of the facilities. These include: Water Aid’s toilet finder, Sit or Squat, and Where to Wee.
1. It is recommended that toilets for disabled people should be referred to as ‘accessible’ toilets rather then ‘disabled toilets, as the latter can be considered stigmatising and offensive. However, in the 1970’s when the facility was introduced, and throughout the 1980’s when more facilities were built, the term ‘accessible toilet’ was not in common currency. Pre 2004 legislation referred to ‘toilets for disabled people’, and today many people with disabilities still refer to the facilities as the ‘disabled toilet’.
2. ‘Away From Home is a term coined by the British Toilet Association to describe all lavatory facilities used outside of the domestic space. This include public toilets operated by local authorities but also provision found in department stores, cafes, supermarkets, public houses etc.
3. The multi-disciplinary consortium is comprised of researchers from: Brunel University, The University of Sheffield, University of the West of England, Bristol Urological Institute, The University of Manchester, Dalarna Research Institute and the Royal College of Art.
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Jo-Anne Bichard & Gail Knight