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
The Assistive Technology Research Series (ATR) aims to disseminate and archive assistive
technology research summaries widely through publishing proceedings, monographs, and edited
collective works. The series aspires to become the primary world-wide source of information in
assistive technology research, through publishing state-of-the-science material across all
continents. ATR defines assistive technology (AT) as any tool, equipment, system, or service
designed to help develop, maintain or improve a person with a disability to function in all
aspects of his or her life. Assistive technology helps people of all ages who may have a broad
range of disabilities or limitations. The ATR series will accept manuscripts and proposals for a
wide range of relevant topics.
Editor-in-Chief :
Rory A. Cooper
Editorial Board:
Angel Gil Agudo, Geoff Bardsley, Robert Bingham, Christian Buhler, H.S. Chhabra,
Gerry Craddock, Jin Dewen, Sten Ekman, Martin Ferguson, Shirley G. Fitzgerald,
Antal (Tony) Huba, Jeffrey Jutai, Kiyomi Matsuo, Mounir Mokhtari, Johan Molenbroek,
Hisaichi Ohnabe, Paul F. Pasquina, Marcia Scherer, Nigel Shapcott, Richard Simpson,
Ronaldo de Souza Moraes Jr., Thijs Soede, Pierre Soto, Eric Tam, Osamu Tanaka,
Julian Verkaaik, Howard Wactlar, Hans-Werner Wahl, Lloyd Walker, Jue Wang,
Brian Woods, Lucas van der Woude, Yusheng Yang
Volume 27
Recently published in this series
Vol. 26. L.H.V. van der Woude, F. Hoekstra, S. de Groot, K.E. Bijker, R. Dekker, P.C.T. van
Aanholt, F.J. Hettinga, T.W.J. Janssen and J.H.P. Houdijk (Eds.), Rehabilitation:
Mobility, Exercise and Sports 4th International State-of-the-Art Congress
Vol. 25. P.L. Emiliani, L. Burzagli, A. Como, F. Gabbanini and A.-L. Salminen (Eds.), Assistive
Technology from Adapted Equipment to Inclusive Environments AAATE 2009
Vol. 24. P. Topo and B. stlund (Eds.), Dementia, Design and Technology Time to Get
Involved
Vol. 23. M. Cabrera and N. Malanowski (Eds.), Information and Communication
Technologies for Active Ageing Opportunities and Challenges for the European
Union
Vol. 22. W.C. Mann (Ed.), Aging, Disability and Independence Selected Papers from
the 4th International Conference on Aging, Disability and Independence (2008)
Vol. 21. A. Mihailidis, J. Boger, H. Kautz and L. Normie (Eds.), Technology and Aging
Selected Papers from the 2007 International Conference on Technology and Aging
ISSN 1383-813X (print)

ISSN 1879-8071 (online)
A Friendly Rest Room:
Developing Toilets of the Future
for Disabled and Elderly People
Edited by
Johan F.M. Molenbroek
Faculty of Industrial Design Engineering, Delft University of Technology,
Delft, The Netherlands
John Mantas
Laboratory of Health Informatics, Faculty of Nursing, University of Athens,
Athens, Greece
and
Renate de Bruin
Faculty of Industrial Design Engineering, Delft University of Technology,
Erin Ergonomics and Industrial Design, Nijmegen, The Netherlands
Amsterdam Berlin Tokyo Washington, DC

2011 The authors.
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)
Library of Congress Control Number: 2011929728
Publisher
IOS Press BV
Nieuwe Hemweg 6B
1013 BG Amsterdam
Netherlands
fax: +31 20 687 0019
e-mail: order@iospress.nl
Distributor in the USA and Canada

IOS Press, Inc.
4502 Rachael Manor Drive
Fairfax, VA 22032
USA
fax: +1 703 323 3668
e-mail: iosbooks@iospress.com
LEGAL NOTICE
The publisher is not responsible for the use which might be made of the following information.
PRINTED IN THE NETHERLANDS

A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People v
J.F.M. Molenbroek et al. (Eds.)
IOS Press, 2011
2011 The authors. All rights reserved.
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 Commissions Work Programme, year on year from 1998 to 2002. This
approach may be summed up with three keywords: problem-solving, holistic and
multidisciplinary. These characteristics are identified as especially desirable in the
emerging field of ageing research, due to the complex and critical nature of many age-
related issues. Few funded projects were able to conduct research in a way which did
justice to all three of these priorities but FRR is one of those that did.
The reader of this book is therefore encouraged to reflect, not only on the insights
afforded by the particular results of this substantial work, chapter by chapter, but also
on the approach which the FRR project represents, through its methods and research
design, being a paradigmatic example of the new ageing research.
This page intentionally left blank
vii
Acknowledgements
The first ideas about writing a book about the sensitive topic of toileting derived from
the EU-funded project Friendly Rest Room (20022005), project number QLRT-
2001-00458 in the Quality of Life and Management of Living Resources, Key Ac-
tion 6: the Ageing Population and Disabilities programme. The Friendly Rest Room
(FRR) project focused on the problems the population elderly and disabled experience
in the toilet environment. The project was initiated in an attempt to enlarge the 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 Solution Kft.; and
Delft University of Technology (Section Applied Ergonomics and Design, Faculty
Industrial Design Engineering). The last one as coordinator of the FRR project also
was responsible for the left time and financial investments needed to publish this book
as it is.
We also want to thank our EU-project officer Dr. Gesa Hansen and our project
technical assistant Ivor Ambrose, who have provided the project with valuable advice
and support along the way.
viii
Last but not least, we would like to thank the hundreds of older or disabled 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
E-mail: rdebruin@ontwerpergonomie.nl
ix
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
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 [15]. 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 projects acronym FRR will be used). The FRR project was
part of the Quality of Life and Management of Living Resources Programme, under
Key Action 6 The Ageing Population and Disabilities and proposal number: QLRT-
2001-00458. The project ran from 2001 until 2005 and during that period a consortium
of 10 institutions in 7 European countries collaborated on the research, design and de-
x
velopment of a friendlier toilet for elderly/disabled users. The contributions of the FRR
consortium partners to this book therefore show the results of about 5 years of 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. Day, 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
xi
is given. In the paper When Ethical Guidance Is Missing and Do-It-Yourself Is Re-
quired: the Shaping of Ethical Peer Review and Guidance in the FRR Project Rauhala
describes what ethical challenges were faced during the project and how researchers
and developers in the FRR project coped with the sensitive topic of toileting and prod-
uct-testing with frail users. In User-Driven Research How to Integrate Users Needs
and Expectations in a Research Project C. Day 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. Day 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 rsum 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
xii
toilet environment show, focusing on the interaction with toilet and the toilet attributes
in search for data to build design guidelines for the FRR toilet.
Buzink et al. describe in Fall Prevention in the Toilet Environment the need for
more appropriate fall preventive measures and explain how a model was developed to
identify basic toilet activities with an increased fall risk. Next a new toilet support was
developed following the guidance of this model. In User Preferences Regarding Body
Support and Personal Hygiene in the Toilet Environment by Dekker et al. the search
for design guidelines continues. The paper covers the most sensitive subject of personal
hygiene and the balancing problems occurring when sitting down and rising from the
toilet. Tests were performed with a setup that consisted of an height adjustable toilet
bowl and various adjustable supports around it. The results give insight in the preferred
type and position of supports as well as more knowledge about personal hygiene 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 Peoples 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: Squatting 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.
xiii
Nevertheless our greying society is expressing the urgent need for research data on
the use behaviour and special needs of people in the toilet environment. This book
hopefully will add to the knowledge needed to develop a perfect friendly rest room, a
toilet of the future that enables disabled and elderly people to maintain their 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. Birkhuser 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.
xv
Contents
Foreword v
Ivor Ambrose
Acknowledgements vii
Johan F.M. Molenbroek, John Mantas and Renate de Bruin
Introduction ix
Johan F.M. Molenbroek, John Mantas and Renate de Bruin
Section 1. General, Organizational and Developmental Issues
Meeting the Challenges of Demographic Change 3

Gertraud Day
Design for All: Not Excluded by Design 7
Johan F.M. Molenbroek, Theo J.J. Groothuizen and R. de Bruin
Experiences with Smart Homes for Older People 19
Ad van Berlo
Health Data Security Issues 27
John Mantas and Joseph Liaskos
Section 2. The Friendly Rest Room Project
Overview of the FRR Project; Designing the Toilet of the Future 35

Johan F.M. Molenbroek and Renate de Bruin
When Ethical Guidance Is Missing and Do-It-Yourself Is Required: The Shaping
of Ethical Peer Review and Guidance in the FRR Project 49
Marjo Rauhala
User-Driven Research How to Integrate Users Needs and Expectations in a
Research Project 60
Christian Day and Marianne Egger de Campo
The FRR-Questionnaire Assessing Who Needs What Where 69
Christian Day
Computer Based Information Gathering 80
Norman Alm, Kenny Morrison, Peter Gregor, Nick Hine, Sian Joel,
Katrina Hands and Marja H. van Weeren
Knowledge Management 94
John Mantas, Joseph Liaskos and Martha Charalampidou
Rapid Prototyping of Interface and Control Software for an Intelligent Toilet 101
Charlotte Magnusson, Norman Alm, Georg Edelmayer, Peter Mayer and
Paul Panek
xvi
The Final FRR Components 112

Theo J.J. Groothuizen, Atilla Rist, Marja H. van Weeren, Dries Dekker,
Renate de Bruin and Johan F.M. Molenbroek
Section 3. FRR Case Studies and User Tests
Elderly and People with Disabilities Limitations in Their Everyday Life 127
Panayota Sourtzi and Terezinha Menezello
Experience of Testing with Elderly Users 141
Gunilla Knall, Panayota Sourtzi and Joseph Liaskos
Laboratory Tests of an Adjustable Toilet System with Integrated Sensors for
Enhancing Autonomy and Safety 151
Paul Panek, Georg Edelmayer, Peter Mayer and Wolfgang L. Zagler
Concept, Setting Up and First Results from a Real Life Installation of an
Improved Toilet System at a Care Institution in Austria 166
Nadia Gentile, Christian Day, Georg Edelmayer,
Marianne Egger de Campo, Peter Mayer, Paul Panek and
Robert Schlathau
Section 4. Aspects of Human-Product Interaction in the Toilet Environment
Fall Prevention in the Toilet Environment 183

Sonja N. Buzink, Renate de Bruin, Theo J.J. Groothuizen,
Eva M. Haagsman and Johan F.M. Molenbroek
User Preferences Regarding Body Support and Personal Hygiene in the Toilet
Environment 194
Dries Dekker, Sonja N. Buzink and Johan F.M. Molenbroek
Biomechanical Aspects of Defecation with Implications for the Height of
the Toilet 207
Chris J. Snijders, Johan F.M. Molenbroek and Rozemarijn A. Plante
Section 5. Design for Improved Toilet Environments
Designing for Older Peoples Experience of Bathing 217

Stella U. Boess
Anthropometrical Aspects of a Friendly Rest Room 228
Johan F.M. Molenbroek and Renate de Bruin
Involvement of Users and Practitioners in Anticipating Future Usage with
Design Models 242
Theo Rooden
Key Dimensions of Client Satisfaction with Assistive Technology:
A Cross-Validation of a Canadian Measure in The Netherlands 250
Louise Demers, Roelof Wessels, Rhoda Weiss-Lambrou, Bernadette Ska
and Luc P. de Witte
xvii
Plea for Use of Lowered Toilet for All 259

Pamela Musch and Maarten den Hartog
Alla Turca: Squatting for Health and Hygiene 271
Oya Demirbilek
Subject Index 281

Author Index 283
Section 1
General, Organizational and
Developmental Issues
A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People 3
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-3
Meeting the Challenges of Demographic

Change
Gertraud DAY1
Past Chair of the NGO Committee on Ageing UN, Vienna, Austria
and
Past Director of EURAG European Federation of Older Persons
General Secretariat, Graz, Austria
Abstract. The shifts in age-group ratios in the population are confronting all
continents with new challenges. At the moment Europe is at the top of the old age
statistics with the highest life expectancy rate. The changes in the age structure of
the population mean new socio-political responsibilities both today and in the
future. Participation of older persons in all decisions concerning them, has to apply
not only for age policies and social programmes, but also for the design of all
kinds of equipment, technical aids, plans for flats or homes for older persons, -
including restrooms. EURAG European Federation of Older Persons, welcomes
the approach of User Driven Research promoted by the European Commission,
GD Research as an important contribution to bringing the European Union closer
to its citizens.
Keywords. Demography, User-Driven Research, Ageing
1. Introduction
The shifts in age-group ratios in the population are confronting all continents with new
challenges. The comparison between the years 1999 and 2050 illustrates the dramatic
rise in the number of older people. United Nations forecasts predict an increase in the
number of over 60 year olds from 10 to 22 percent by the year 2050 alone. At the
moment Europe is at the top of the old age statistics with the highest life expectancy
rate. In the period 1960 to 1995 life expectancy in the European Union rose by 8 years
for men and 7 years for women. In 1995 almost one fifth of the population was over
60; by the year 2020 probably one in four will be in this age group. There is a
particularly striking increase in the number of the very old by about 40 percent.
The fact that an ever increasing number of people are reaching an advanced age
and that these are often years of health and activity can be counted as a very real
progress. Yet the changes in the age structure of the population mean new socio-
political responsibilities both today and in the future. Both governments and society are
called upon to join in facing these new demands.
Demographic change calls for a new definition of the relationship between the
generations. The International Year of Older Persons proclaimed by the United Nations
1
Contact Information: Gertraud Day, Independent Expert; Adress: Kaiser-Franz-Josef-Kai 56, 8010 Graz,
Austria; Tel: +43 316 678724; Mobile: +43 650 6787240; Email: gertraud.daye@aon.at
4 G. Day / Meeting the Challenges of Demographic Change
in 1999 gave an important impetus to this process. It resulted in a heightened awareness

that only A Society for all Ages will be in a position to tackle a common future. There
are no age limits to make a social political contribution. Older people are busy every
day in thousands of ways demonstrating that age is no barrier to embracing new
experiences, enriching our communities and enjoying life [1].
Yet, it must not be overlooked that people as they age are confronted with
deteriorating health and, often, have to cope with a restricted mobility. Consequently,
supportive measures and technical aids are required in order to enable older persons to
continue an active life in society even in advanced age.
2. The Importance of User Involvement Strategies
In adopting the Regional Implementation Strategy for the Madrid International Plan of
Action on Ageing 2002 [2], the representatives of the Member States of the United
Nations Economic Commission for Europe, gathered at the UNECE Ministerial
Conference on Ageing in Berlin in September 2002, gave particular priority to:
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. Day / Meeting the Challenges of Demographic Change 5
longer in their own homes, and/or to lead relatively more independent lives even if
living in an older peoples 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 peoples 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
6 G. Day / Meeting the Challenges of Demographic Change
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 fr 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] Day C. Master thesis at the University of Graz, Department of Sociology; 2004
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-7
Design for All: Not Excluded by Design

Johan F.M. MOLENBROEKa,1, Theo J.J. GROOTHUIZENb, R. DE BRUINc
a
Faculty of Industrial Design Delft University of Technology, Delft, The Netherlands
b
Design Consultant Groothuizen Beheer bv, Rotterdam, The Netherlands
c
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
8 J.F.M. Molenbroek et al. / Design for All: Not Excluded by Design
that year. For example The Netherlands are anticipated to have nearly 14 thousand
centenarians by then [3].
Although more and more of the older people are longer fit -quite a few even climb
to the top of the Mount Everest at the age of 70+ [4, 5, 6] people surviving to the ages
of 80 and 90 often are in a health situation that is very delicate. In the Netherlands at
least 30% of the people aged 65+ has one or more disabilities and 50% of the people
aged 90+ is demented [7]. Because of our modern healthcare people are surviving
serious illnesses more often. While staying alive they often inherit one or more
disabilities. It causes a growing need for services and products that can help them to
maintain their quality of life and stay independently at home for as long as possible.
In addition to the growing group of elderly and disabled people, currently another
population is calling for attention and rises in number and severity; obese people. In
many western countries almost 50% of the people are overweight. They too need
products and services that are better equipped to their needs (think about for example
toilet seats and supports for heavy people). In short one can conclude that the European
population now more than ever is in great need for products and services Designed for
All.
1.2. History of Design for All
The term Design for All (DfA) was first embraced and perhaps even initiated by the
European Institute for Design for Disabled (EIDD). Soon after its establishment in
1993, the EIDD developed the mission statement: Enhancing the quality of life
through Design for All. Design for All refers to design for human diversity, social
inclusion and equality [8]. The practice of Design for All makes conscious use of the
analysis of human needs and aspirations and requires the involvement of end users at
every stage in the design process [9]. Or as put on the EDeAN Design for All
Education and Training website [10]:
Design for All is a process whereby designers, manufacturers and service

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

of that regions 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 9
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 citizensaccess 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].
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 Copenhagens 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]
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 cant 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]:
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.
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
toilets are that comfortable for all of its users. Lets 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 childrens 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. Designers 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
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
other aspects like cognitive and social characteristics that play a role in the way
products are used. And maybe even more important: Designers should be properly
educated to read and use these sources in a correct way!
3.3. Education
In the curriculum of leading educations for engineering, architecture, software

programmers or city planners, Design for All plays in general a marginal role. On the
other hand, almost all curricula for education of designers of artefacts and services
include courses, which form a knowledge base to apply Design for All principles.
There are a few courses known at university level. Most are mentioned at the
website of the Institute of Human Centered Design in Boston [33]. From here a popular
free Newsletter about Universal Design is edited by Elaine Ostroff and distributed. In
this newsletter the highlights from each country are listed.
One of the known courses at university level is the elective course Inclusive
Design of the Industrial Design Engineering Faculty of the Delft University of
Technology (the Netherlands) that is educating product designers since 1987. Students
at the faculty of Architecture from the same university on the other hand receive
surprisingly few or no lectures in Design for All. It seems that despite some
exceptions e.g. the University of Buffalo where Prof Edward Steinfeld initiated IDEA
Center for Inclusive Design and Environmental Access [34] still much is to gain in
educating future designers, architects and planners about Design for All.
4. Conclusions
Design for All or Inclusive Design can be considered a design philosophy with the aim
to design products and services for the widest possible audience. In the "world of
design", mainly the responsibility of (industrial) designers, architects and city planners,
but also ergonomists and behavioural scientists, the practise of the principles of Design
for All is rapidly growing.
It must be stressed that applying Design for All principles should be evident for all
public products and services. People, users cannot avoid nor choose public services or
components of the public building environment. Many governmental organisations,
city councils or policy makers are not aware of the great responsibility they have
concerning the access of public products, services and space. It is surprising how many
public buildings, even newly created, do not offer accessibility for all.
An increasing number of design firms and in-house design departments offer
services related to the principles of Design for All. Governments increasingly
understand the importance of creating a non-excluding society, offering equal
opportunities and improvement of quality of live for all, organising conferences,
workshops and setting up organisations with the task to select best practices and give
awards to designs or environments that pay special attention to Design for All aspects.
But in spite of all these initiatives and achievements, Design for All is still a
special kind of design, a design for a special target user group. Should we not all
expect that the main principles of Design for All, the principle of trying not to exclude
anybody, would be a normal designers objective?
For some design schools, such as the Faculty of Industrial Design Engineering at
the Delft University of Technology, human centred design and sustainable
wellbeing is the core of their curriculum. Hopefully, educations for business

management, marketing, engineering and business administration will pay more
attention to the role of integrated design and development processes and the principle
of Design for All. This could be a sustainable strategy for improvement of the quality
of live.
For product designers, and the many professions involved in designing our living
environment, it should not be required to follow a special Design for All education
though. Designers, and certainly product designers, should always try to include as
many users in the use of their products. This implies that they should also be aware of
whom they exclude. It should not be what you have been told or some tools you can
use, but a basic mentality of every designer. Design aims to fulfil future needs, which
are nowadays aimed at the quality of life of the whole human race: Design for All.
As Susan Szenas, editor-in-chief of the Metropolis magazine, expressed it in her
keynote speech at the conference Designing for the 21st century (Rio de Janeiro, 2004):
The time is coming for building that road to a design that no longer needs to call
itself sustainable or universal - just good, need-oriented, environmentally sensitive
design. Just design. Design with justice at its core. [35]
References
[1] Summaries of EU legislation. The demographic future of Europe from challenge to opportunity.
[Internet] 2008 [update 2008 Dec 10, cited 2011 Feb 2] Available from:
http://europa.eu/legislation_summaries/employment_and_social_policy/situation_in_europe/c10160_en
.htm
[2] Vaupel JW, Jeune B. The emergence and proliferation of centenarians. Monograph, The
MaxPlanckInstiture, Germany; 2000. Available from:
http://www.demogr.mpg.de/Papers/Books/Monograph2/the%20emergence.htm
[3] CBS Statistics Netherlands. Web magazine. More male centenarians. [Internet] 2010 Sep 16 [cited
2011 Feb 2] Available from: http://www.cbs.nl/en-
GB/menu/themas/bevolking/publicaties/artikelen/archief/2010/2010-3205-wm.htm
[4] BBC News. 70-year-old claims Everest record. [Internet] 2003 May 22 [cited 2011 Feb 2] Available
from: http://news.bbc.co.uk/2/hi/south_asia/3049603.stm
[5] Katsusuke Yanagisawa, Oldest to Climb Mount Everest. [Internet] 2008 Jan 28 [cited 2011 Feb 2]
Available from: http://katsusukeyanagisawa.blogspot.com
[6] EverestNews.com. Everest 2008: A 77 year old man Summits Everest. [Internet] Available from:
http://www.everestnews.com/everest2008/76yearoldeverest01152008.htm
[7] Statline, Centraal Bureau voor de Statistiek.[Internet] 2011 [cited 22 Feb 2011]. Available from:
http://statline.cbs.nl/statweb/
[8] About EIDD. EIDD Design for All Europe. [Internet] 2008 Jan 25 [updated 2010 Oct 28; cited 2011
Jan 26]. Available from: http://www.designforalleurope.org/About-EIDD
[9] European Institute for Design and Disability. The EIDD Stockholm Declaration 2004. 2004 [cited 2011
Jan 26]. Available from: http://www.designforalleurope.org/Design-for-All/EIDD-
Documents/Stockholm-Declaration
[10] EDeAN European Design for All e-Accessibility Network. Design for All Education and Training.
[Internet] 2011 [cited 2011 Feb 8] Available from: http://www.education.edean.org
[11] Interview with Pete Kercher. EIDD Design for All Europe. [Internet] 2007 Nov 7 [updated 2008 Apr 8;
cited 2011 Jan 26]. Available from: http://www.designforalleurope.org/Design-for-All/Articles/
[12] Universal Design. Wikipedia, the free encyclopedia. [Internet] 2011 Jan 22 [cited 2011 Jan 27]
Available from: http://en.wikipedia.org/wiki/Universal_design
[13] European Design for All e-Accessibility Network (EDeAN). Available from: http://www.edean.org
[14] The Center for Universal Design. North Carolina State University. [Internet] 2008 [cited 2011 Feb 1]
Available from: http://www.design.ncsu.edu/cud
[15] Americans with Disabilities Act, Disability Resources. United States Department of Labor. [Internet]
2011 [cited 2011 Feb 1] Available from: http://www.dol.gov/dol/topic/disability/ada.htm#doltopics
[16] NEC Corporation. Design, Universal Design, The need for Universal Design. [Internet] 2011 [ cited
2011 Feb 2] Available from: http://www.nec.co.jp/design/en/ud/index.html
[17] Macdonald AS. Universal Design in Japanese Technological Industries. In: Clarkson J, Langdon P,
Robinson P, editors. Designing Accessible Technology. London: Springer-Verlag; 2006
[18] Helen Hamlyn Centre. Royal College of Art. About us. [Internet] 2010 [updated 2010 Sep 21, cited
2011 Feb 2]. Available from: http://www.hhc.rca.ac.uk/
[19] Coleman R. Designing for Our Future Selves. In: Preiser WFE, Ostroff E, editors. The Universal
Design Handbook. New York: McGraw-Hill; 2001
[20] Joseph Friedman. Wikipedia, the free encyclopedia. [Internet] 2011 Feb 4 [cited 2011 Feb 8] Available
from: http://en.wikipedia.org/wiki/Joseph_Friedman#Invention_of_the_flexible_straw
[21] Miesenberger K. EDeAN Publication 2009, Principles and Practice in Europe for e-Accessibility
[Internet]. 2009. Chapter 1, Design for All Principles; p.15-25. [cited 2011 Jan 26]. Available from:
http://www.edean.org/Files/EDeAN_Publication_2009.pdf
[22] Bike Europe, Website for Bike Professionals. Facts & Figures, Market Reports, The Netherlands 2009:
E-Bike Dictates Dutch Market. [Internet] 2010 Jul 1 [cited 2011 Feb 16]. Available from:
http://www.bike-eu.com/facts-figures/market-reports/4267/the-netherlands-2009-e-bike-dictates-dutch-
market.html
[23] Laslett P. Design Slippage Over the Life-Course. In: Graafmans J, Taipale V, Charness N, editors.
Gerontechnology: A Sustainable Investment in the Future, Studies in Health Technology and
Informatics, Vol. 4. Amsterdam, The Netherlands: IOSPress; 1998.
[24] Inclusive Design Education Resource. The Design Council and the Helen Hamlyn Research Center
[Internet]. 2011 [cited 2011 Jan 26]. Available from:
http://www.designcouncil.info/inclusivedesignresource
[25] Molenbroek JFM, Bruin R de. Anthropometrical Aspects of a Friendly Rest Room. This volume.
[26] Norman DA. The Design of Everyday Things. New York: Basic Book;1988
[27] Molenbroek JFM. DINED. Interactive tool for selecting mainly Dutch data about body dimensions.
[Internet] 2009 Oct 17 [cited 2011 Feb 22] Available from: http://www.dined.nl
[28] CEN/CENELEC Guide 6: Guidelines for standards developers to address the needs of older persons
and persons with disabilities [Internet] 2002 [cited 2011 Feb 22] Available from:
http://www.cen.eu/boss/supporting/Reference%20documents/guides/Pages/default.aspx
[29] Inclusive Design Toolkit. BT. [Internet] 2011 [cited 2011 Mar 15]. Available from:
http://www.inclusivedesigntoolkit.com/
[30] EIDD Design for All Europe. [Internet] 2011 [ cited 2011 Mar 15] Available from:
http://www.designforalleurope.org
[31] The Center for Universal Design, Environments and Products for All People. NC State University.
[Internet] 2011 [cited 2011 Mar 15]. Available from: http://www.design.ncsu.edu/cud/
[32] Include Conference. Helen Hamlyn Centre for Design, Royal College of Art. [Internet] 2011 [cited
2011 Mar 15] Available from: http://www.hhc.rca.ac.uk/448/all/1/include-conference.aspx
[33] Institute for Human Centered Design (www.humancentereddesign.org) .
[34] Center for Inclusive Design and Environmental Access. [Internet] 2009 [cited 2011 Feb 22] Available
from: http://www.ap.buffalo.edu/idea/
[35] Szenasy S. Keynote speech. In: Sandhu J, editor. Proceedings Inclusive Design Research Associates,
Ltd. Designing for the 21st Century III, An International Conference on Universal Design; 2004 Dec 7-
12; Rio de Janeiro, Brazil.
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-19
Experiences with Smart Homes for Older

People
Ad VAN BERLO1
Smart Homes Corporation, Eindhoven, The Netherlands
Abstract. In the Netherlands, in the late 90s a first pilot with 120 smart home
apartments for independent living of senior citizens was realised. The home
automation consisted of all sorts of applications for safety & security, care and
comfort. The first experiences showed that several mistakes in human interfacing
and layout still occurred and clearly tempered the enthusiasm of many residents.
Overall however, there is feeling of satisfaction and security among them.
Keywords. Home automation, Safety, Security, Care, Comfort, Experiences
1. Introduction
The terms 'smart homes', 'intelligent homes', and 'home networking' have been used for
more than a decade to introduce the concept of networking devices and equipment in
the house. According to the Smart Homes Corporation, the best definition of smart
home technology is: the integration of technology and services through home
networking for a better quality of living. Areas of application are: home automation &
energy control, information & communication, working & productivity and
entertainment. These areas particularly refer to the technical network islands, which
regularly exist apart from each other.
With reference to the definition up to present time, the implementation of complete
smart homes with all network islands is limited to some demonstration houses and
high-end luxurious villas. In Europe demonstration houses have been built in a.o.
London, Milan, Zurich, Duisburg and Eindhoven. Looking at houses with single
network islands, there is a different situation. Home automation and energy control has
been implemented in some thousands of houses Europe wide [1,2]. If simple stand-
alone plug and play tools for controlling lights (for instance X10 tools) are accounted
for as smart home technology, many thousands of homes all over the world may be
called smart. For achieving "intelligence", however, one really needs a network with
sensors, actors and software and not single stand-alone solutions. Single networks in
the other application domains are particularly coming up in the working and
productivity area. Here, PC-networking is meant, where all PC's in the house, the
printer, scanner, PDA etc. are linked to each other via an ethernet network, including
firewall protection and the use of a server.
1
Contact Information: Ad van Berlo, Smart Homes Corporation; Address: PO Box 8825, 5605 LV
Eindhoven, The Netherlands; Website: www.smart-homes.nl; Email: info@smart-homes.nl
20 A. van Berlo / Experiences with Smart Homes for Older People
In this paper, the review on smart home technology will be limited to the area of
home automation, as this is the area of most interest for older people so far.
2. Home Automation for Older People
Only recently, several projects with smart technology in the houses of older people
have been realised or started. The Smart Homes Corporation has been initiator and
consultant for many of these projects in the Netherlands. In 1997, in the Province of
North-Brabant in the Netherlands, it was felt that demonstration projects were needed
for those people who would have a clear benefit: older people who want to be
independent and out of care as long as possible. The purpose of doing demonstration
projects was to identify the real wishes and needs of older people themselves, to find
solutions from the technology offer on the market and to try to understand which extra
steps would be involved in the building process. Five projects spread over the province
(2,3 million inhabitants) with in total 120 apartments of around 70 - 80 m2 were
initiated for senior housing. From the beginning (early 1998) senior citizens were
involved to express their wishes and needs. All five projects were subsidised as far as
consultancy and project leadership by the Smart Homes Corporation concerns. In 2000,
all five projects were finished and older citizens are actually living now in the houses.
In the five demonstration projects and those that followed, the applications were not
always the same. However, 80% of the applications in each project are from the
following list:
x Safety & Security

Access control
Intruder alarm
Smoke alarm
Automatic lighting at night
Automatic cooker switch off
x Care
Active person alarm
Passive person alarm
Authorised access to the apartment for the care worker
x Comfort
Automatic lighting
Automatic screens and curtains
The projects differ from each other that for instance in one project there are no
automatic curtains and in the other there is no intruder alarm. The implemented
technology varies widely. This is due to the fact that there are many suppliers of bus-
systems and safety alarm systems, many installers with different views and preferences
and of course due to the fact that the amounts of investment differ from project to
project. Basically, one can speak of home automation when there is a bus-system
involved, which acts as the electronic nervous system of the house. There are many
proprietary systems on the market. In Europe, there are efforts made to make a leading
standard for bus-systems, but after many years this is still a slow ongoing process.
A. van Berlo / Experiences with Smart Homes for Older People 21
3. Applications
3.1. Safety & Security
3.1.1. Access Control

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

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

A smoke detector is installed in all projects, most frequently near or in the kitchen. In
some cases there are also smoke detectors in living room and bedroom. If smoke is
detected an alarm signal is given to a call centre automatically. First, the call-centre
operator will speak to the tenant via the safety alarm phone to verify whether there is a
real fire.
Figure 1. The tenant opens the front door via Figure 2. Access control via TV and alarm phone
magnetic card
Figure 3. The tenant switches intruder alarm on / Figure 4. Passive infrared sensor (PIR) with night
off via proximity key light
3.1.4. Automatic Lighting at Night

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

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

3.2. Care
3.2.1. Active Person Alarm

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

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

If care is needed in one of the apartments of a flat, which is located somewhere in
town, the care worker needs the key of the front door of the resident. In most villages,
an extra key is often given at neighbours or children. But when the front door is well
locked, it is not always possible to open it with this key. In cities, many residents do
not have an address where they can leave the key of their home. In this case, the care
worker must bring a bunch of keys of all the apartments where care is needed. This is
not a safe situation, since criminals can get easy access to the various apartments if
they take these keys. Therefore, the concept of electronic locks was introduced, where
care workers get access to the individual apartment when they arrive. Different
technical solutions have been worked out, where the care worker just like the resident-
can get automatic access.
3.3. Comfort
3.3.1. Automatic Lighting

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

Automatic screens are more common than automatic curtains. In most projects the
latter is an option, for which the residents have to pay themselves (see Figure 8).
Figure 7. PIR in the bathroom for automatic light Figure 8. Automatic curtain
4. Experiences and Reactions of Older Residents
The demonstration projects were carried out in order to gain more insight in real wishes
and needs and actual use of smart home technology by the older residents: to find
solutions from the technology offered on the market and to learn about the process of
implementation. Here, only the first results of interviews with the residents will be
reported.
Starting point was that the residents, who moved to new built apartments, should
be able to stay in their new dwelling for the rest of their lives. The age of the residents
varied between 62 and 85. A majority was living alone, but there were many couples as
well. They live fully independent, but if care would be needed, they will receive it from
the regional Home Care organisation. Only, if a resident should require intensive
nursing care, a move to a nursing home is foreseen. All apartments were designed with
two bedrooms, a bathroom, a living room and a connected separate kitchen. The flats
vary between 18 and 80 apartments. For all residents the move to the new apartment
meant a reduction in available space and the abandoning of the garden, but they all
strongly desired the new living space. Reasons were that some residents did not feel
safe and secure in their old house anymore, that it was too big to maintain or that they
expected an increasing need for care. Moving to a smart home was not their purpose,
because they did not know about the existence and the facilities in it. The smart homes
were simply offered because it was their turn on the waiting list of the Dutch housing
regulation system.
A general comment of many residents was that moving into a new house with
different functions, such as switching the house "on/off", automatic lights, intruder
alarm, etc. was extra difficult. They would have preferred a gradual introduction of the
new functions after they were accustomed to the house.
For couples, the passive alarm was not desired yet. In these cases the installers
turned this application off. For the single person households, in most cases, the
maximum time for inactivity was desired at 4 hours. This was due to the fact that some
persons do not move out of the chair for 2 - 3 hours or longer. In the first month of their
stay in the new house, many persons forgot to switch the house "on/off", which resulted
in many false alarms for either inactivity or intrusion. In most apartments the number
of false alarms was after a month reduced to zero. But many residents still do not like
the extra handling. They are forced to think about it all the time and that does not
contribute to the feeling that a smart house does everything automatically.
Another aspect of importance is that most residents want to keep the control over
their house. They want to overrule automatic functions or alarms. It is also a fear that
the house is not accessible or usable if the electric power fails.
In the layout of outlets and buttons and the programming of functions, the
installers still make mistakes. Often this makes the applications not understandable or
not usable. In the mean time most of the programming issues have been solved, but an
improvement of the buttons or optimal placing of outlets is not always possible (see
Figure 9 and 10).
Despite the aforementioned shortcomings there is an overall feeling of safety and
security among the residents of the demonstration projects. One feels protected and has
a guarantee on follow up if something happens. Those residents who still feel well and
active do not want all applications to be active from the beginning. They are very
satisfied with the options in the house in case they really need it.
Figure 9. Two bed cords too close to each other: Figure 10. The buttons are almost behind the bed
one for active alarm, one to switch off the lights furniture
5. Conclusions
Real smart homes with all network islands and possible applications are limited to
demonstration houses so far. Home automation is implemented in thousands of houses
world wide, but is still in its infancy. Several economic and socio-cultural factors will
cause changes in society, which are favourable for a breakthrough of smart home
technology. There are also important technical drivers, such as internet, broadband and
wireless solutions.
Older persons and in many cases also older people with a minimal pension, have
been the "test" group for starting demonstration projects with home automation in the
past years. They have clearly outspoken needs and wishes. The implementation of the
first generation of demonstration projects, with emphasis on safety & security, care and
comfort, showed that mistakes in human interfacing and layout still occur and temper
the enthusiasm of many residents. Overall however, there is feeling of satisfaction and
security among them.
Other factors still account for the slow progress: costs, lack of standardisation and
missing skills at installers. The Internet, broadband and wireless solutions are keywords
in an irreversible move to further introduction of smart home technology. The question
is at which speed of progress. But it is absolutely certain that in the near future all
houses will be connected to the electronic highway. It is only logical that these houses
will be smart themselves by networking all devices and equipment in order to get
maximal benefit and fun. The benefit and usefulness has been demonstrated in the
smart homes for older people.
References
[1] Berlo A van, Vermijs P, editors. Domotica opent deuren [in Dutch]. Akon Series. Ouder worden in deze
tijd. Volume 3, 1993.
[2] Berlo A van. Veilig en comfortabel wonen [in Dutch]. Akon Series. Ouder worden in deze tijd. Volume
9, 1994
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-27
Health Data Security Issues

John MANTAS1, Joseph LIASKOS
Laboratory of Health Informatics Faculty of Nursing, University of Athens
Abstract. Health data are considered as personal and sensitive. The storage,
process, access and communication of health data through health information
systems, require appropriate methods that will ensure their privacy, confidentiality,
integrity and other aspects of security. Methods to provide security are part of
most computer systems, but healthcare systems are distinguished by having
especially complex considerations for the use and release of information.
Availability, accountability, authentication, authorization, perimeter definition,
role-limited access control are key functions that need to be considered, Different
types of information kept in the health care records have different rules for release,
as determined by laws and by institutional policy following legal and ethical
considerations.
Keywords. Health Data, Information Systems, Confidentiality, Computer Security
1. Introduction
Health care records contain much information about patients. These documents and
databases include reasonable innocuous data ranging from height and weight
measurements, blood pressures, and notes regarding bouts with the flu, cuts, or broken
bones to very privacy-sensitive information about topics such as fertility and abortions,
emotional problems and psychiatric care, sexual behaviours, sexually transmitted
diseases, human immune-deficiency virus (HIV) status, substance abuse, physical
abuse, and genetic predisposition to diseases. The health care record may contain these
privacy-sensitive data. Health information is considered to be confidential, and access
to this information must be controlled because disclosure could harm us, for example,
by causing social embarrassment or prejudice, by affecting our insurability, or by
limiting our ability to get and hold a job. Health data also must be protected against
loss [1]. If we are to depend on electronic health care records for care, they must be
available whenever and wherever we need care, and the information that they contain
must be accurate and up to date. Orders for tests or treatments must be validated to
ensure that authorised providers issue them. The records must also support
administrative review and provide a basis for legal accountability. These requirements
touch on three separate concepts involved in protecting healthcare information [2]:
1
Corresponding Author: John Mantas, Laboratory of Health Informatics, Faculty of Nursing,
University of Athens, Papadiamantopoulou 123, 115 27, Athens, Greece; Email: jmantas@nurs.uoa.gr
28 J. Mantas and J. Liaskos / Health Data Security Issues
x Privacy refers to the desire of a person to control disclosure of personal health

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

of significant economic, psychological, and social harm that can come to individuals
when personal health information is disclosed [4]. The disclosure of patients sensitive
information about sensitive health data such us mental health, sexually transmitted
diseases, adolescent care [5], drug addiction and genetic fingerprints creates many
ethical problems [6].
2. Health Data Security
Data security is defined as the result of effective data protection measures; the sum of
measures that safeguard data and computer programs from undesired occurrences and
exposure to accidental or intentional access or disclosure to unauthorized persons, or a
combination thereof; accidental or malicious alteration; unauthorized copying; or loss
by theft or destruction by hardware failures, software deficiencies, operating mistakes;
physical damage by fire, water, smoke, excessive temperature, electrical failure or
sabotage; or a combination thereof. Data security exists when data are protected from
accidental or intentional disclosure to unauthorized persons and from unauthorized or
accidental alteration[3]. Concerns about and methods to provide security, are part of
most computer systems, but healthcare systems are distinguished by having especially
complex considerations for the use and release of information. In general, the security
steps taken in a healthcare information system serve five key functions: [2], [7]
x Availability should ensure that accurate and up-to-date information is

available when needed at appropriate places.
x Accountability should help to ensure that users are responsible for their access
to and use of information based on a documented need and right to know.
J. Mantas and J. Liaskos / Health Data Security Issues 29
x Authentication and authorization are processes that should ensure the

correctness of the claimed identity and give permissions and privileges to do
specific actions.
x Perimeter definition should allow the system to control the boundaries of
trusted access to an information system, both physically and logically.
x Role-limited access should enable access for personnel to only that
information essential to the performance of their jobs and limits the real or
perceived temptation to access information beyond a legitimate need.
In all these functions the role the human factor (i.e. administrators, health care
providers and patients users of the health data) is very important. There is a great
need that all health data users should understand and have effective control over
appropriate aspects of information confidentiality and access.
2.1. Availability
The primary approach to ensuring availability is to protect against loss of data by

performing regular system backups. Because hardware and software systems will never
be perfectly reliable, information of long-term value is copied onto archival storage,
and copies are kept at remote sites to protect the data in case of disaster. For short-term
protection, data can be written on duplicate storage devices. If one of the storage
devices is attached to a remote processor, then additional protection is conferred.
Critical medical systems must be prepared to operate even during environmental
disasters. Therefore, it is also important to provide secure housing and alternative
power sources for CPUs, storage devices, network equipment, and so on. It is also
essential to maintain the integrity of the information-system software to ensure
availability. Backup copies provide a degree of protection against software failures; if a
new version of a program damages the systems database, the backups allow operators
to rollback to the earlier version of the software and database contents [2].
2.2. Accountability
Accountability for use of health data can be promoted both by surveillance and by
technical controls. The knowledge from health care professionals that their actions in
accessing and using data records are being watched, (e.g. through scanning of access
audit trails in log files), serves as a strong impediment to abuse [2]. The technical
controls to ensure accountability include two major functions: authentication and
authorisation.
x The user is authenticated through a unique identification process, such as, for
example, name and password combination.
x The authenticated user is authorised within the system to perform only certain
actions appropriate to his role in the healthcare systemfor example, to
search through certain health care records of only patients under her care.
2.3. Authentication and Authorisation
Authentication is the major means of defence used in the security of information

systems, in order to verify that a claimed user identity is indeed correct. The main
approaches to user authentication are something the user knows (e.g. password or PIN),
something the user has (e.g. a card, digital signature or other token) and something the
user is (e.g. a biometric characteristic such as fingerprints, voice, DNA, etc.) [8].
Something that determines the place the user exists (e.g. telephone number, IP address)
may also be used as an authentication means. Authentication is a communication
security service, which provides the basis for important application security services
like authorisation and access control [9].
Authorization is the means to define who can access what information.
Authorization process allows access to resources only to those permitted to use them.
An authorization mechanism is an integral part of most commercial database systems
[10]. Each authenticated user is permitted to do specific pre-defined actions on the data,
which they are deriving by his specific role.
Authentication and authorisation can be performed most easily within an
individual computer system, but, because most institutions operate multiple computers,
it is necessary to co-ordinate these access controls consistently across all the systems.
Enterprise-wide access-control standards and systems are available but have been
deployed to only a limited extent. Tools for applying authentication include digital
signatures, encryption, and access control lists [9].
2.4. Perimeter Definition
Perimeter definition requires that you know who your users are and how they are
accessing the information system. For healthcare providers within a small physician
practice, physical access can be provided with a minimum of hassle using simple name
and password combinations. If a clinician is travelling or at home and needs remote
access to a health care record, however, greater care must be taken to ensure that the
person is who he claims to be and that communications containing sensitive
information are not observed inappropriately. But where is the boundary for being
considered a trusted insider? Careful control of where the network runs and how users
get outside access is necessary. Most organisations install a firewall to define the
boundary: All sharable computers of the institution are located within the firewall.
Anyone who attempts to access a shared system from the outside must first pass
through the firewall, where strong authentication controls are in place. Having passed
this authentication step, the user can then access services within the firewall (still
limited by the applicable authorisation controls). Even with a firewall in place, it is
important for enterprise system administrators to monitor to ensure that the firewall is
not bypassedfor example, a malicious intruder could install a modem on an inside
telephone line or load unauthorised software [2].
Strong authentication and authorisation controls depend on cryptographic
technologies. Cryptographic encoding is a primary tool for protecting data that are
stored and are transmitted over communication lines. Two kinds of cryptography are in
common usesecret-key cryptography and public-key cryptography. In secret-key
cryptography, the same key is used to encrypt and to decrypt information. Thus, the
key must be kept secret, known to only the sender and intended receiver of
information. In public-key cryptography, two keys are used, one to encrypt the
information and a second to decrypt it. Because two keys are involved, only one need
be kept secret. The other one can be made publicly available. This arrangement leads to
important services in addition to exchange of sensitive information, such as provision
of digital signatures (certifies authorship), content validation (indicates the contents of
J. Mantas and J. Liaskos / Health Data Security Issues 31
a message have not been changed), and no repudiation (indicates that an order or
payment for goods received cannot be repudiated). Under either scheme, once data are
encrypted, a key is needed to decode and make the information legible and suitable for
processing [7].
Keys of longer length provide more security, because they are harder to guess.
Because powerful computers can help intruders to test millions of candidate keys
rapidly, keys of 56-bit length are no longer considered secure, and keys of 128 bits are
entering service. If a key is lost, then the information encrypted with the key is
effectively lost as well. If a key is stolen, or if too many copies of the key exist for
them to be tracked, then unauthorised people may gain access to information. Holding
the keys in escrow by a trusted party can provide some protection against loss.
Cryptographic tools can be used to control authorisation as well. The authorisation
information may be encoded as digital certificates, which then can be validated with a
certification authority and checked by the services so that the services do not need to
check the authorisations themselves. Centralising authentication and authorisation
functions simplifies the co-ordination of access control, allows for rapid revocation of
privileges as needed, and reduces the possibility of an intruder finding holes in the
system [2, 7].
2.5. Role-limited Access Control
Role-limited access control is based on extensions of authorisation schemes. Even

when overall system access has been authorised and is protected, further checks must
be made to control access to specific data within the record. health care record is not
partitioned according to external access criteria, and the many different collaborators in
health care all have diverse needs for, and thus rights to, the information collected in
the health care record. Examples include the following [2]:
x Patients: the contents of their own health care records.

x Community physicians: records of their patients
x Speciality physicians: records of patients referred for consultations.
x Public health agencies: incidences of communicable diseases
x Medical researchers: anonymous records or summarisation of data for patient
groups
x Billing clerks: records of services, with supporting clinical documentation as
required by insurance companies
x Insurance payers: justifications of charges
Different types of information kept in the health care records have different rules
for release, as determined by law and as set by institutional policy following legal and
ethical considerations. Based on institutional policy, such notations might be masked
before release of records for research purposes. Depending on the study design, the
patients name and other identifying information might also be masked.
Data protection law in most European countries requires that data be held only for
a defined purpose, and for no longer than is necessary [11]. Health data can be used for
purposes of administration, audit and performance review but patient identifiers should
preferably be removed beforehand so that individual's identity is not revealed by
unusual combinations of apparently anonymous data [7].
3. Conclusion
To protect the confidentiality of health care records against inappropriate release to

collaborators, the records should be inspected before release, but such checking
requires more resources than most healthcare institutions are able to devote. To date,
relatively few resources have been devoted to system security and ensuring
confidentiality of healthcare data; most such resources are used to resolve problems
after a violation is reported. Even minimal encryption is rarely used because of the
awkwardness created in handling the keys and accessing the data. Concerns over
privacy protection are increasing, however, and such concerns are beginning to be
supported by legal requirements of responsible trusteeship by collectors and holders of
health care records. To respond to these new requirements, we need better tools to
protect privacy and the confidentiality of health information. Each country in E.U. but
also European commission [12] tries to protect peoples right for a safe handling of
personal data stored in an EPR by setting the minimum necessary requirements for
each health organization that uses it and by creating laws and ethical regulations for the
same purpose. Moreover, the American "Health Insurance Portability and
Accountability Act" of 1996 mandated the development of standards to protect the
confidentiality and security of patient medical records [13].
References
[1] Bakker A. Data protection and confidentiality. Studies in Health Technology and Informatics.
2002;65:450-64.
[2] Wiederhold G, Rindfleisch TC. Essential Concepts for Biomedical Computing. In: Shortliffe EH,
Cimino JJ, editors. Biomedical Informatics: Computer Applications in Health Care and Biomedicine.
3rd ed. New York (NY). Springer; 2006. p.186-232.
[3] American Society for Testing and Materials Committee E31 on Healthcare Informatics, Subcommittee
E31.17 on Privacy, Confidentiality, and Access. Standard guide for confidentiality, privacy, access, and
data security principles for health information including computer-based patient records. Philadelphia,
Pa.: ASTM, 1997:2. Publication no. E1869-97.
[4] Barrows RC Jr, Clayton PD. Privacy, confidentiality, and electronic medical records. Journal of
American Medical Association. 1996;3(2):139-48.
[5] Council on Scientific Affairs. Confidential health services for adolescents. Journal of American
Medical Association. 1993;269:1420-1424.
[6] Annas GJ. Privacy rules for DNA databanks: protecting coded future diaries. Journal of American
Medical Association. 1993;270:2346-2350.
[7] Rindfleisch TC. Privacy, information technology, and health care. Communications of the ACM.
1997;40(8):92-100.
[8] Wood HM. The use of passwords for controlled access to computer resources. NBS Special
Publications, US Dept. of Commerce/NBS. 1977;500509.
[9] Blobel B, Roger FF. A systematic approach for analysis and design of secure health information
systems. International journal of medical informatics. 2001 Jun;62(1):51-78.
[10] Rabitti F, Bertino E, Kim W, Woelk D. A model of authorization for next-generation database systems.
ACM Transactions on Database Systems (TODS). 1991;16(1):88-131.
[11] European Official Journal (European Parliament). Directive on personal data protection. EEC: Brussels.
1990.
[12] European Commission. Ethical review of research proposals. 2007 [cited 2009 May 5]. Available from:
http://ec.europa.eu/research/science-society/index.cfm?fuseaction=public. topic&id=73.
[13] US Department of Health and Human Services, Office for Civil Rights. Summary of the HIPAA
privacy rule. [cited 2007 Feb 2]. Available from: http://www.hhs.gov/ocr/privacysummary.pdf.
Section 2
The Friendly Rest Room Project
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-35
Overview of the FRR Project; Designing

the Toilet of the Future
Johan F.M. MOLENBROEK1 and Renate DE BRUIN
Faculty of Industrial Design Engineering Delft University of Technology, Delft, The
Netherlands
Abstract. Although the topic still is surrounded by taboos in our modern society,
the toilet area recently is becoming more and more subject of study and even
redesign. The objective of the EU funded project Friendly Rest Room (2002-
2005) was to provide recommendations for improving the toilet area, in particular
focussing on the special needs of elderly and disabled, by performing several user
studies and exploring the potential of assistive technologies. The 10 project
partners from 8 different European countries assured as well a multidisciplinary as
multicultural vision on the subject matter. This chapter describes the approach that
was chosen and in more detail the different ergonomic user studies that were
performed. Problems and experiences with regards to ethics and cultural
differences will be discussed. The results are presented in a basic list of user
problems and illustrated by the first product development steps of the toilet of the
future.
Keywords: Applied Ergonomics, Inclusive Design, Toilet, Rest Room, Elderly,

Disabled, Assistive Technologies, Ethics, Cultural Differences
1. Introduction
In our daily live we are increasingly being supported by the application of new
technologies, from self-thinking washing machines to personal assisting mobile
phones. These modern machines often do not resemble their earliest versions at all and
usually for the better (everybody who has washed by hand and board once will
immediately agree). There is however one essential appliance we use multiple times
every day which somehow escaped this modernisation: our toilet.
The toilet that is most commonly used in the western society is the sitting-type
toilet referring to the sitting posture one has when using it. This type of toilet looks not
so much different to the first patented design for a water closet by Alexander
Cummings in 1775[1]. Except for some improvements regarding water flush and
sewage, the toilet basically has not changed since [2]. This is illustrated by the toilet
bowl from 1910 in figure 1.
Apparently the design of the toilet is satisfactory to the majority of mankind, or
maybe not? For a fact there are in the market a whole collection of products available
that cunningly respond to shortcomings of the standard toilet; toilet brushes, toilet
1
Corresponding Author: Johan Molenbroek, Faculty of Industrial Design Engineering, Delft University
of Technology; Address: Landbergstraat 15, 2628 CE Delft; Email: j.f.m.molenbroek@tudelft.nl
36 J.F.M. Molenbroek and R. de Bruin / Overview of the FRR Project
fresheners, toilet seat cleaners, toilet seat paper, toilet seat raisers for elderly, child
toilet seats, toilet chairs, special soft toilet seats, toilet arm support bars, toilet back
support bars, turning aids, stand-up toilet mechanisms, toilet paper tongs etc. From this
collection add-ons alone one can conclude that the current toilet design clearly does
not cover for all the users needs. Especially when it comes to hygiene, comfort and
safety for children, elderly and disabled our modern toilet is pitifully failing.
The rise in the ageing population will almost certainly blow up the difficulties even
further. Not only the safety of older persons is at stake, since the risks of falling in the
toilet area are high [3], also health care workers that assist elderly and disabled in their
daily routines are suffering from a bad toilet design. They often have to work in
difficult postures when transferring patients to and from the toilet and as a result back
pains are a common noted complaint [4,5].
Clearly more research can and should be done to improve the toilet area. It is
necessary to map the actual needs of the user, based on behaviour, habits and culture,
the needs of caretakers etc. Study results should be translated into a toilet design that
integrates all functions and offers a total approach instead of designing tools to
overcome the flaws of existing sanitary. The use of new technologies in this toilet
design makes sense: the modernisation of our toilet can begin.
Figure 1. A toilet bowl from ca. 1910

J.F.M. Molenbroek and R. de Bruin / Overview of the FRR Project 37
2. The Friendly Rest Room Project
2.1. General Objectives
The Friendly Rest Room (FRR) project (2002-2005) was initiated in an attempt to
enlarge the autonomy, independence, dignity and safety of elderly and disabled people,
and thus raise their overall quality of life. The FRR project was partially funded by the
European Commission as project QLRT-2001-00458 in the Quality of Life and
Management of Living Resources, Key Action 6: the Ageing Population and
Disabilities programme.
The user group elderly and disabled was chosen because of the obvious problems
this group encounters in the current toilet design. The general idea was though that a
toilet that suits the elderly and disabled, will also suit the young and healthy. This
approach Inclusive Design or Design for All (ensuring that the needs of the widest
possible audience, irrespective of age or ability are addressed [6]) - was followed in the
FRR project and now forms the first step in adapting our toilet design to the modern
ages.
The FRR project aims at developing a user-Friendly Rest Room for the elderly and
persons with limited abilities, which is facilitated by recent sociological, ergonomic
and anthropometrical studies and technology developments. A more user-friendly lay-
out of the room will be combined with a more user-friendly design of sanitary modules.
A smart toilet that will compensate the special needs of the user in a friendly way and
increase their pleasure in life is the desired result [7].
The objectives of the FRR-consortium are in short:
x To develop Quality of Life products for the ageing population and people with
limited abilities
x To generate knowledge and understanding regarding toileting, personal care
and hygiene, and accident prevention
x To establish an independent consortium to implement additional research and
development projects in the domain of caring homes for independent living
2.2. Project Partners
Ten organisations and companies located in seven different European countries

together form the FRR project-consortium, guaranteeing a wide geographic and
cultural coverage. Each consortium partner represents a different area of expertise and
as a whole the FRR consortium offers expertise in the fields of advanced robotics,
rehabilitation technology and engineering, health care informatics, applied computing,
product systems and ergonomics, product design and development, geriatrics and
gerontology, sociology and ethics. An overview of the consortium partners is given in
table 1.
2.3. Process
Research activities and design and development activities have taken place
simultaneously in this project. The research objectives can be divided into two parts;
Table 1. The project-partners of the Friendly Rest Room project
FRR Consortium partners

Abbrev. Organisation / Company Residence Area of expertise
DUT Section Applied Ergonomics and Delft, The General Ergonomics,
Design, Department Industrial Netherlands Anthropometrics and Bio-
Design, Faculty of Industrial mechanics, Informational
Design Engineering, Delft ergonomics, Safety studies and the
University of Technology Application of Product
Ergonomics to Design Projects
FORTEC Research Group on Vienna, Austria Electrical Engineering,
Rehabilitation Technology, Informatics, Biomedical
Institute Integrated Study, Engineering and Precision
Vienna University of Mechanics
Technology
CERTEC Division of Rehabilitation Lund, Sweden Rehabilitation Engineering and
Engineering Research, Design, Human Machine
Department of Design Sciences, Interaction
Institute of Technology, Lund
University
EURAG European Federation of Older Graz, Austria Social Science, User Needs of
Persons Elderly
UOA Health Informatics Laboratory, Athens, Greece Health Care Informatics, Health
Faculty of Nursing, University Informatics Education and
of Athens Standardisation
UNIDUN Faculty of Engineering and Dundee, United Computer-based System Design ,
Physical Sciences, Department Kingdom Computer-based Interviewing
of Applied Computing, Techniques
University of Dundee
LM Landmark Design Holding BV Rotterdam, The Industrial Design, Inclusive Design
Netherlands
SIVA Fondazione Don Carlo Gnocchi Milan, Italy Medical, Social and Vocational
Onlus, Servizio Informazioni e Rehabilitation, Assistive
Valutazione Ausili, Assistive Technology, Education and
Technology Research and Information
Information Service
HAGG Hellenic Association of Athens, Greece Health and Social Welfare,
Gerontology and Geriatrics Gerontology and Geriatrics, Health
Promotion
CSO Clean Solution Kft. Debrecen, Development and Implementation
Hungary of Assistive Products for Elderly
and Disabled
the first objective was to gather general knowledge about the problems elderly and
disabled encounter in the toilet area. This knowledge then was translated into a set of
design specifications gradually building up during the course of the project. The
research activities that have been performed in this regard are:
x General literature study,

x Interviews with elderly, disabled and their caretakers about the toilet
environment (CERTEC, FORTEC, EURAG, LM, TUD, UOA, HAGG)
x Multiple case-studies of elderly and disabled in their home toilet environment
(SIVA),
x Questionnaire on toilet issues amongst elderly and disabled (EURAG),
x Development of a computer based interview tool (UNIDUN),
x Questionnaire on body posture during toileting and cleansing (LM),
x Study into user needs and preferences regarding illumination within the toilet
area (CERTEC)
x Behavioural study of independently living elderly in their home toilet
environment (TUD)
x Study into comfort of the toilet seat (TUD),
x Study into fall prevention in the toilet area (TUD).
x Behavioural study into the preferences of support bars near the toilet bowl
(TUD) and
x Behavioural study on body posture during dressing/undressing, toileting and
cleansing (TUD).
The second objective was to study whether the design solutions based on the
growing design specifications were fulfilling the user needs and preferences and
whether they indeed formed a solution that enabled elderly and disabled to use the
toilet more safely and independently. This was done by testing several successive FRR
prototype generations at 5 European test sites, the so called User Research Bases
(URB). An overview of the URBs and the different test stages is given in table 2.
Table 2. Overview of URBs and the different successive prototype stages tested
Organisation / Residence Prototypes stages

Company
EPT(1) APT(2) BPT(3) PPPT(4)
URB Athens UOA, HAGG Athens, Greece X X X X
URB LUND CERTEC Lund, Sweden X X X X
URB Vienna FORTEC, Vienna, Austria X X X X

EURAG
URB Delft DUT, LM Delft, The X
Netherlands
URB Italy SIVA Milan, Italy X
(1) Engineering ProtoType, (2) Alpha ProtoType, (3) Beta ProtoType, and (4) PreProduction ProtoType
In these URBs the FRR prototypes or parts of the prototypes were tested by in total
more than 230 test persons from the user group of elderly and disabled.
Next, the general design and development objective was to translate the needs and
preferences of the users into concrete product proposals. Developing a fully market
ready Friendly Rest Room within the lifespan of the project was not feasible within the
scope of this project, the results rather should serve as a basis for further developments
of user-friendly restroom products.
The designers of the FRR (LM) aimed at creating a coherent environment in which the
user feels at ease and in control, masking the technology which is used to make the
environment adaptable to special needs. The design had to be culturally independent
since the FRR should be used in the whole of Europe, and of course -while aiming
principally at the user group elderly and disable- it should be accessible to as many
users as possible.
The design process started with the thorough inventory of user needs and problems
regarding the toilet area. Literature study was used, but additional and very important
information was gained from the performed observations and interviews. After
analysing the findings the first idea sketches were made, which were shown to users
and experts. Their feedback was incorporated into the designs and subsequently the
first prototypes were built and tested with actual users in a laboratory situation. These
user test results were again incorporated into the designs, the redesigns were again
evaluated by users and experts, and another series of (adapted) prototypes were built
and tested. The cycle of design-evaluation-prototype-user test has been run through
several times before the final FRR design was a fact. With every step the knowledge
about user needs, preferences and problems in the toilet area grew, and the necessary
design specifications of the user-friendly toilet area became more precise. The
prototypes were constructed and produced by the production company (CSO) in the
final materials as much as possible, though sometimes less expensive and/or easier to
process, materials, like MDF or steel, also were used.
The end result is a well thought-out layout of the toilet room, combined with a
more user-friendly design of sanitary modules, which are perfectly in tune with each
other, and addition of smart parts that automatically can adapt to compensate for the
special needs of the user (see figure 2).
2.4. Ethics and Cultural Differences
An ethical committee was appointed for the project and advised the project on sensitive
aspects of testing the FRR prototypes with elderly and/or disabled. Test subjects were
always informed beforehand by means of a paper information kit and short before the
user test subjects were instructed verbally by one of the researchers and asked to sign
an informed consent. It was made clear to the test persons that they could end the test
session on any point of time and that they were not obliged to answer questions they
felt embarrassed with.
The set up of URBs located in different European countries was to gain test results
that would mirror the different toilet habits, preferences and needs all over Europe.
Figure 2. Final design of a Friendly Rest Room
3. Ergonomic User Studies
Being the projects expert in the field of user-product interaction and translating
ergonomic user needs into product specifications, Delft University of Technology
(DUT) carried out several ergonomic user studies. Three of them will be described in
more detail.
3.1. Study into Comfort of the Toilet Seat
In this study the objective was to define variables in the experience of comfort while
sitting on a toilet seat. The test was conducted at a local DIY store. Subject were
randomly selected by asking people shopping at the store to participate in the research.
In total 20 persons participated (11 males and 9 females).
The test set up consisted of six toilet seats fixed on toilet bowls that differed with
regards to shape and dimensions, except for 2 seats that only differed in colour.
After a short introduction subjects were asked to try the seats, with clothing. The
seats were presented in different order to the subjects to avoid any carry-over-effects.
The subjects were asked to describe the comfort of each seat and to compare and rank
them. Following a short questionnaire was filled out.
Test results showed that the subjects could feel the difference in comfort between
the seats and could distinguish several critical seat dimensions; slope and shape of the
seat borders, shape and size of the hole, rounding of edges and total seat length and
width. Surprisingly the seats that only differed in colour were rated very differently on
the above dimensions, suggesting that to a certain extent visual aspects influence the
experience of comfort.
3.2. Behavioural Study into the Preferences of Support Bars near the Toilet Bowl
The objective of this study was to collect both qualitative and quantitative information
on the preferences of elderly users regarding the use and position of three different
types of supports. In the preparation phase the test set up was evaluated by performing
a pilot test with 5 student subjects that wore limiting braces and other gear to simulated
old age.
A typological sample (stature, body mass, pulling force) was selected from a group
of elderly earlier involved in gerontology studies at DUT. A total of 15 subjects
participated in the study, 6 males and 9 females, age 58-79 yr. The test was partly
recorded on video.
A test frame was developed around a height adjustable toilet with three types of
adjustable supports; a horizontal front support, vertical front supports and horizontal
side supports. Subjects were asked to sit down and stand up using the supports at
various positions after having set the toilet at a comfortable height. For each type of
support the subjects had to indicate the most comfortable position. They were also
asked to point out which of the supports they would prefer in each step of the toilet act
(sitting down, cleaning, and standing up).
The results incorporate quantified data on the absolute positions that were
preferred during the different operations of toileting. Most subjects stated that sitting
down and standing up is easier with than without the supports. This applies to all three
types of support. The horizontal front supports showed some disadvantages though, for
several subjects experienced feelings of confinement. For standing up and sitting down
50% of the subjects preferred the vertical supports (n=7). The horizontal bars were also
chosen for standing up and sitting down, but subjects showed equal preference for the
front support and the side supports. With regards to cleaning activities the vertical
supports and the side supports were equally preferred. Some subjects indicated that
they did not have a preference for any particular support when cleaning their body parts
[8].
3.3. Behavioural Study on Body Posture During Dressing/ Undressing, Toileting and
Cleansing
In this study the objective was to gain insight in the use patterns and preferences
regarding different methods of perineal hygiene after using the toilet.
In the second part of the previous described study subjects were asked to pretend
to go to the toilet in the laboratory toilet environment. They were asked to act as they
would do normally, undress (to the level of underpants), sit down, simulate cleaning
their intimate body parts with different types of cleaning utilities, stand up and dress
again.
Standard ethical guidelines were followed: Subjects were carefully prepared, orally,
in written and by means of informed consent. Additional ethical measures were taken
to decrease the feeling of discomfort when subjects had to undress; during the actual
user test female test subjects were accompanied by female researchers only and
similarly male subjects were accompanied by male researchers.
The final part of the test consisted of a multiple-choice picture questionnaire,
which addressed common toilet behaviour and postures during toileting including
cleaning activities. A special multiple-choice picture questionnaire was used to explain
the postures precisely, and to make filling the questionnaire easier and less
embarrassing.
The results of the test revealed valuable insights into the behaviour patterns of
different toilet activities including methods for perineal cleansing [9].
4. Results
In the FRR project new scientific, technical and professional knowledge has been
gained about user problems and needs extracted from user involved testing and
research, behavioural aspects concerning toileting and personal hygiene, the perception
of safety, requirements with regard to assistive technologies, ergonomic and
anthropometric data on elderly, the use of inclusive design" principles and the use of
computer based interviewing.
This knowledge was translated in a pre-production prototype of a restroom / toilet
environment, which includes a range of innovative solutions for improving the user
friendliness. The prototype includes amongst others a highly accessible space saving
door, a "design for all" door handle, an individual adjustable toilet module, different
types of grab bars to offer body support and guidance while moving or while using the
toilet, a system for supporting sitting down or standing up, a manual control interface
and a wash basin for personal hygiene while using the toilet.
Services offered provide control and monitoring functionalities, user interfaces,
illumination functions for rest rooms, multilingual voice control and output functions,
emergency and alarm functions, smart card technology for storing individual data,
sensor systems for monitoring user activities and system software for control and
interfacing [10].
An illustration of how the knowledge about user needs and problems was
translated into a user-friendly restroom design is given by a description of found user
problems and the corresponding FRR design solution ordered by the four general user
areas (see figure 2) that can be distinguished in the toilet environment. See table 3a-3d.
Table 3a. User problems in the user area environment and the corresponding FRR design solutions
Difficult to store Walking stick, The support surfaces of the toilet seat
personal belongings sanitary towels, can also be used to put down personal
stoma requisites belongings or handle sanitary provisions
ENVIRONMENT
Difficult to distinguish Diminished sight The colours of floor, wall, sanitary

the sanitary from the components and essential controls have
environment and floor been chosen to contrast with each other
from wall or otherwise a contrasting band of
colour is put on wall and skirting-board.
This makes it easier to judge the
dimensions of the toilet area and locate
its components and controls.
Table 3b. User problems in the user area access and the corresponding FRR design solutions
User User problem Underlying cause FRR design solutions

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

or with an elbow
Difficult to manoeuvre Diminished arm A door2 with hinges around two points
through the door opening force, use of walking slides in a top rail, resulting in a
aid or wheelchair sideways and inwards moving door.
Less space is needed when turning,
hence a larger door width is possible.
Movement of the door is very light.
Difficult to lock the door Psychological: fear A floor fall monitoring system that
of accidents or death senses unusual user movements or
stillness combined with an alarm system
Table 3c. User problems in the user area commute and the corresponding FRR design solutions
Difficult to move to Wheelchair, walking Different spatial dimensions are chosen

the toilet: too little aid for wheelchair (1.90x2.50m) and
manoeuvring space walking aid (1.20x1.80m) and as less
objects as possible on or near the floor
COMMUTE
e.g. hanging toilet bowl

Difficult to move to Walking limitations The toilet area is circumcised by a wall
the toilet: large space mounted support bar, which makes the
without any support path from door to toilet provided with
continuous support. The bar has an
extruded shape with no external
mounting points and a rounded inside,
which makes it very easy to clean.
Table 3d. User problems in the user area toilet and the corresponding FRR design solutions
Difficult to undress, Loss of balance, Vertical toilet support bars offer support
turn round and sit diminished muscle while standing, turning and sitting down.
down flexibility The bars can rotate in a horizontal plane
to accommodate to different user
dimensions or can be moved entirely
sideways to have them out of the way.
The toilet2 that can be adapted in height
and angle automatically by means of
remote control or voice activation.
Difficult to undress Wheelchair Combined with the automatic toilet;
and transfer to toilet A toilet seat with extra support surfaces
adjacent to the seat, the total forming a
rectangular shape, is facilitating the
independent transfer from wheelchair to
toilet and vice versa.
Difficult to sit stable Paralyses Combined with the automatic toilet;
on toilet Horizontal toilet support bars offer
TOILET
support when sitting on the toilet and

can be automatically adapted in height
and width by remote control or voice
activation.
Difficult to clean Loss of balance, Combined with horizontal body support
intimate body parts diminished muscle bars;
flexibility A moveable washbasin can be used to
clean hands or body parts while seated
on the toilet. The washbasin is equipped
with faucet and shower function.
Underneath the basin an additional light
source improves visibility while
cleaning intimate body parts.
Difficult to stand up Diminished force, Combined with vertical and horizontal
and dress loss of balance, support bars, transfer toilet seat and
diminished muscle automatic toilet;
flexibility The curved ending of the horizontal
support bars is facilitating a natural hand
grip when standing up.
(1) Earlier developed product by LM, (2) Earlier developed product by CSO
The final FRR pre-production prototype was tested and evaluated by elderly and
disabled test persons at 5 different URBs and demonstrated at the Rehacare Fair in
Dusseldorf, Germany, November 2004 (see figure 3). The most essential parts of the
final prototype were also installed in day-care centre for MS patients Caritas Socialis
in Vienna, Austria, January 2005 and effectively tested for 39 days by patients (n=29)
and nurses (n=12).
The test results showed a high degree of satisfaction amongst users, as well as a
positive effect on the perception of autonomy, safety and dignity amongst users [11]. In
conclusion we can say that the objectives of the project have been reached.
5. The First Friendly Rest Room: Toilet of the Future?
The FRR project has been a unique and successful project with regards to several
aspects. First of all knowledge and understanding has been gained about toileting,
accident prevention, personal care and the application of new technologies in the toilet
environment. Secondly several prototypes of user friendly rest rooms have been
developed, built and tested with elderly and disabled test users. However, what has not
been attended to might be even more interesting. For instance topics as; general user
behaviour in the toilet, including habits, rituals, cultural differences; the experience of
hygiene; the experience and acceptance of new technology; standards and building
regulations; influence of architects and real estate developers; socio-economical issues
on financing; application of innovative materials; all have been studied little or not at
all. Partly this can be explained by the lack of time and resources within the projects
parameters. For the other part it was caused by a hidden problem: the taboo subject
matter. The problem was not that the test persons were unwilling to participate. They
were on the contrary remarkably straightforward about their habits and problems,
perhaps being less embarrassed by the subject of toileting when faced every day with
problems or even the need for personal assistance in this private area. The sensitivities
lay with the researchers themselves. Despite that test persons were carefully prepared
the usually young and healthy researchers found it inappropriate to ask them about
their toileting habits. The fact that test persons were older and disabled persons, for
whom a lot of respect was felt, made it even more inappropriate. The extent to which
Figure 3. Final prototype of a Friendly Rest Room

the taboo subject influenced the researchers differed culturally, as in some European
countries it was more an issue than in other, though it was to a certain amount present
in every country. The multiple-choice picture questionnaire on toilet postures as a
result was vividly rejected by some of the project partners because of the drawn
pictures of body postures which were regarded unacceptable [12].
Nevertheless it is essential in user centered design to know everything about the
reality of user behaviour, and as a derivative about the needs and problems of the user
group. This is even more important when a topic is concerned that is generally not
spoken about, like toileting. The user problems with toileting that were found in this
project, were found more or less in passing, for instance through remarks of subjects
during the prototype testing.
Another pitfall for user centered design, encountered in the project and caused by
the taboo subject, is that researchers to avoid talking in detail about the topic of
toileting are letting the test users simply decide that a product is good or not, but never
ask why. It is undisputed that of all things the why question in particular has to be
answered in order to come to a truly user centered design. The risk is especially in
innovative products for instance when new technologies are applied- that test users
tend to agree with solutions they are familiar with, not necessarily being the best
solution from an ergonomic point of view.
So is a user-friendly rest room still staying in the future? Although the projects
objectives have been reached, the final prototype still is far from market ready and
many areas of study are yet to be explored. For this reason it may come to no surprise
that the final tests also revealed a lot of unanswered questions regarding technology,
costs, safety, hygiene, and brought many supplementary suggestions for improvement.
Concluding, there still is a long road of research and development to go before we can
truly say our toilet environment is adapted to the requirements of modern time;
designed for all, irrespective of age or ability. Though now the first step is made.
References
[1] Horan JL. The Porcelain God. A social history of the toilet. London: Robson Books Ltd; 1996.
[2] Mllring B. Toiletten und Urinale fr Frauen und Mnner, die Gestaltung von Sanitrobjekten und ihre
Verwendung in ffentlichen und privaten bereichen. Dissertationsgeschrift, Fakultt Bildende Kunst,
Universitt der Knste Berlin; 2003.
[3] Buzink SN, Molenbroek JFM, Haagsman EM, Bruin R de, Groothuizen ThJJ. Falls in the toilet
environment: a study on influential factors. Gerontechnology. 2005;4:15-26.
[4] Kothiyal K, Yuen TW. Muscle strain and perceived exertion in patient handling with and without a
transferring aid. Occupational Ergonomics. 2004; 4:185-197
[5] Garg, A, Owen BD, Carlson B. An ergonomic evaluation of a nursing assistants' job in a nursing home.
Ergonomics. 1992;35:979- 995.
[6] Molenbroek JFM, Veenstra R, Stephan CA, Swarte G. Design for All in werksituaties, inventarisatie
van werkaanpassingen. The Hague: Ministerie van SZW. Werkdocumenten no. 202.
[7] Bruin R de, Molenbroek JFM, Groothuizen ThJJ, Van Weeren M. On the development of a friendly rest
room. In: Proceedings of Include: Inclusive design for society and business Conference, Helen Hamlyn
Research Centre, Royal College of Arts. 2003;London.
[8] Dekker D, Buzink SN, Molenbroek JFM, Bruin R de. Hand supports to assist toilet use among the
elderly. Applied ergonomics. 2007;38(1):109-118.
[9] Buzink SN, Dekker D, Bruin R de, Molenbroek JFM. Methods of personal hygiene utilized during
perinal cleansing: acceptance, postures and preferences in elderly Dutch citizens. Tijdschrift voor
Ergonomie. 2006;31(3):36-44.
[10] Groothuizen ThJJ, Rist A, Van Weeren M, Dekker D. The Final FRR Components. This volume.
[11] Gentile N, Day C, Edelmayer G, Egger de Campo M, Mayer P, Panek P, Schlathau R. Concept,
Setting Up and First Results from a Real Life Installation of an Improved Toilet System at a Care
Institution in Austria. This volume.
[12] Day C. Sitzen Sie bequem? Zur Bedeutung soziologischer Perspektiven in der Technikentwicklung am
Beispiel eines interdisziplinren EU-Projekts [Diplomarbeit]. Institut fr Soziologie, Karl-Franzens-
Universitt Graz: Graz; 2004.
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-49
When Ethical Guidance Is Missing and Do-

It-Yourself Is Required: The Shaping of
Ethical Peer Review and Guidance in the
FRR Project
Marjo RAUHALA 1
fortec Research Group on Rehabilitation Technology Institute integrated study
Vienna University of Technology, Vienna, Austria
Abstract. The purpose of this paper is to describe and discuss the approach for the
tasks of ethical peer review and ethical guidance which was adopted in the project
Friendly Rest Room for Elderly (FRR). Two aspects of user involvement were of
special concern for the ethical reviewers: first of all, the target group consisted of
potentially frail (or, vulnerable) users, and, second of all, problems relating to
toileting and personal hygiene are considered taboo subjects in most regions of
Europe. A mixture of a normative and empirical approach to ethics was adopted
for guiding the project's user involvement. Ethical guidelines and principles
relevant for the FRR context were identified and empirical work was performed to
study their implementation. As methods for data collection, participant observation
of prototype trials and interviews with users and developers were applied. In
addition, the ethical peer reviewers participated closely in the drafting of
information materials for users and in planning and designing of the user trials. In
designing the user tests, much attention was paid to efforts to lessen the taboo
effect faced by participants who were asked in the presence of a research team to
talk about their toileting routines and difficulties. In this paper, the normative and
empirical work performed by the ethical review team in the FRR project is
described and key observations are discussed. In conclusion, the main lessons
learned in the continuous process of ethical peer review in the FRR project are
presented.
Keywords. Ethics, Peer Review, Ethical Guidance, User Involvement, Assistive

Technology, Potentially Vulnerable Users.
1. Introduction, Background, and Approach
At the time when the Friendly Rest Room project was about to commence, few
research and development projects outside the medical and health care realm that were
financed within the European Commissions framework programs had been requested
to incorporate a systematic ethical peer review process in their work. The 5th European
Community Framework Programme placed ethics very high on its agenda in general,
1
Contact Information: Marjo Rauhala, fortec - Research Group on Rehabilitation Technology, Institute
integrated study, Vienna University of Technology, Favoritenstrasse 11/029, A-1040 Vienna, Austria; E-
mail: marjo.rauhala@fortec.tuwien.ac.at; Website: http://www.fortec.tuwien.ac.at ; Tel: + 43 1 58801-42
918; Fax: + 43 1 58801-42 999.
50 M. Rauhala / The Shaping of Ethical Peer Review and Guidance in the FRR Project
explicitly stating in various official documents the need of all its research activities to
respect an ethical framework (see [1]). The FRR project was predominantly a
technology research and development project which was financed in the Thematic
Programme Quality of Life and Management of Living Resources and its Key Action
6 called the Ageing Population and Disabilities. The three partners who were
responsible for carrying out user studies and trials with prototypes were technical
universities without established procedures for research clearance.
The FRR projects consortium had to react on a short notice to the financiers
demand to construct a framework for ethics for the entire duration of the project. In
finding a solution, the consortium faced a major challenge: there was little formal
guidance available with regard to developing an ethical framework for a technology
R&D project like the FRR. A number of questions surfaced. Given the context of
toileting, what ethical issues would need to be addressed? How to help engineers and
developers with little previous exposure to research ethics identify relevant ethical
issues and to address them at an appropriate time in the projects trajectory? What kind
of documentation would be needed? Who should translate the relevant, more abstract
ethical principles into action guides that are suited for the engineering practice? The
situation was complicated by the fact that the consortium consisted of a
multidisciplinary team the members of which had varying degrees of experience in
handling topics of research ethics. It was agreed that two experts with backgrounds in
bioethics, ethics and technology research and development, and ageing, would be
invited to draft an overall concept for the projects approach to ethics. This concept for
ethical peer review and guidance was then implemented for the entire duration of the
project. In what follows, the approach taken and the main observations and lessons
learned during the course of the ethical peer review in the FRR project will be
described.
2. Three Observations to Consider: Continuity, Taboo Effect, Potential

Vulnerability
In drafting the approach for ethical peer review in the FRR project, the peer reviewers
took three central observations as their starting point. First of all, it was likely that
predicting emerging ethical issues for the entire trajectory of the project would be
difficult. Hence, the ethical peer review and guidance should be continuous and geared
toward identifying and addressing ethical issues as they surfaced during the projects
lifetime.
Second of all, the topic of personal hygiene and toileting can be considered a
sensitive area of research. The research participants could feel embarrassed or
uncomfortable when confronted with questionnaires and interviews in which they were
asked to disclose any challenges experienced in toileting and personal hygiene. Not
only the risk of embarrassment but also physical risks, such as the risk of falling and
being injured, would need to be addressed in the prototype trials of the friendly rest
room unit. Given the taboo subject it was hypothesized that the approach adopted for
preparing the users for their participation and the process of informed consent would
have a decisive role in guaranteeing users well-being. In other words, the goal of the
preparation would be to help participants become open and confident in providing their
ideas, concerns, and feedback to the research teams. Special attention would need to be
paid to building trust between the users and researchers.
M. Rauhala / The Shaping of Ethical Peer Review and Guidance in the FRR Project 51
Third of all, the user groups whose contribution and commitment to the project
was perceived essential were considered potentially frail or vulnerable.2 As a user-
driven project, the FRR intended to rely on a close and continuous cooperation with
older persons and persons with disabilities from the very beginning (see for example
[3]). Hence, various risks and safety issues had to be taken into account and addressed
in the projects approach to ethics and ethical review.
Furthermore, it was agreed that despite many differences, a number of similarities
could be identified between research participation in the contexts of technology
development and clinical research [4]. This fact had implications to the shaping of the
normative framework and the process of informed consent.
In sum, the ethical reviewers felt that the user-driven approach in the FRR project,
its user group, and the sensitive area of research placed much responsibility in the
projects research teams. Thus the FRR ethical review and guidance should attempt to
achieve more than merely providing the projects researchers a predefined set of
principles and action guides from existing frameworks for ethical review. 3 Ideally, the
FRR concept of ethical peer review and ethical guidance could provide the research
teams with tools to reflect on, and in case necessary, improve their work practices with
regard to ethics. In this way, the approach was in agreement with Flaskerud and
Winslow [5], according to whom Issues of providing informed consent, maintaining
confidentiality and privacy, weighing the risks and benefits of a study and paying
attention to issues of fairness are all especially important when working with groups
who are vulnerable. The approach also took some elements of action research as the
project workers were engaged in a new inquiry which, in the words of Martin [6],
meant an invitation to challenge prior beliefs and understandings and reframe what
they know. In what follows, the background commitments and assumptions that
contributed to the shaping of the ethical peer review in the FRR project will be
described.
3. Constructing a Framework: Sources for Guidance for a Normative and

Empirical Approach
In drafting the approach for the ethical peer review, the tenets of participatory systems
design (PD) (see for example [7]) were relied on. Additionally, a number of commonly
accepted international ethical guidance documents from other related fields of research
involving people, mainly those from the medical and health care research, were
investigated and adapted for the FRR context.
It is the core philosophy of PD to offer the stakeholders and target groups to take
part in the development of a system or application that has direct relevance to their
work or personal life. In PD projects users are considered co-designers with a voice,
meaning that their ideas and preferences are taken seriously by integrating them in the
2
For a very useful and informative account on vulnerability and research, see the Social Science Research
Ethics web-resource of the University of Lancaster [2]. The website provides a range of resources designed
to help social science researchers increase their knowledge and understanding of the processes and practices
involved in undertaking ethically sound research.
3
Frameworks for ethical review have been formulated to address ethical issues in various disciplines that
rely on research participation of human subjects. See for example [8]. The kind of formal review described in
this document, for example, was not available for the research teams at the three sites of user trials in the
FRR project.
emerging design. A commitment to participatory design had two interrelated

implications for the ethical guidance and the user involvement in the FRR project: First
of all, serious effort had to be invested in making users feel safe, open, and confident as
providers of feedback. Second of all, the design of user trials and user needs elicitation
had to allocate the users an active role in the process making use of techniques that
allow ways for lay participants to influence design without being technical experts
themselves. Such techniques include prototyping, storytelling, and observing the users'
at work or in everyday situations of technology use.
The essential principles and norms that guide appropriate research with all human
beings are anchored in widely accepted international declarations of human rights,
research guidelines, and opinions and recommendations of high level working groups.
These include the Helsinki Declaration of the World Medical Association (WMA) [9],
which spells out the Ethical Principles for Medical Research Involving Human
Subjects; the International Ethical Guidelines for Biomedical Research Involving
Human Subjects by the Council for International Organizations of Medical Sciences
(CIOMS) and the World Health Organization (WHO) [10], and the relevant opinions
issued by the European Group on Ethics in Science and New Technologies (EGE) (see
for example [11]). The role of ethical principles is important in formulating the
foundation of the research participants rights and the researchers responsibilities
toward the participants for the duration of a given research endeavour (and beyond). In
the FRR project, the principles of autonomy, dignity, and privacy formed the core
principles that shaped the framework for ethics and they were incorporated in the
process of informed consent, which was tailored for the project from established
guidelines in clinical research [9, 10]. Facing the lack of specific guidelines addressing
ethical dimensions of research participation in technology R&D settings, the ethical
reviewers considered adapting already established frameworks for ensuring
participants safety and well-being the best solution, even if it meant coming up with a
do-it-yourself approach for the FRR context.
Drawing on the above-mentioned documents, the ethical framework then focused
on the following aspects of the FRR projects user participation:
x Safety;
x Well-being and comfort (psychological and physical);
x Sensitive area of research, or, a potentially taboo subject;
x Voluntariness;
x The process of informed consent;
x Privacy; and,
x Avoiding raising unfounded expectations.
Whereas the research teams appreciated the normative dimensions related to their
work at hand, they needed support in translating more abstract principles into
practicable action guides with relevance to their tasks. It was therefore proposed that in
addition to a normative approach to user participation some empirical work, in forms of
participant observation of user tests and interviews with participants and research
teams, would be performed within the ethical review. The reasons for proposing an
empirical rather than a strictly normative approach to practicing ethics in the FRR
project were the facts that the technologies to be designed were highly complex, the
intended user groups were heterogeneous (and potentially vulnerable), and systems
designers had relatively limited experience in addressing ethical issues as part of their
technical work in a substantiated, grounded way. 4 The empirical approach allowed
studying the ways in which the normative guidance was inscribed in the projects
documents and reports, design of user trials, and their implementation. Even more
importantly, it was possible to observe in which ways ethical guidance was translated
and integrated into the interaction between the research teams and the participants.
Furthermore, the ethical reviewers gained valuable insight into the role of research
ethics and ethical guidance in the settings of day-to-day research and development
work, and, into the motivational bases and concerns of users who volunteered to share
their intimate experiences with an unfamiliar team of researchers. 5
4. Context and Case: Challenges for Ethical Review and User Participation
In a nutshell, the challenge for the user involvement and ethical review and
guidance in the three research sites in Austria, the Netherlands, and Sweden can be
summarized as follows. How can (potentially vulnerable) users be brought into a
laboratory setting to openly talk about their difficulties related to personal hygiene and
demonstrate their preferred ways of being seated on a prototype toilet unit and
cleansing themselves while a research team is recording their every move?
4.1. Research Setting: Out of Place
The research setting where the toilet prototype was to be tested posed additional
challenges. The first prototype consisted of an ordinary toilet seat embedded in exposed
machinery that controlled the movements of the toilet bowl and the units grab bars. At
the test site in Austria, the trials of which are the main source of information for this
article, no actual toilet facility was available for setting up the prototype. Instead the
unit stood in the office of two of the projects researchers, obviously displaced amongst
desks and computers. The test design required the trial participants to talk through and
demonstrate their preferred toileting routines, including, ways of transferring to and
from the toilet seat (in many cases from a wheel chair), being seated, cleaning
themselves, and finally getting up off the unit. Participants were asked to repeatedly try
out different heights and tilts of the toilet bowl in order to find comfortable positions
for transferring, sitting down, being seated, and getting up. The entire test situation
would be videotaped and take up to 1,5 hours. Including a test leader, 4-5 researchers
would be present, asking questions, taking notes, and taking up space in the small
room. Obviously, for the researchers to obtain useful data, the users would need to feel
comfortable and safe during the trials. Although the research team who had assembled
the prototype and whose work space it occupied soon began to treat the toilet bowl as
an additional seating arrangement in their office, the (female) social scientists and the
4
The FRR consortium consisted of a multidisciplinary and multinational team of researchers and
developers with varying degrees of experience in systematically reflecting on the ethical dimensions of their
work. The process of translating the normative recommendations into the engineering and design practice
contributed to a shared view on ethics in the project. The empirical work, the findings of which were fed
back to the partners and researchers, served to evaluate how the projects commitment to ethics had been
implemented in the practice.
5
Some of the lessons learned and the possibilities and limitations of ethical review have been discussed
elsewhere, see [12].
ethical reviewer who were visitors to the site, could not be persuaded to take a seat in
the presence of their (male) colleagues. Only gradually did the team members
overcome the strangeness of the situation. Despite the fact that no clothes were
supposed to be removed for the test, it became obvious that the users would be likely to
experience the same unease at the user trials as the projects social scientists and the
ethical reviewer. The question then turned on how to remove the unease and taboo
effect and replace them as much as possible with comfort and confidence.
The trials of the FRR prototypes had to be constructed to meet the criteria of:
x Safety for participants, bearing in mind some users were mobility impaired,
relying on wheel chairs and other walking aids, and faced an increased risk of
falling at every transfer to the toilet seat;
x Respect for autonomy, voluntariness, and non-coercion, bearing in mind that
some users lived in institutional care settings with limited chances to leave the
premises;
x Well-being and dignity of participants while being exposed to a potentially
embarrassing research situation; and,
x Privacy while participants intimate data was collected and interviews and
trials were audio and video recorded; and
x Sensitivity toward users specific needs as visitors to a research site.
After careful and relatively time-consuming planning, the above-listed criteria

became inscribed in the trial plans. A detailed script was prepared, rehearsed, piloted,
and revised.
4.2. Step-By-Step Informed Consent: Peeling Away the Taboo
Although not all risks of injury could be eliminated, the user trials were physically as
safe as regular daily toilet use. Whether it would be equally safe from the psychological
point of view was thought to depend on how well the research team would succeed in
preparing the users for confronting the prototype and their potentially embarrassing
tasks. Because increased familiarity with the prototype appeared to have changed the
way the members of the research team treated the prototype, it was thought that a
similar development could take place in the users.
An extensive process of informed consent was devised with the goal of removing
the taboo effect of the research situation and making the participants feel confident,
open, and safe. Different media were used to convey information about the project, the
depth of the information increased with time. The initial recruitment took place through
a peer, a kind of expert user in the project, who used a self-help group meeting of the
target group to informally tell potential users about the project and its aims. Those who
showed interest in participating in the project received more extensive written material
with photographs about the prototype, including one with a researcher seated on the
unit. Users were provided detailed information regarding expectations on time to be
spent, a schedule of events, descriptions of tasks, and the setting itself. In an informed
consent form, the main information was summarized, and the usual rights of research
participants were repeated.
Included in the informed consent document were then, for example, the
participant's right to interrupt the participation at any time, right to refuse to answer
questions, as well as a reminder that the development project is a long-term one, that
may not result in a short-term solution for the participant's situation. To provide users
with a chance to exercise their rights, the research teams were trained to continuously
refresh the participants informed consent, even in-between the tasks, through
questions such as: Are you all right? Would you like to have a break?
Finally, when the users arrived at the site, they were first greeted and showed a
video of the functions of the prototype demonstrated by a researcher in the team. Only
after asked if they were willing to proceed to seeing the prototype, did they enter the
laboratory. Before the testing itself started, one of the social scientists would
demonstrate how he/she would operate the prototype while seated. By this time, users
were usually very curious to get started themselves. In this way, gradually peeling
away the taboo effect through information and familiarity with the project that
increased step-by-step seemed to have worked well.
Awareness of the risk that users could be intimidated by the prototype and test
situation contributed to carefully planned user trials and to an informed consent process
that helped neutralize the research context and empowered the participants. It could be
observed that the participants knew what they were confronted with and that they felt
their effort and feedback was valued. Furthermore, users showed much courage in
telling their personal stories indicating trust had been built in the projects research
teams.
In addition to a careful process of informed consent, a strict data protection policy
was implemented in the project. For example, users were assigned codes, any data
collected was stored on secured servers, pictures and video materials were only used
internally within the project and limited educational purposes if users had explicitly
agreed to it.
5. Description of the Empirical Work
In order to investigate the implementation of the normative approach to the user

trials and the process of informed consent the ethical reviewers performed some
empirical work in the project. They collected data through participant observation of
trials, interviews with trial participants, project researchers, and test leaders, and
analysed available project materials and reports. Participants were interviewed in three
settings: at the end of each trial, in their homes, or in a focus group at the end of the
project. The material was recorded in field notes and to some extent on audiotape. One
of the ethical reviewers was in close and continuous contact with the developers at one
of the research sites. One cycle of the user tests was observed at the Swedish test site
where interviews with users were also conducted. The findings were fed back to the
researchers at the respective test sites and the consortium and reported in the projects
deliverables.
5.1. Observations: Dealing With Unexpected Reactions and Incidents
Three cycles of user tests were completed without incidents. In the fourth cycle, when
organizing the tests had become somewhat of a routine, some problems emerged. In
what follows, the incidents will be described.
One test user broke into tears during the coffee break, possibly as a reaction to
having failed in a task he had been asked to perform. The task required a capacity in
the participant, namely, raising his voice which had been affected as a result of his
recent stroke. A successful rehabilitation made the man physically appear a healthy
volunteer to the research team. What the team could not foresee was how the mans
failure to activate an alarm with his voice meant would mean a sad reminder of the loss
of health and control in his life. The participants unexpected emotional response made
the team members reflect on what they could have done differently to prevent the
feeling of failure. There was in hindsight some indication of the users hesitance
with regard to the task as he attempted to tell the test leader that the feature might not
suit stroke patients. But it was not obvious for the research team that the user wanted to
discontinue.
An interview with a projects secondary user, a nurse employed in a long-term care
facility, revealed that the user trials were an exciting event for the participants from her
unit. Many residents of retirement homes rarely have a chance to leave their facilities.
One of the older participants in the project had never visited a university institute. The
nurse reported the participants showing signs of being nervous and not sleeping well
prior to the tests. Furthermore, the projects participants included persons whose
strength would vary on a daily basis, depending on external factors, such as room
temperature, medication, intensive therapies, etc. One very committed participant was
seemingly fatigued as a result of a recent period of therapy but he ensured the team he
was fine. In transferring to the toilet seat, he could not hold back his bowel movement.
Despite his discomfort and the team members explicit offers to discontinue, the
participant wanted to try out all the new features of the prototype. Should the team
have interrupted the test situation against the participants wishes? Because the team
members personally knew the participant, they respected his judgment and allowed him
to complete all the tasks.
Wishing to help the project gain some publicity, a healthy volunteer in his 70s
brought along a journalist to observe his own test and to report about the project in a
local newspaper. As soon as the user was seated on the toilet unit, the journalist started
to take pictures. Because users privacy and dignity had been an important
consideration in planning the user participation, the ethical reviewer informed the
journalist about the projects approach to ethics and privacy. The projects photo and
video material was kept for internal use only. All users had been promised this would
be the case. The user himself, a retired local politician, also expressed his wish not to
be shown in the local newspaper seated on a toilet bowl. He would prefer being
photographed standing next to the prototype together with researchers. Such pictures
were indeed taken by the journalist. However, when the newspaper appeared, the user
was depicted alone seated on the toilet prototype. In the accompanying story the user
was identified by name.
5.2. Observations about Users Contribution
The users that participated in the test cycles can be described as very active,
courageous, and willing to openly tell the project team about their personal experiences
with existing toilets and their expectations of the FRR. Two observations can be made.
On the one hand, it is possible that the recruited group was special with regard to their
attitude toward toileting. One participant said there was nothing embarrassing for her in
the topic of personal hygiene because through her long-standing illness she had become
used to hospitals and research situations. On the other hand, it is also possible that the
users were sufficiently prepared and therefore willing to communicate openly in the
interview and test situations. One user explicitly mentioned that the information
provided was serious. For this user respect for privacy and the fact that no pictures
would be published were important. She admitted that toileting was a sensitive topic
and that it had to be addressed accordingly. She found the university a trustworthy
project partner. A healthy volunteer described her experience in the project in terms of
fun and having felt very safe. For a secondary user caring for his wife the detailed
information provided to participants was central. He compared the trial with a visit to a
doctor; both cases required detailed information for decision making.
Another user expressed her gratitude and relief that a research project would
finally address a topic of such immense importance to her personal well-being. This
participant had become increasingly home-bound because the only toilet she could
safely and confidently use was the one in her home. This participant contributed
information in a courageous, honest, and open way which communicated much trust in
the researchers but also hope in the new technology. Looking back at this particular
participant, it was important for the project team not to raise unfounded expectations.
This meant communicating to the users from the start that the project could not
guarantee improvement in their individual situations.
6. Lessons Learned Concluding Thoughts
In the course of the ethical review in the FRR it became evident that the users
appreciated the information materials provided for them prior to the beginning of each
test cycle. The users interviewed in Sweden pointed to two main sources of trust and
credibility: the fact that the project partner was a university and the quality of the
written information that was provided to them before the test cycles. Another source of
trust mentioned by users was being personally acquainted with someone associated
with the project. In Austria, the projects expert user helped recruit most of the
participants making him a personal connection to the project. It appeared that the
nature of the information, who provides it, and the institutions involved in the research
play an important role in building trust in the users. These factors are then of central
importance with regard to the maintenance of trust throughout the project and beyond.
In the FRR project much attention was paid to easing of potential anxieties or
embarrassment in users who were invited to test a toilet in a research context. However
carefully the test situations were thought out ahead of time and however well they were
rehearsed, not everything could be controlled or foreseen. Experiencing a failure in test
situation can act as a sad reminder of the loss of personal control and trigger an
emotional response. In such cases, the researchers can only apply their human and
personal skills to offer comfort. Such unexpected reactions can also enhance sensitivity
in researchers with regard to future cooperation with (potentially vulnerable) users.
Even though the framework for ethical guidance could not prevent the particular
incidents in the FRR project, they provided the research team with useful tools for
discussing the issues.
During the FRR project the partners who conducted user tests came to adopt a
shared view of the ethical dimensions of user involvement, which became inscribed in
the projects approach to planning the user trials and the preparation of users. The
shared view and understanding of appropriate and acceptable ways of confronting users
with potentially embarrassing research situations can be called the practice or ethics of
user involvement of the FRR project. Unfortunately there is no way to control how
actors who are not committed to the normative frameworks that are shared in a project
make use of the materials they have access to. In this way, a well-meaning user who
intended to promote a good cause, ended up against his wishes in a newspaper article
which depicted him sitting down on the toilet prototype. Despite the users protest and
the ethical reviewers intervention the picture was published. This example serves to
show that those who are external to a particular practice do not necessarily feel
obligated to respect its rules. Nor do those who share the common view or practice
necessary have any means, beyond kind words, to persuade others to follow their good
example.
In conclusion, the FRR projects approach to ethical review and ethical guidance
was successful in drawing the researchers, in particular the engineers and developers,
attention to the ethical aspects of their day-to-day work. It also provided them with
useful tools for addressing ethical issues in their future projects.6
Acknowledgements
The concept of ethical peer review for the FRR project is based on close cooperation between the author and
Ina Wagner, professor for Multidisciplinary Systems Design and Computer-Supported Co-operative Work
(CSCW) and Head of the Institute for Technology Assessment and Design, Vienna University of
Technology.
References
[1] Council Decision of 25 January 1999 adopting a specific programme for research, technological
development and demonstration on quality of life and management of living resources. [Internet] 1999
[cited 2010 Dec 30] Available from: http://eur-
lex.europa.eu/Notice.do?mode=dbl&lang=en&ihmlang=en&lng1=en,de&lng2=da,de,el,en,es,fi,fr,it,nl,
pt,sv,&val=329567:cs&page=#top.
[2] Social Science Research Ethics [Internet] 2011 [cited 2011 Jan 27] Available from:
http://www.lancs.ac.uk/researchethics/index.html.
[3] Panek P, Alm N, Day C, Edelmayer G, Gentile N, Magnusson C, Mayer P, Molenbroek JFM,
Neveryd H, Rauhala M, Rist A, Schlathau R, Zagler WL. Friendly Rest Room Project: A Toilet
Prototype for Improving the Quality of Life of Old People and Persons with Disability. In: Pruski A,
Knops H, editors. Assistive Technology: From Virtuality to Reality.Amsterdam: IOS Press;2005,pp. 8-
12.
[4] Rauhala M, Topo P. Independent living, technology and ethics. Technology and Disability.
2003;15(3):205-214.
[5] Flaskerud JH, Winslow BJ. Conceptualizing Vulnerable Populations in Health Related Research.
Nursing Research. 1998;47(2):69-78.
[6] Martin AW. Large-group Processes as Action Research. In: Reason P, Bradbury H, editors. Handbook
of Action Research: Participatory Inquiry and Practice. London: SAGE; 2001, p200-208.
[7] Computer Professionals for Social Responsibility (CPSR). What is participatory design? [Internet] 2005
May 6 [cited 2011 Jan 27] Available from: http://cpsr.org/issues/pd/introInfo/
[8] Finnish National Advisory Board for Research Ethics (TENK). Ethical principles of research in the
humanities and social and behavioural sciences and proposals for ethical review. [Internet] 2009 [cited
2011 Mar 1] Available from: http://www.tenk.fi/ENG/publications.htm
6
Experiences of project workers with the continuous ethical review in the FRR project have been
published elsewhere. Please, see [13].
[9] World Medical Association (WMA). The Declaration of Helsinki. Ethical Principles for Medical
Research Involving Human Subjects. Adopted by the 18th WMA General Assembly, Helsinki, Finland,
June 1964, and last amendment by the 59th WMA General Assembly, Seoul, October 2008.
[10] The Council for International Organizations of Medical Sciences (CIOMS) in collaboration with the
World Health Organization (WHO). International Ethical Guidelines for Biomedical Research
Involving Human Subjects. CIOMS, Geneva, 2002.
[11] European Group on Ethics in Science and New Technologies (EGE). Ethical issues of healthcare in the
information society. Opinion n 13 - 30/07/1999. [Internet] 2011 [cited 2011 27 Jan] Available from:
http://ec.europa.eu/european_group_ethics/docs/avis13_en.pdf
[12] Rauhala M. Ethical Counselling as a Working Method in Designing Technology for People with
Dementia. In: Topo P, stlund B, editors. Dementia, Design and Technology: Time to Get Involved.
Amsterdam: IOS Press; 2009, pp. 97-110.
[13] Rauhala M, Edelmayer G, Topo P, Zagler WL. Ethics and Assistive Technology Development - Project
Workers' Experiences with Continuous Ethical Review. In: Eizmendi G, Azkoitia JM, Craddock GM,
editors. Challenges for Assistive Technology. Proceedings of the 9th European Conference for the
Advancement of Assistive Technology in Europe (AAATE). Amsterdam: IOS Press; 2007, Volume
20, pp. 610-614.
60 A Friendly Rest Room: Developing Toilets of the Future for Disabled and Elderly People
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-60
User-Driven Research How to Integrate

Users Needs and Expectations in a
Research Project
Christian DAY1, Marianne EGGER DE CAMPO
EURAG European Federation of Older Persons,
Abstract. Within the FRR-project, user involvement was understood as a core task
of researchers, designers and developers in the consortium, urging them strongly to
justify their decisions with comments and expectations from potential users. What
distinguishes our research structure from most other approaches to user
involvement is the fact that, from the very beginning, primary and secondary users
as well as representatives from the ethical review team had a say in structuring the
research procedures and choosing the appropriate methods. Not only design
decisions, but also research decisions were agreed with user representatives. In
order to achieve that in an effective manner, we relied on a structure that combined
continuous and specialized ways of collaboration with the user. This way of
structuring user-driven research developed within the FRR-project constitutes an
approach that could be used as a model for similar research projects, especially for
those involving vulnerable users.
Keywords. Toilet, User Needs, User Involvement, Triangulation, Research Ethics,

Assistive Technology, User-driven Research
1. Introduction
From the very beginning the FRR project claimed uniqueness in terms of considering
users' expectations in research and development. For instance, in the part of the
contract describing the work to be done within the FRR project, it is stated that users
are actively involved, as equal partners, and influence all research stages.
This chapter describes the approach to user involvement applied within the FRR
project, and its implications. Reflecting both the professional background and the role
of EURAG within the FRR-consortium, it is mainly concerned with the involvement of
users into research activities. Actually, it focuses on how to integrate users in research
about their own needs, expectations and preferences. The main task of researchers
engaged in this kind of work is to assess users opinions and needs towards certain
aspects of the area of interest, in this case toileting. It does so by collecting reactions
towards given equipment or sketches of possible solutions, as well as by asking users to
indicate problems with standard toilets. Toileting is in any case a multi-dimensional
phenomenon, relating technology and design, aspects of health and hygiene,
psychological, social and societal factors. From the beginning of the project, it was
clear that a research design depicting this multi-dimensionality has to combine
1
Corresponding Author: Christian Day, University of Graz, Department of Sociology; Address:
Universitaetsstrasse 15/G4, 8010 Graz, Austria; E-mail: ch.daye@uni-graz.at
C. Day and M. Egger de Campo / User-Driven Research 61
quantitative and qualitative methods. Research, thus, requires a methodological setting

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

between the actor responsible for a product or service (either being the producer or the
62 C. Day and M. Egger de Campo / User-Driven Research
provider) and the consumer of the respective product or service. In this general
definition, user involvement has particularly economic relevance. The decision whether
a product or a service fails or succeeds in the market is finally taken by the consumer.
This also applies to assistive technology (AT) products. The risk of launching or
offering an AT-product of low usability remains high as long as the preferences, needs,
objections and suggestions of the consumer are not taken into account. At all stages in
the lifetime of a product, from its development to its distribution and finally to its use
by the consumer, users can and should be involved. Thus, at least three levels of user
involvement can be distinguished:
The first level is the area of development. User involvement in this context is a
research and development strategy. Potential users shall steer, or at least guide the
development process, thereby trying to ensure a higher acceptability of the later
product. Examples for strategies of user involvement efforts at this level are user-
driven research, when the focus is on research, and user-centered design, when the
focus is on design. The following paragraphs focus on user-driven research, though
some of the considerations presented show intersections with other levels of user
involvement.
The process of choosing an AT-device can be understood as the second level of
user involvement. It deals with the decision which device is best for which person. It
was found that the less the consumer is involved in this process of selection and
delivery, the more likely s/he is to refuse to use this device, a phenomenon called
abandonment [4]. Scientific effort in this area on the one hand aims at raising the
awareness of the experts towards the social and psychological importance of user
involvement, for example as stated in [5] The delivery of technology is not an end in
and of itself; the processes involved in ensuring adequate attention to the finer points of
technology integration include a unique understanding of the person with a disability.
Professional efforts to deliver the targeted technology can be successful only if
attention is given to the needs of the individual. And, on the other hand, on developing
didactic routines for the user that deliver the knowledge requested to actively
participate in the selection process [ 6].
The third level, the area of support services and evaluation after the delivery of the
AT-device, has raised growing awareness throughout the past decade. Developed
initially for justification purpose towards the (mostly public) investors [7], research
activities in this area repeatedly showed that a continuous personal interaction with the
user of a certain AT-device has presumably the same impact on the success of the
delivered AT-device as the delivery of the right customized technology [8].
Considering this, the practice of user involvement transcends its mere economic
relevance. Within AT-development efforts funded by public sources, it relates to
societal and political normative concepts like democracy, equality, legitimacy, active
citizenship, participation and transparency [9]. Considering this as a normative basis,
we defined the basic principle of user involvement as follows: The development of the
FRR should be primarily based on values of needs instead of market. [10] The
development should be guided by the needs, wishes, expectations and constraints of the
target population instead of the interests of stakeholders that will not use the FRR
themselves.
3. User Categories
In order to define the target group of the FRR-project, the following rough categories
of users were distinguished:
Primary users: This category comprises older persons and persons with (physical)
disability.
Secondary users: This term refers to persons assisting primary users. Here, above
all, we find family carers or relatives; further, this category contains caregivers,
nurses, therapists, practitioners and the like, but also cleaning staff should be
considered to assess questions of hygiene.
Tertiary users: Within this group, we find decision-makers and stakeholders from
local and national authorities, insurance companies, hospital managers,
organizations that provide AT-devices etc.
Due to the basic principle of user involvement mentioned above, users from the
first two categories were involved in the research and development activities. As
tertiary users are assumed to represent a market perspective, their contribution is
mostly valuable for the levels of AT provision and service delivery as described in the
previous paragraph, but it can be regarded as less essential at the level of the initial
design and development phases.
4. User-Driven Research
Development work is oriented towards potential consumers this notion can

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

and are also aware of the opportunities it can bring to their development work, most
companies do not follow this strategy for the reasons mentioned in [11].
Metaphorically spoken, they still prefer to use the highway, avoiding the narrow
passes, even if the risk of driving past the place they want to reach is relatively high.
They see the advantages user-driven research and user-centered design can to offer, but
the effort necessary to apply these strategies properly, i.e. soundly, thoroughly and
continuously, surmounts what they are willing (or able) to invest.
It can be assumed that this is partly a problem of interdisciplinarity. Depicting a
phenomenon in its multi-dimensionality requires experts from many different fields.
However, it can be assumed that another significant problem in this context arises
when dealing with the question how continuous collaboration can be carried out in a
way that is at the same time efficient in terms of budget (both for the users, and for the
researchers) and effective in terms of valuable results assuring a high quality
development process.
5. User Board & User Club
A possibility to solve the dilemma between time and budget restrictions and high
validity of users' response is to combine continuous and specific forms of interaction
and collaboration with the user. Within the FRR-project, we structured the
collaboration with users along two principle lines. The first line was built up by users
who have professional experience with the situation of specific user groups.
Represented in the user board, they continuously followed, commented and sometimes
criticized the projects development activities, forming thus a kind of continuous
monitoring board. This user board involved specialists from various backgrounds:
primary users experienced in representing the interests of specific user groups, a
general practitioner, nurses and therapists with different areas of expertise. All together,
the user board consisted of seven persons that agreed to accompany the project and to
be available for the researchers in case of questions during the process of development.
The second line, called user club, was understood as a form of specific
collaboration. Some of the users in this club, in total about 50-60 persons, were invited
at strategic points of the development process in order to evaluate the current status of
technological features and provide ideas for further development activities. Usually,
this collaboration took place in the framework of laboratory tests that were carried out
regularly within the projects development. Within the FRR-project, five test cycles
were carried out, thus forming a cyclic sequence of development phases oriented at a
continuous enhancement of the developed features [16]. The test participants were
selected together with members of the user board according to the principles of
theoretical sampling [12]. In the context of FRR research activities, theoretical
sampling means the conscious selection of test users according to their experience and
knowledge, given the area the research is concerned with. The test participants were
chosen according to the assumed contribution they could bring to the project. E.g.
when testing a toilet is adjustable in height and tilt which addresses people with
restricted mobility, the theoretical sampling suggests to choose people with mobility
problems. This, on the one hand, reduced unnecessary effort on the part of primary
users and thereby counteracted the possibility of disappointment which forms a
massive though often not considered ethical problem. On the other hand, it helped to
focus on certain aspects of the users interaction with the given equipment, thus
enhancing the efficiency of our research. Theoretical sampling thus provides a rather
powerful strategy for user driven research, above all as it avoids the narrow logic of
random sampling that, at least in our opinion, proved to be rather misleading in
contexts similar to ours.
The main characteristics of the two forms of collaboration are summed up in Table
1. By helping us with choosing the test participants, the user board acted as a kind of
mediator between the user club and the FRR-research and development team. Most of
the members of the user board were professionally related to members of the user club.
The combination of these two lines of collaboration allows for a development process
steered by the primary and secondary users, whereas the involvement is structured
soundly, thoroughly and continuously and the data gathered by this involvement show
high degrees of systematization and complexity.
Table 1. Continuous collaboration versus specific collaboration
Continuous collaboration Specific collaboration

User board User club
Members of the user board continuously accompany Members of the user club were involved in the
the project and are available for the research and project at defined strategic points to evaluate the
development team, optimally throughout the projects progress and provide input for further
lifetime of the project. development.
They participated in all central decisions of Nevertheless, they were kept up to date by regular
development as well as of research activities. news
Further, they participated in the tests as pilot testers.
This way of collaboration is very intensive in terms The reason for that was to achieve a continuity of
of time. It requires a lot of flexibility, commitment test participants, thereby broadening the quality of
and commitment of the users. the data.
Within the FRR-project, user involvement in research and design activities was
carried out in five places, the so called User Research Bases (URBs). These URBs
were located at the premises of project partners in Athens, Delft, Lund, Milan, and
Vienna. In total, more than 250 documented tests were carried out within three years of
project lifetime [16].
6. Four Phases of User-Driven Research
Based on these two forms of collaboration, one is enabled to tackle all the tasks
research implies in a way that really merits the term user-driven. Referring to the
FRR project, these tasks can be assigned to four decisive phases.
6.1. Phase 1: Setting Up the User Board
In the first phase, the user board has to be set up, possibly taking into account the
challenges of the coming years and thus inviting persons that themselves can contribute
and are also willing to contribute to the projects activities. It is further wise to consider
the opportunities secondary users could bring in terms of selecting test participants
from their professional scope. URB Vienna acted as prototypical unit, delivering inputs
to the other URBs of the FRR-project.
6.2. Phase 2: Structuring the Collaboration
Together with the members of the user board, the basic grid for the collaboration within
the coming years is being planned. It should be made clear to all persons involved how
many resources (mainly in terms of time) are available both from the user board
members and the project partners involved. That is of central importance, above all
when the collaboration of the user board happens on a voluntary basis. Though the user
board members get reimbursed their travel expenses, there were no funds available to
pay them equally as project employees as it once was suggested by the FORTUNE-
consortium [13]. It is clear that this second phase cannot be clearly separated from the
first phase, because the general conditions of collaboration of course have to be made
transparent to potential members of the user board.
6.3. Phase 3: Planning of Joint Activities
It was a crucial point for the implementation of user-driven research that the user board
members as well as the ethical review team were involved in planning the research
activities. Together, it was decided which topics were most promising and should be
addressed, and which methods (tests, focus groups, etc.) were best suited to study these
topics. Further, the test populations were chosen by the user board according to the
principles of theoretical sampling as shortly described above.
Jointly a so called FRR Information Kit was developed, a collection of
information material on the background of the project, the purpose of the specific test
round, and the technological equipment the participants were invited to test. Further, it
contained a confidentiality agreement needed for reasons of patent application and,
most important, information on the informed consent the users were asked to give.
Thus, this information kit was part of the informed consent procedure. As Fischman
puts it, Obtaining consent is more than simply having a potential research participant
sign a consent form; it is a process by which necessary information is communicated to
the participant by the researcher. [14] The conception of informed consent as a
process understands the signing of the consent form as the last step of an intensive
communication process between the researcher and the participant that started some
weeks before the actual test, and thus the signing, takes place [15].
Also, a test script (see Table 2) was developed that provided the base for every
testing activity. The total duration of the test, thereby, was about two hours. After each
point the voluntary users were asked whether they were willing to continue the test.
As this kind of planning was repeatedly done (i.e. prior to every test round), we
ensured that every step in the research process could be taken in a cooperative
atmosphere and, most importantly, in an ethically safe way.
6.4. Phase 4: Evaluation of the Projects Outcome Validation
Finally, user involvement must be considered in the end of a project when evaluating
whether the project has reached its objectives. This final decision whether or not the
project was successful is up to the users, thus finalizing the process of user involvement
in a sound way. This does not have to be a simply binary decision relying exclusively
on the categories of Yes or No. As the chapters on the validation phase in this volume
shows, validation activities can contribute to a more thorough understanding of

problems with the proposed design [17]. Experiencing design in daily life might lead to
other attitudes towards the given device, its functionality and its design, thus possibly
requiring re-design.
Table 2. Test script
(1) Welcoming: First, the project partners introduced themselves. They made clear that any questions the
test user might have would be answered at any time. To ensure that test participants can at any time address
the representatives of the FRR-project, we were wearing name tags during the whole test run.
(2) Introduction: The participant was introduced to the FRR-project and its aims. Optionally, a video-tape
was presented showing the current prototype. The purpose of this video was to introduce the functions of
this prototype.
(3) Confidentiality agreement: The confidentiality agreement was signed.
(4) Demonstration: After this, the voluntary participants were asked to go into the room where the tests
were carried out. Here, once again, a project employee demonstrated on the spot the features of the
prototype and how to handle them.
(5) Instructions: The next step was that each point of the informed consent form was read out and
explained. After the instructions the persons were explicitly asked whether they wanted to participate in the
tests.
(6) Informed Consent: If all questions were completely clarified and after it was made sure that the test
user participated voluntarily, s/he was asked to confirm the consent with a signature.
(7) Test: The participants were asked whether they wanted to do the test on their own or with support of
the (nursing) staff present. Then, the test was carried out.
(8) Interview: After the test the participants were asked to give feedback in a semi structured interview
about how they have experienced the test, whether something was unpleasant, whether they find the
technical possibilities of this prototype helpful or not.
(9) Thank you: Finally, all the persons involved in the testing procedure came together to explicitly thank
the participant for his/her time and effort.
7. Conclusions
User involvement in the user driven research design is twofold: firstly it integrates
users in decision-making processes concerning the collection of data (i.e. sampling,
methodology). Secondly users' responses at various stages of development of the FRR
were analyzed (by content analysis) and complemented by findings from literature.
This knowledge (documented in deliverables and reports to the consortium) enhanced
and guided the design and engineering decisions by setting goals and priorities and by
feeding back creative new ideas from practice.
Acknowledgements
We are very grateful for continuous support from our user board members Robert Schlathau, representative
of the Austrian Multiple Sclerosis (MS) Society, Vienna (AT); Ramona Rosenthal, manager of a day care
center for MS patients, Vienna (AT); Christine Pauli, nurse at a center for neurological long-term care,
Vienna (AT); Niki Stefanakis, voluntary coworker at project partner fortec, Research Group on
Rehabilitation Technology, Vienna (AT); Eduard Riha, secretary-general of the Austrian National Council of
Disabled Persons, Vienna (AT); Karin Schliefsteiner MD, practitioner in Graz (AT); and Silvia Dvorak,
nurse at the Geriatric Center Wienerwald, Vienna (AT).
References
[1] Denzin NK. The research act: A theoretical introduction to sociological methods. New York: McGraw-
Hill; 1978.
[2] Janesick VJ. The Dance of Qualitative Research. Metaphor, Methodolatry, and Meaning. In: Denzin
NK, Lincoln YS, editors. Handbook of Qualitative Research. London-New Delhi: Sage Publications,
Thousand Oaks; 1994, p.209-219.
[3] Eftring H. The Useworthiness of Robots for People with Physical Disabilities [Doctoral Dissertation].
Certec, Division of Rehabilitation Engineering Research, Lund University; 1999. Available from:
http://www.english.certec.lth.se/doc/useworthiness
[4] Phillips B, Zhao H. Predictors of Assistive Technology Abandonment. Assistive Technology.
1993;5:36-45.
[5] Brown-Triolo DL. Understanding the Person Behind the Technology. In: M.J. Scherer MJ, editor.
Assistive Technology. Matching Device and Consumer for Successful Rehabilitation. Washington
D.C.: American Psychological Association; 2002, p.31-46.
[6] Andrich R, Besio S. Assistive Technology education for end-users: the Eustat perspective. In:
Placencia-Porrero I, Ballabio E, editors. Improving the Quality of Life for the European Citizen.
Technology for Inclusive Design and Equality. Amsterdam: IOS Press; 1998, p.152-155.
[7] Gelderblom GJ, De Witte LP. The Assessment of Assistive Technology Outcomes, Effects and Costs.
Technology and Disability. 2002;14:91-94.
[8] Wessels RD, De Witte LP, Weiss-Lambrou R, et al. A Dutch Version of QUEST (D-QUEST) applied
as a routine follow-up within the service delivery process. In: Placencia-Porrero I, Ballabio E, editors.
Improving the Quality of Life for the European Citizen. Technology for Inclusive Design and Equality.
Amsterdam: IOS Press; 1998, p.420-424.
[9] Day, G. Meeting the Challenges of Demographic Change. This volume.
[10] EURAG. Guidelines for User Involvement. Internal document FRR project; 2001 Jan.
[11] Baldursdottir R, Flo R, Hurnasti T, et al. User Involvement in the Development of Assistive
Technologies in the Nordic Countries (USDAT). In: Marincek C, Bhler C, Knops H, et al, editors.
Assistive Technology Added Value to the Quality of Life. Proceedings of the AAATE 2001.
Amsterdam: IOS Press; 2001, p.95-98.
[12] Glaser BG, Strauss AL. The Discovery of Grounded Theory. Strategies for Qualitative Research. New
York: Aldine de Gruyter; 1967.
[13] Bhler C. Guidelines for Participation of Users with Disabilities in R&D Projects. In: Marincek C,
Bhler C, Knops H, et al, editors. Assistive Technology Added Value to the Quality of Life.
Proceedings of the AAATE 2001. Amsterdam: IOS Press; 2001, p.104-109.
[14] Fischman MW. Informed Consent. In: Sales BD, Folkman S, editors. Ethics in Research with Human
Subjects. Washington D.C.: American Psychological Association; 2000, p.35-48.
[15] Ethical Review Team. On informed consent procedures for testing the FRR. Internal document FRR
project; 2001 May.
[16] Panek P, Edelmayer G, Mayer P, Zagler WL. Laboratory Tests of an Adjustable Toilet System with
Integrated Sensors for Enhancing Autonomy and Safety. This volume.
Setting up and First Results from a Real Life Installation of an Improved Toilet System at a Care
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-69
The FRR-Questionnaire Assessing

Who Needs What Where
Christian DAY1
EURAG European Federation of Older Persons,
Abstract. A questionnaire measuring difficulties with toileting and users preferred

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

Assistive Technology, User Driven Research
1. Introduction
Since the early nineties of the last century, studies repeatedly show the importance of
non-technical aspects in the area of Assistive Technology (AT). The success of an AT-
device, defined by complete or partial physical rehabilitation or, if not possible, the
enhancement of the users quality of life, can not be guaranteed solely by the
functionality of the device. It is strongly depending on social and psychological factors
[1, 2]. To consider psychological and mental factors as well as factors of the social and
societal environment of the individual is thus an essential demand towards Research &
Technological Development (RTD) efforts in this area. The questions that shall be
raised in the beginning of such a project must not be reduced to a functional or
technological perspective. Questions like: What functions should an innovative toilet
include?, should be seen in combination and interrelation with socio-psychological
dimensions, as e.g. simplified by the question: Which non-technological requests must
such a toilet meet in order to be helpful? The more sophisticated this linkage is, i.e. the
1
Contact Information: Christian Day, University of Graz, Department of Sociology; Address:
Universitaetsstrasse 15/G4, A-8010 Graz, Austria; E-mail: ch.daye@uni-graz.at
70 C. Day / The FRR-Questionnaire Assessing Who Needs What Where
better these different dimensions are combined into a holistic picture, the lower the risk
of developing a product that in the end does not provide any significant improvement
for the users it is designed for.
The questionnaire of which the results are presented here is understood as a bridge
between technological and non-technological aspects of toileting, capturing thus the
problem of toileting as a multidimensional phenomenon interrelated with concepts like
personality, technology, societal environment, culture [3, 4, 9]. Its items were
developed based on the outcomes of an exploratory research phase carried out in the
beginning of the FRR-project, in which twelve in-depth interviews were carried out
with care workers in Austria, trying to assess the most important problems when using
standard toilets.
The resulting questionnaire contained 61 items on four pages. It was distributed in
the German speaking area of Central Europe (Austria, Germany and Switzerland),
translated and disseminated in Greece and in Italy, as well. The questionnaire was used
as an anonymous paper and pencil questionnaire to ensure confidentiality of a rather
sensitive matter in every day life.
So far, no comparable study has been conducted. This questionnaire therefore
represents a unique data source, combining technological and non-technological
perspectives to a multifaceted picture of toileting. After describing the general
characteristics of the national sub-samples (paragraph 1), insights are reported into the
need for new technology in this area gained by the questionnaire by assessing the
extent to which the lack of usable toilets de facto reduces the quality of life of elderly
and disabled persons. It is argued that every effort spent in the development of
innovative solutions is justified by the massive restrictions caused by the lack of
adequate toilet solutions (paragraph 2). Further, the questionnaire assessed the
prevalence of difficulties with toileting and the acceptance of proposed solutions and
assisting devices, thus guaranteeing a development process steered by users towards an
AT device that allows for an improved quality of life (paragraph 3). Finally, the
questionnaire's potential to study cultural differences with toileting throughout Europe
is demonstrated and the main arguments of users against an installation of such a toilet
are reported, thus ensuring that AT products developed in this area in the future will be
tailored to users and consequently customers (paragraph 4).
2. The Samples
2.1. Description of the Samples
The data analysis of which the results are presented here is based on four sub-samples
that represent a total of 345 respondents. These four sub-samples are distinguished
according to the recruitment process and are named as follows: Older People from
Central Europe (1), Members of Austrian MS Society (2), Greek respondents (3), and
Italian respondents (4). For better readability, onwards they will be referred to via the
numbers. The recruitment of the sub-samples was carried out by FRR-partner
organisations in several phases and by different means. Sub-sample (1) was recruited
by contacting member organisations of EURAG in the German speaking area of
Central Europe, sending them a certain amount of questionnaires. Sub-sample (2) was
established by including the questionnaire in the bi-monthly journal of the Austrian MS
Society, asking the readers to complete the questionnaire and send it back. Further, the
C. Day / The FRR-Questionnaire Assessing Who Needs What Where 71
questionnaire was disseminated by project partner HAGG (Hellenic Association of

Gerontology and Geriatrics, Athens), thus building up sub-sample (3). In Italy, the
questionnaire was disseminated both by project partner SIVA in Milan (Servizio
Informazioni Valutazione Ausili) and by SSSUP (Scuola Superiore SantAnna) in the
region of Pisa among older persons living both in their homes and in care institutions;
the respondents are comprised in sub-sample (4).
In Table 1 the age of the respondents is described by minimum, maximum, median
and mean. The variable gender is described by its distribution (in %, see Table 1). In
general, it can be said that the samples concentrate on persons aged 50+, thus ensuring
that the persons contributing to the project via the questionnaire represent the main
target user group, i.e. the older population of several European countries. Further, it is
obvious that women dominate all the samples with a proportion of about 2:1. This high
proportion of females in the study on the one hand reflects the demographic situation,
i.e. women outnumbering men in the elderly [5]. On the other hand, it can be argued
that the way of disseminating the questionnaire via institutions in the social and health
care sector (where there are more female clients) resulted in a higher participation of
women. However, as Figure 1 shows, this proportion is nearly the same in all age
groups, thus decreasing the risk of unintended bias when comparing the sub-samples.
The age cohort that finds itself represented best is the one reaching from 61 to 70
years of age. About a third of the interviewees are in this cohort. As the first cohort is
characterized by a very unsophisticated up to 40, it becomes clear that the focus of
the questionnaire lies upon people in the second half of their lives. As 63
questionnaires were completed by people aged 81 or above, almost 20% of the
respondents are aged 81+, making this database a relatively unique source of
information.
Understood as different groups (and thus assuming, to some extent, homogeneity
within these groups), these four samples enable us to investigate cultural dimensions
that otherwise could not be investigated. Figure 2 shows the distribution of the variable
frequency of assistance2 for the four samples (in %).
Table 1. General characteristics of the samples
Sample name Age Gender (in %)

Min. Max. Median Mean Female Male
(1) Older People from Central 38 91 73 69,9 72.5 27.5
Europe (N = 93)
(2) Members of Austrian MS 29 81 54 51,5 66.2 33.8
Society, (N = 77)
(3) Greek respondents, (N = 126) 21 96 73 70,7 65.9 34.1
(4) Italian respondents, (N = 27) 24 93 78 72,5 66.7 33.3
2
The respective item reads: Please also indicate how often the persons assisting you come to you: daily
at least once a week less frequently never.
35
30
25
Percent %
20 female
15 male
10
5
0
up to 40 41 to 50 51 to 60 61 to 70 71 to 80 81 to 90 90 and
more
Figure 1. Age-gender distribution (n = 345)
"Please indicate how often the persons assisting you come to you"
80
Elderly A-CH-D
Percent (%)
60 Austrian MS Society
40 Greek To 65
20 Greek Over 65
Italian resp
0
Daily Weekly Less Never
Figure 2: Frequency of assistance (n = 345)
The frequency of assistance the respondents get is reported as an indicator of the

dimension of health or dependency on assistance. Existing differences between the
various samples like those that can be read from this graph, e.g. that an overwhelming
majority of the Italian respondents need care on a daily basis, must be taken into
account when interpreting the national results. Further, it is suggested that dividing the
Greek sample into two subsamples along the variable age allows for leveling out an
internal heterogeneity and thus allows for a more elaborated analysis.
However, it should be noticed that there is neither a significant relation between
age and the frequency of assistance nor between age and the degree of dependency
(measured by ADL scores [6]). Thus, in this sample, age is not a valid predictor with
regard to the question how frail or healthy a person is. 3
3
This presumably is a speciality of our sample, but nevertheless underpins the notion that we achieved to
depict the population we wanted to depict.
2.2. Sampling for FRR-Questionnaire
The rationale behind samples is, in general, that they enable the researcher to draw
conclusions valuable for larger population that is represented by the relatively smaller
sample. Usually, when dealing with questionnaires, random sampling methods are
applied. Randomness in this context is defined each case of the studied population
having a fixed or calculable chance of being selected, i.e. of being part of the sample.
Probability statistics then measure quantitatively the risk of drawing wrong conclusions
about the population [7]. This sampling method, however, requires some knowledge
about the prevalence of the studied property, as an estimate of this prevalence is a basic
term in the formula that is used to calculate the optimal sample size at given validity
parameters [8]. As this background estimation of the prevalence was not available, it
was decided to give up the idea of random sampling and choose the pragmatic solution
of using available contacts of the partner organisations to distribute the questionnaire.
By these means, the sample was built up as depicting not a whole population (e.g. of a
country), but the target population the FRR shall be developed for. From this
perspective, the chosen approach seems to be more effective, though generalizations
can only be drawn about a part of the whole population.
3. The Need for Solutions
As mentioned above, the questionnaire was not restricted to a technology-oriented

perspective but comprised various kinds of questions and dimensions of interest. The
results reported in this chapter relate to a set of items that measures the extent to which
the quality of life is affected by the lack of useable solutions in the everyday toilet. It
investigated social and psychological considerations of the respondents, asking them to
judge to what extent a series of statements is true for them.
A quarter of the respondents stated that when using a toilet they are always afraid
something could happen to them (e.g. falling or fainting; see Figure 3). In addition to
the actual costs of accidents possibly caused by inadequate technology, the emotional
costs of fear provide a massive argument for efforts to be spent in the development of
better technical solutions in the toilet area. Further, this implies that, in congruence
with the philosophy applied in the FRR-project, problems typically encountered when
using a toilet are problems that can be solved only by designing a whole room concept.
More than 50% (accumulated) of the respondents agreed that it applies at least to
some extent that they avoid going out longer in order not to need to use a toilet (see
Figure 4). This finding underpins the assumption that the lack of adequate toilet
facilities manifests itself as an inescapable restriction in the lives of older people or
people with physical disabilities. It affects their quality of life because it excludes them
from participating in social life to the extent they would like to.
Even from these short blank figures it becomes obvious that people from our target
population feel inhibited in their daily life by the lack of adequate solutions in the area
of toileting. This lack sets limits to their mobility that they cannot overcome, a fact
which heavily impacts their quality of life. Consequently, the approval towards new
solutions is rather high: About 60% stated that having user-friendly toilets installed in
public areas would very much improve their every day life.
"When using the toilet I am afraid something could happen to me"
40
applies completely
30 applies to some extent
20 does not really apply
10 does not apply at all

don't know
0
in %
Figure 3. Experienced fear on the toilet (n = 323)
"I try to avoid going out in order not to need to use a toilet"
40 applies completely
30 applies to some extent
20 does not really apply
10 does not apply at all
0 don't know
in %
Figure 4. Avoidance of going out (n =337)
"Do you think that the installation of such user friendly public rest
rooms would improve your every day life?"
60
yes, very much
50
40 a bit
30 hardly
20 no, not at all
10
don't know
0
in %
Figure 5. Opinions on improvement of every day life (n = 298)

4. Challenging Technology What to Improve?
To develop innovative toilet concepts is, as shown, an urgent request. But where to
begin? To ensure that the direction for design and development work is given by the
users, the questionnaire included an item block that asked the user to evaluate several
parts of a standard toilet. By specifying how often they experience difficulties when
using standard technology, they provided us with valuable information on how to
improve the current situation. The respective items assessed how often the respondents
experience difficulties with certain features of standard toilets.4
Within the frame of this analysis, two main measures are used to describe the
importance of a problem: the rank and the score. The score is a measure that is
calculated for each problem using the data of the questionnaire and then standardized in
order to be comparable with scores from other samples. It multiplies the count of the
always-answers with 10, adds the count of the sometimes-answers multiplied with
5, and divides it through the number of valid answers. The higher this score, the
Overall ranking of problems
7,0
1. no place to store
2. grips
6,0 3. room size
1 4. door
5,0 5. toilet seat
2
3 6. toilet bow l height
4,0 4 7. floor
Scores
5 8. mirror
6
3,0 7 9. light sw itch
8
9 10 10. toilet paper not in reach
12 14 11. w ash bow l height
2,0 11
13 15 12. w ash bow l size
13. toilet bow l size
1,0
14. flush
15. cannot use toilet paper
0,0
Problem s
Figure 6. Ranking of Problems
4
The header of this first item block read: Please try to imagine an ordinary toilet. What kind of difficulties
do you experience when using an ordinary toilet? (If you have adapted the toilet in your private home please
try to imagine a public toilet!), giving the following options: always often sometimes never dont
know.
more important a problem was rated by the respondents. By ranking the problems
based on their score, the urgency of various problems can be shown by sample. Thus,
we obtain a Ranking of Problems that describes the internal relations between the
problems in a simple dichotomous way (higher/lower).
As displayed in Figure 6, the most pressing problem is the missing place to put a
walking stick or other personal belongings, followed by missing or inadequately-
mounted grips and the fact that the room size is not satisfying.
The same analysis routine was applied with a second item block suggesting
technological solutions. 5 This item block was thus investigating the acceptance of
several ideas that were proposed in the very beginning of the project. The results are
displayed in Figure 7.
Considering that the maximum score one item can reach is ten, it can be said that
the acceptance of the proposed solutions is very high, especially for the first five items
reaching from 8.69 to 7.82 points. An alarm device that is mounted in a well reachable
position is regarded as most important, followed by a place to put a walking stick or
other personal belongings, and by grips mounted on each side of the toilet and at
Overall ranking of improvements
10,0
1.alarm device
9,0 1 2
2.place to store
3 4
8,0 5 3.grip
7,0 6 4.light
7
6,0 8 5.flush
9 10
11
Scores
12 6.doors
5,0 13
7.toilet bow l height
4,0
8.bidet function
3,0
9.w ash bow l heigt
2,0
10.mirror
1,0 11.toilet seat
0,0 12.chip card

Im provem ents 13.voice control device
Figure 7. Ranking of Improvements
5
Here, the header read: Currently engineers and technicians are developing a user friendly toilet. It
should consider the needs of aged and impaired users. Please indicate whether the following adaptations
would be an improvement for you!, giving the following options: That would be a: significant improvement
some improvement hardly any improvement no improvement at all dont know.
adjustable height. It can further be said that there is congruence between the
experienced problems and the accepted solutions, indicating the validity of the results
and reinforcing the request for better technological solutions in the respective areas.
5. Further Considerations What to Take into Account When Reinventing the

Toilet?
5.1. Cultural Differences
On grounds of the existing data base, it can be shown that there are cultural differences
that manifest themselves in the evaluation of problems. It can be assumed that these
differences are partly caused by differences in the physical abilities and partly by the
fact that the term standard toilet in different cultures refers to essentially different
technical environments. Considering for example that older persons from Central
Europe encounter more often the problem of toilet paper out of reach than the other
respondents might partly be explained by different physical abilities. However, it
remains unclear why the Greek older persons do not encounter the same problems. The
most striking difference is that the Greek respondents have much more troubles with
the toilet seat than other respondents; while it is ranked on 11th and 14th place by the
samples from Central Europe (1) and (2), the Greek respondents (3) rank it 1st,
regardless of their age. Here, it is rather likely that this is caused by different technical
environments.
Cultural differences of this kind should be taken into account when trying to
come up with technical solutions that meet the needs of the users. A scientific
explanation of these phenomena would however require further in-depth research,
while a quantitative questionnaire can only indicate possible areas of differences.
5.2. Gender Differences
Further, it can be assumed that within the different cultures, there are gender
differences in response to the questionnaire. A respective analysis revealed that when
evaluating problems, gender does not play a major role. Only within the Greek
respondents, one item showed a significant gender correlation, saying that Greek
women are more likely to assess the height of the toilet bowl as a problem than their
male compatriots (Spearman-Rho = -0.201*6) which may indicate that the interviewed
men use the standard toilets in a different position. According to a personal
communication with the Greek researchers the gender difference in sitting comfort is
not a result of the squatting type toilets which would cause female users more strain
when physically impaired. Most private homes as well as most public buildings are
equipped with Central European standard toilets. Still, though, some respondents might
have considered the existence of squatting type toilets when filling in the questionnaire.
In general, the problems older persons and persons with physical disabilities have to
face when using standard toilets can be treated as independent from gender.
6
Significant at the 0.05-level.
5.3. Counter-Arguments
The most decisive arguments against the installation of innovative toilet solutions as
developed within the FRR-project were the following (see Figure 8).
insecurity
no need
size of room
money
0 10 20 30 40 50 60 70
in %
Figure 8. Arguments against installation of innovative toilet solutions (n = 345)
The most important conclusion to be drawn from this graph is that the developed
toilet solution must be affordable: 64.7% stated that money was a decisive counter-
argument. This is essentially underpinning the modular approach chosen by the FRR-
consortium in the first year of the project. This modular approach enables users to
choose which feature they need most urgently, thereby reducing the costs significantly.
A second important conclusion is, as it also was suggested by the high acceptance of
the proposed solutions, that a defensive attitude towards unknown technology
(technophobia) is not as relevant as it was assumed, especially for older persons, in the
beginning of the project. An overwhelming majority does not assess insecurity as a
relevant argument against the installation of such a toilet. However, still a fifth
anticipates insecurity, which leads to the conclusion that technophobia is a relevant
issue for design and development, though there also is an explicit and known request
for new technology in the toilet area.
6. Conclusions
It was demonstrated how valuable the input of a questionnaire can be for an RTD-
project, especially when dealing with an area that is as unexplored as it is the case with
toileting. Design links culture and technology. And if researchers achieve to transpose
this linkage into their research instruments, it is likely that the final output of the
development process will be a product that is of value for the persons it was designed
for. Providing a bridge between technological and non-technological aspects, the
questionnaire developed and disseminated as part of FRR User Needs Research
succeeded to deliver valuable and, above all, new knowledge on toileting, thus being an
instrument to advocate the needs of users and steer the development process.
References
[1] Phillips B, Zhao H. Predictors of assistive technology abandonment. Assistive Technology. 1993;5:36-
45.
[2] Brown-Triolo DL. Understanding the person behind the technology. In: Scherer MJ, editor. Assistive
technology. Matching device and consumer for successful rehabilitation. Washington: American
Psychological Association; 2002, p.31-46.
[3] Scherer MJ. Living in the state of stuck. How assistive technologies impacts the lives of people with
disabilities. Cambridge, MA: Brookline Books; 1993.
[4] Scherer MJ, Craddock G. Matching Person & Technology (MPT) assessment process. Technology and
Disability. 2002;14:125-131.
[5] UN, Department of Economic and Social Affairs, Population Division. World Population Ageing 1950-
2050. New York: United Nations Publications; 2002.
[6] Sonn U. Longitudinal Studies of Dependence in Daily Life Activities among Elderly Persons.
Methodological development, use of assistive devices and relation to impairments and functional
limitations. Scandinavian Journal of Rehabilitation Medicine. Oslo, Copenhagen, Stockholm & Boston:
Scandinavian University Press; 1996; Supplement No.34.
[7] Becker HS. Tricks of the trade. How to think about your research while youre doing it. Chicago,
London: The University of Chicago Press; 1998, p.67-108.
[8] Bortz J. Statistik fr Sozialwissenschafter. Berlin, Heidelberg, New York: Springer; 1999, p.103.
[9] EURAG. Deliverable 4.1.4. FRR project document; 2004 Sep.
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-80
Computer Based Information Gathering

Norman ALMa,1, Kenny MORRISONa, Peter GREGORa, Nick HINEa,
Sian JOELa, Katrina HANDSa and Marja H. VAN WEERENb
a
School of Computing University of Dundee, Dundee, UK
b
Landmark Design BV, Rotterdam, The Netherlands
Abstract. Toilets and toilet habits are perceived as a taboo subject that people may
be reluctant or embarrassed to talk openly about. In the past, appropriately
designed Computer Based Interviews have been shown to encourage more honest
answers to sensitive questions than other forms of interview, and can be more
interesting and engaging that filling out a paper questionnaire. This chapter
presents Dundee Universitys role within the Friendly Restroom project which was
primarily to provide Computer Based Interviews and other computer-based
requirements gathering tools to be used to elicit toileting requirements of elderly
people. Dundee University also investigated the feasibility of using Virtual
Reality technologies, such as 3D environments and 360 degree panoramas, to
support this information and requirements gathering.
Keywords. Computer Based Interviews, Toilets, Virtual Reality, Information

Gathering
1. Introduction
An important part of the Friendly Restroom (FRR) project was to ensure that the
designs produced met the real needs of potential users, and that users were involved
throughout the project in sharing their experiences, giving their views, and helping
guide the design process. One novel method of gathering the views of users which was
employed was the use of computer-based interviews (CBIs). The project developed a
number of CBIs and other novel information gathering tools.
The CBI has a 30 year history and has been shown to elicit revealing results. Due
to its nature, the computer, unlike its human counterpart, is not judgmental, never
bored, or impatient and does not become embarrassed. Because of this, people being
interviewed about potentially embarrassing subjects often find a CBI to be pleasant,
and easy to use. They often report they feel more empowered than in a face-to-face
interview resulting in a greater number of answers and information of a higher quality
[1,2,3,4,5].
The CBI team at Dundee University has many years experience in using this
method as a tool for gathering information. Their experience includes interviewing
primary school children, university students, scientists, people with alcohol problems,
1
Corresponding Authors: Applied Computing, University of Dundee, Dundee DD1 4HN, UK; E-mail:
[nalm, kmorrison, pgregor, nhine, sjoel, khands]@computing.dundee.ac.uk
N. Alm et al. / Computer Based Information Gathering 81
patients and staff at a secure psychiatric institution and parents of children with
behavioral problems [6,7,8,9,10].
2. Computer Based Interviews
Given the sensitive and possibly embarrassing nature of discussing toileting needs with
strangers, it was decided to apply CBI to this task within the FRR Project. Using a
computer-based approach also offered the advantage of easily including multimedia
material into the interviews, and allowing for the possibility of delivering interviews
remotely, over the internet. What was not clear at the outset of the project was how
much cultural differences between the participating countries would affect the degree
of embarrassment felt by participants in discussing toileting needs. In the event, we
found that a stronger determining factor here was age, with older participants who we
worked with being quite at ease discussing this subject, without the need for any
account to be taken of sensitivities in this area. However the use of CBIs might still be
of benefit, where the population of participants is more uneasy about discussing these
subjects than the participants we worked with.
The first CBI to be developed was web-based and consisted of two parts. Firstly an
interview was developed which primary and secondary users could access directly.
Secondly a translation tool was created which allowed the partners in the FRR project
to translate an original English questionnaire version into their language, and which
ultimately would allow users from other countries to complete the questionnaire in
their own language directly.
2.1. CBI Interface
The system allowed the user to select their language of choice from a menu of flag
symbols. The interface was designed so that the users attention was drawn to the
centre of the screen, as the page was framed by a border. The interface also had a menu
at the top of the page which allowed the user to see instructions on how to use the CBI
as well as an option to return to the beginning of the questionnaire. The interview took
a linear approach, with each screen showing one question at a time. Once the user
selected their answer for that question from the page, another page was shown until the
last question of the interview.
At the end of each section in the interview, the user was shown a next section
screen. This allowed the user to be informed of how far through the interview they
were. In addition, by splitting the CBI into sections the questionnaire was in more
manageable groups for allowing differing presentational choices e.g. the number of
buttons could vary between one section and another or there could be multiple choices.
At the end of the interview the user could see the answers they entered. The user
could print a hard copy of these answers for their records. If the user had made an error
in these answers, there was an option to add comments in a text box which could note
the error, or the user could choose to go back to the page of the error and re-enter the
correct answer, overriding the original. Once the user submitted their answers they
were stored on a central database on the web server.
82 N. Alm et al. / Computer Based Information Gathering
2.2. Translation Tool
The Translation Tool had three options:
x Allowing the user to translate the master questionnaire into the language of
their choice
x Allowing that translation to have multimedia added to it
x Allowing the user to see the interview making use of that translation
The user had the ability to translate the master questionnaire from English into
another language. The process of translation could be done in sections and did not need
to be done all at once. The user had the ability to add images (jpeg or gif format) to the
translation. The interface for this process showed the series of questions from the
translated questionnaire and allowed the user to select an image from their own system
which they could upload to the server. The image was then associated with the question
or answer decided upon and was positioned, when shown, against it (Figure 1). The
option to only allow jpeg and gif uploads was made in order to limit the size of the files
which could be uploaded. However, the tool could be adapted so that more file types
could be included e.g. higher resolution images, sound clips, or other multimedia files.
The user was able to test and view the text they translated by using the User option
of the Translation Tool. This User option of the tool acted very much as the user CBI
does, with sections, one question per page and a view results page.
Figure 1. Interview with pictures. Questionnaire content and drawings from Landmark Design BV
3. User Trials and Focus Groups
Dundee University performed user-trials of the web-based CBI and two focus group
discussions relating to the interviews and their graphics were also held. Data was
produced on the attitudes of older people to a computer based interview on rest room
requirements.
3.1. CBI User Trial:

The CBI trial was performed in a cybercaf for older people in Airlie, a small village is
Scotland. The participants age range was between 50 70, with one individual over
70. Eight persons participated in the trial and each completed 63 questions. The health
problems that participants listed were back pain, pain in their fingers, hands and feet,
and some eyesight problems.
The main points gathered from the CBI included: most persons found that it was
often, or sometimes, the case that the toilet was hard to flush, the wash bowl too high
or too low or that there wasnt anywhere to put a walking stick or personal belongings.
The most popular toilet adaptations were grip bars, an emergency button and a place to
put walking sticks or personal belongings. These findings were similar to those that
were received using the paper questionnaire.
3.2. CBI Focus Group:

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

A second focus group was held, also in the cybercaf in Airlie to discuss the graphics
that were to be used in the CBIs. The graphics were produced by Landmark Design, an
FRR partner based in The Netherlands. For this focus group there were six participants,
whose ages ranged from 60 to 75. Initially, there was a demonstration of the graphics
and then a discussion on their acceptability. After this the group easily got into a
discussion about their recommendations for improving toilet access and usability,
making use of the picture as prompts occasionally.
The consensus was that the pictures were acceptable, and helpful to the discussion,
but they could be improved for more general acceptability by making the characters
into humorous cartoon type figures (e.g. teddy bears). This would have the effect of
making the material less personal. The use of humor was recommended as a way to
make possibly embarrassing material more comfortable to discuss. Some felt that the
pictures could be a little less explicit but the overall opinion was that they had been
well done and were very thorough. The point was made that the group knew each other
very well, and so felt at ease discussing these matters in the group setting. A group of
strangers might not do so well, and possibly individual interviews would be better.
4. Standalone Computer Based Interviews
Dundee University first designed and developed a predominantly text based computer
based interview on rest room requirements which could be accessed from a website and
which automatically stored results for subsequent analysis. An authoring and
translation tool, which was accessible from a website, was also developed. This tool
enabled partners to remotely construct interviews and produce translations of the
interview in their own language. Field work with potential users identified the need for
a version of the interview that could be run in a standalone format with no need for a
good internet connection. This could be run from a laptop and taken to homes where
internet access is not available.
A version of the standalone interview incorporating illustrations was produced
(Figure 2). It stored the results of the interview into a text file on the computer's hard
disk. A dynamic version of the standalone interview was also completed which can
retrieve the interviews constructed using the web-based authoring and translation tool.
The standalone versions of the interview were developed using Macromedia Director.
Figure 2. An example question from the standalone CBI with pictures

5. Information Gathering and Virtual Reality
After completion of the web-based and standalone CBIs, an investigation was

undertaken to determine the feasibility of using Virtual Reality (VR) technologies to
support our information and requirements gathering. It was decided that these
technologies should be web-based. The FRR project consortium consists of partners
spread across Europe. Using the internet would make it easy to demonstrate, distribute
and use the interviews. The VR software was designed to be easily accessible from any
computer with an internet connection. The continuing increase in bandwidth size,
broadband networks, desktop processing power and reduction of costs mean that the
capabilities of the internet are rising and using 3D and VR based web-technologies
over the internet will become more and more feasible.
5.1. 360 Degree Panoramic Views
Initial investigations focused on web-based 360 degree virtual reality representations of

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

Figure 5. Image stitching
5.2. 3D Virtual Reality Scenes
Following the 360 degree panoramic views, an investigation was carried out of other
web-based VR technologies. This included 3D environments where the user can feel
immersed within the scenes. A web-based 3D environment tool was developed. Using
this tool, the user is presented with a 3D VR environment (Figure 6) and was free to
move around within this scene. Navigation was by using the computer keyboard arrow
keys. As well as being able to move freely, the user could also make comments and
notes about the scene within the actual environment itself by writing/drawing on the
walls or floor (Figs.7, 8, 9 and 10). To perform this action, the user first clicked with
the mouse on the desired wall. Comments were then entered by keyboard typing or
freehand writing using the mouse. Standard paint/drawing functions were also available
e.g. shapes, line-drawing, erasing etc. Although the user could draw/paint within the
environment, the layout of the environment itself could not be changed. This tool
provided a novel way of obtaining user-feedback, although it was not clear what would
be the possible advantages/disadvantages of such a system. Therefore a small pilot
study was performed where the use of a more traditional paper-based interview was
compared with the interactive environment. Scenarios using a virtual onscreen notepad
were also included for comparison.
5.3 VR Pilot Study
There were twelve user evaluations performed. The twelve users rated their level
of computer experience somewhere between intermediate and expert. Five users were
between 18-25, five users between 26-35 and two users were between 36-60. There
were six females and six males.
The users participating in the task were presented with a small 3D VR environment
consisting of a living room scene and were asked to imagine they were browsing a
virtual catalogue. The users were then asked to select one item from the scene that they
liked and one item that they didnt like. They were instructed to record their selections
and make some comments about what they liked/didnt like about their selected items.
There were four different methods for recording selections and comments and the
users were asked to work through them in the order below. The expectation was that as
they worked their way through the methods, the user was gradually becoming more
immersed within the scene when recording their information.
x Method 1 - Paper/pen (M1) - A traditional method of recording information

x Method 2 - Onscreen notepad (M2) (Figure 11) - An onscreen virtual notepad
beside the 3D scene. The users could type onto the notepad
x Method 3 - Notepad on the wall (M3) (Figure 12) - A virtual notepad on one
of the walls within the scene itself. The user clicked on the notepad to begin
typing onto the notepad
x Method 4 - Drawing/writing on the floor/walls (M4) - The user could
write/draw on the walls or the floor of the scene. The user selected a wall by
clicking on it. Alternatively the user could click on the floor and view the
scene from a top-down angle (Figure 10)
After completing the four methods the users were asked to complete a
questionnaire.
The user evaluations were split into four groups. The evaluations were performed
individually:
x Group 1 - The users were asked to work through the methods in the order
above. Method 4 including an option to type using the computer keyboard as
well as other paint/draw functions (four users)
x Group 2 - Again the users worked through the methods in the order above.
Method 4 had the ability to type using the keyboard removed (four users)
x Group 3 - The same as the 2nd group, however the users were asked to work
through the methods in reverse order to that listed above (2 users)
x Group 4 - The same as the second group, however the task was performed
using a tablet PC, a notebook computers where it is possible to write on the
screen display using a special-purpose stylus) (two users)
Using M2 and M3, the users are asked to type onto a virtual notepad, and upon
reaching M4, Group 1 continued to type i.e. they immediately looked for a blank space
on the wall and used the type function from the paint options and tended to ignore the
option to draw within the scene. It was decided to remove the ability to type using the
keyboard from M4 for Group 2. While not having been told this, Group 2 expressed the
feeling that they missed being able to type after using M2 and M3. For Group 3 the
methods were used in reverse order i.e. the users had not been asked to do keyboard
typing when they first arrive at M4. No comment was made by Group 3 about typing
until they reached the notepad methods when they commented on how much easier it
was to type than to write freehand. Group 4 used the tablet PC with stylus and seemed
to find M4 much easier to record their feedback, however one user did comment that
they found it difficult to write fluently with the stylus.
The users were asked which method they preferred overall. M2 was preferred by 9
users and 3 users preferred M4. All the users highlighted the fun aspect of M4.
Although M2 was the overall preference there was a consensus that ideally some
combination of M2 and M4 would be the desired option, the users could use the
onscreen notepad and still be able to use the drawing capabilities of M4 if they desired.
5.3.1. Observations for Each Method

Method 1 - Paper/pen
Nothing of any note.
Method 2 - Onscreen notepad
Users had no problems with this method. One user who preferred M2
commented on the fact that they liked being able to look around and type at
the same time.
Method 3 - Notepad on the wall
Nearly all the users expressed a dislike of having to find the notepad on the
wall in M3. Although, when they do find the notepad they intuitively know
what to do, one user commented that it looks obvious what it is, and what its
for. The majority of users comment that it is not apparent what the advantage
of having a notepad on the wall as opposed to at the side of the scene. One
user suggested more notepads spread throughout the virtual room but then
suggested that this would make the scene seems messy. 3 users suggested a
virtual post-it note system where comments could be written and then
stuck to the selected items. A couple of users suggested signs to where the
notepad is within the scene.
Method 4 - Paint/write on the walls
A few users expressed confusion when they tried to draw on the furniture in
the scene, or select objects by clicking on them. Most users have a play about
first, they realize they can start again with a blank canvas. However, during
the study the male users were more likely to use the paint abilities freely, all
the male users didnt feel or worry that they were vandalizing the scene as
they realized they were in a virtual environment. The 3 users who were
reluctant to scribble or paint on the walls were all female. One female user
said they didnt like writing on the wall as they felt they were vandalizing
although they said they would use such a system for virtual decorating.
Another female user said they enjoyed drawing and making patterns but
would rather use typing to convey their thoughts. Although one of the male
users who used the typing when beginning M4 mentioned that he noticed the
painting functions, it just that he doesnt want to draw. One user commented
on how much they enjoy writing all over the walls.
When using M4, only one of the users referred to an object using the drawing
features e.g. by circling them or drawing arrows the other users tended to look for the
biggest blank space on the wall and record their comments there. Initially some of the
users had some confusion when coming out of the 3D scene to the static 2D view used
for drawing/writing in M4. They initially thought they were still in a 3D environment,
although they were soon able to adapt.
5.3.2. User Suggestions/Comments About M4

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

There were three attitude style questions, within the questionnaire that was given after
the task, where the users were asked to rate from 1(negative) to 7(positive).
Q1. How would you rate the usability of each method?

Q2. How helpful would you rate each method as an effective tool used for
information gathering?
Q3. How would you rate each method as being enjoyable to use?
M1. Paper/pen
M2. Onscreen notepad
M3. Notepad on the wall
M4. Drawing/writing on the floor/walls
Table 1. A table of averages for each question and each method
M1 M2 M3 M4
Q1 4.6 5.8 4.2 4.4
Q2 5.0 6.0 5.0 4.4
Q3 2.8 4.8 4.3 5.7
Total: 12.4 16.6 13.5 14.5
M2 scored the highest overall. M4 scored highly for enjoyment as opposed to M1

which scored very low.
5.4 Conclusions
The onscreen notepad was found to be the most usable and most helpful information
gathering tool. The users can view the scene and record their feedback simultaneously
and also view the scene and their comments side by side. The enjoyable aspect of
drawing on the walls of the scene was clear from users' spontaneous comments. A
combination of the onscreen notepad and scene-drawing ability might be a good
choice. However, it was not clear whether the ability to draw within the scene would
actually benefit information gathering.
Figure 6. The 3D living room scene Figure 7. The paint/drawing screen
Figure 8. The paint/drawing screen Figure 9. The 3D scene after writing
Figure 10. The top-down view Figure 11. Onscreen notepad

Figure 12. Notepad on the wall
6. Summary
In its work with older people the FRR project found that participants were generally
unconcerned about talking about toilets and toilet-habits. In this respect, the CBIs that
were designed did not prove as necessary as first expected. However, it was shown
that the CBI was still beneficial for gathering and storing data electronically, especially
when dealing with large user-groups and sizable amounts of data.
In group discussions and focus groups it was discovered that the elderly user group
proved to be equally open and frank. The use of drawings within the CBIs was
discussed with such user groups and the addition of drawings was found to be an
effective addition to the interviews. However, it was suggested that general
acceptability could be increased by making the characters more humorous cartoon-type
figures. This would have the effect of making the material less personal and the use of
humor was recommended as a way to make possibly embarrassing material more
comfortable to discuss.
The feasibility of using web-based virtual reality tools to support information and
requirements gathering was also explored throughout the project. This included 360
degree panoramic representations of rest room environments, produced by stitching
together sequences of digital photographs. The users clicked on hotspots within the
scene to get a close-up of an object or to move to another room within the virtual tour.
Virtual environments incorporating 3D models were also investigated where the
user may feel more immersed within these scenes as they are able to move more freely
within the scene. A novel idea was introduced where the user could make comments
and notes about the scene within the actual environment itself by writing/drawing on
the walls or floor. A pilot study was performed where the use of a more traditional
paper-based interview is compared with the interactive environment as well as
scenarios using a virtual onscreen notepad. From this pilot study it was determined that
the onscreen notepad was the preferred choice of the participants as a tool for
information gathering, however the participants highlighted the enjoyment aspect of
being able to draw and write within a 3D environment.
References
[1] Dove GAW, Wigg P, Clarke JHC, Constantinidou M, Royappa BA, Evans CR, Milne J, Goss C,
Gordon M, de Wardener HE. The therapeutic effect of taking a patient's history by computer. Journal of
the Royal College of General Practitioners. 1977; 27:477- 481.
[2] Duffy JC, Waterton JJ. Under-reporting of alcohol consumption in sample surveys: The effect of
computer interviewing in fieldwork. British Journal of Addiction. 1984;79:303-308.
[3] Holt S, Guram M, Smith M, Skinner HA. Computer assessment of life-style in a gastroenterology
clinic. Digestive Diseases and Sciences. 1992;37:993-996.
[4] Locke SE, Kowaloff HB, Hoff RG, Safran C, Popovsky MA, Cotton DJ, Kinkelstein DM, Page PL,
Slack WP. Computer based interview for screening blood donors for risk of HIV transmission. Journal
of the American Medical Association. 1992;268:1301-1305.
[5] Skinner HA, Allen BA. Does the computer make a difference? Computerized versus face-to-face versus
self-report assessment of alcohol, drug and tobacco use. Journal of Consulting and Clinical
Psychology. 1983;51:267-275.
[6] Morton HG, Alm N. Computer-aided interviewing of parents in a child psychiatric clinic. Journal of
Microcomputer Applications. 1990;13:273-280.
[7] Peiris D, Alm N, Gregor P. Computer interviews -- an initial investigation using free text responses in
People and Computers. In: Kirby MAR, Dix AJ, Finlay JE, editors. Proceedings of HCI'95 : People
and Computers. Cambridge: Cambridge University Press; 1995, 281-288.
[8] Alm N, Arnott, JL, Murray IR, Buchanan I. Virtual reality for putting people with disabilities in
control. In: Proceedings of IEEE Systems Man and Cybernetics Conference. San Diego; 1998, 1174-
1179.
[9] Peiris R, Gregor P, Alm N. The effects of simulating human conversational style in a computer-based
interview. Interacting with Computers. 2000;12(6):635-650.
[10] Williams B, Peiris DR, Gregor P, Alm N, Cumming S, Flockhart G, Groundwater M. Computer-based
interventions for assisting people who have suffered disabling trauma.. New Technology in the Human
Services. 1999;12:69-75.
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-94
Knowledge Management
John MANTAS1, Joseph LIASKOS and Martha CHARALAMPIDOU
Laboratory of Health Informatics Faculty of Nursing, University of Athens, Athens,
Greece
Abstract. The main target of this chapter is the presentation of the knowledge
management approach in the Friendly Rest Room (FRR) European project. The
intention was to organize the data collected during the project. The approach is 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.
Keywords. Knowledge Management, Knowledge Base, Co-operative Work
1. Introduction
Across a wide variety of fields, data are being collected and accumulated at a great
pace. The information extraction process from rapidly growing volumes of data requires
analysis and organization of the information content which is a huge amount of work. The
World Wide Web (WWW) has drastically changed the availability of electronically
accessible information. Since textual format is a very flexible way to describe and
disseminate various types of information, large amounts of information are stored as text.
This amount of data has made it increasingly difficult to find, access, present, and maintain
the information required by a wide variety of users.
There is a growing need for a new generation of computational techniques and tools to
assist humans in extracting and managing useful information (knowledge) from the rapidly
growing volumes of data. Knowledge management refers to the methods and tools for
capturing, storing, organizing, and making accessible knowledge and expertise within and
across communities [1].
In this chapter the approach is presented for knowledge management and information
dissemination within the Friendly Rest Room (FRR) project, using the World Wide Web.
1
Corresponding Author: John Mantas, Laboratory of Health Informatics, Faculty of Nursing, University of
Athens, Papadiamantopoulou 123, 115 27, Athens, Greece; Email: jmantas@nurs.uoa.gr
J. Mantas et al. / Knowledge Management 95
Finding the right piece of information is a very crucial task for the implementation of the
FRR scopes. The aim of our effort was to develop a system, which supports information
extraction and content categorization.
2. The FRR Project
Friendly Rest Room (FRR) is an EU project within the Quality of life program, which
aims at making toilet facilities better suited for elderly and people with disabilities. It also
involves research to define user parameters for design and development. All the elements
of the FRR are individually adjustable to meet the needs of older persons with different
functional limitations or disabilities, allowing them to gain greater autonomy,
independence, self-esteem, dignity, safety, improved self-care and therefore enable them to
enjoy a better quality of life.
Among the project objectives lies the generation of valuable knowledge and
perceptions (not existing today) regarding toileting, personal hygiene, and falls prevention
among the aging populations in Europe. The FRR knowledge base is used at the service of
wide range of applications, innovations and solutions to improve the level of Quality of
Life and of public health theory and practices among the aging populations. The
measurable objective is the independent continuation of the "FRR- New Knowledge Base"
after the ending of the FRR Project.
3. FRR and Knowledge Management
The knowledge gathering, organization and management in FRR project is two fold:
x Within the project consortium a shared workspace is used and

x A FRR Knowledge Base was developed.
3.1. BSCW Server
Our initial intention was to find a way of dynamic information exchange between the
participating individuals in the project, offering them a possibility of proposing new ideas
and enriching the existing ones. Normally, the information is presented in the format of
documents of various formats e.g. .doc, .xls, .pdf, etc. All these should be organized in a
non-static way: a partner adds a new document with new ideas, collected data, research
outcomes, etc. and the others enrich this document by adding their own knowledge. This
was the original idea of building new knowledge.
The BSCW (Basic Support for Cooperative Work) server is the environment that was
used for the implementation of these purposes (Figure 1). BSCW supports asynchronous
and synchronous cooperation with the partners in the project, over Internet [2, 3]. For
asynchronous cooperation, BSCW offers shared workspaces that are used to store, manage,
jointly edit and share documents. There is the possibility of sharing documents (of all
96 J. Mantas et al. / Knowledge Management
formats) by using any standard web browser and independently of the specific computer
system that the partners use, moreover the system keeps all informed of any relevant events
in a shared workspace. For synchronous cooperation, BSCW provides tools for planning
and organizing meetings, for starting virtual meetings on the basis of conferencing
programs or by telephone, for communicating with partners who are currently logged in to
a shared workspace and therefore are likely to be working on a common task.
Figure 1. BSCW Server
3.2. FRR Knowledge Base
After the collection of new knowledge, the next step was the development of an
environment for the knowledge management. A website composed of various elements was
developed. This environment was named the FRR Knowledge Base (Figure 2).
The FAQ link offers some key Questions-Answers to basic topics regarding the
project and the knowledge management in it. The LEXICON link opens a webpage where
important concepts related to the basic aspects of the project, the disabled people, and to the
technological issues, are included with their definition (Figure 3).
Finally, the SEARCH link opens a page (Figure 4) where the user is able to perform
an advanced search in the library of FRR Knowledge Base. This library contains all the
documents gathered in the BSCW server and was continually updated during the project.
Figure 2. FRR Knowledge Base
Figure 3. FRR Lexicon

Figure 4. Advanced Search in FRR Library
The SEARCH library is basically divided into four sub-libraries: the User_Needs, the
Technical_Resources, the URBs (User-driven Research Bases) and the Evaluation sub-
libraries. Each one contains all the relevant documents.. In the User_Needs sub-library all
the information about the needs of the target population of the project (the disabled and
elderly people) is included; the Technical Resources contains the technical achievements of
FRR in a detailed way; the URBs sub-library refers to the collection and statistical analysis
of data concerning the target population; finally, in the Evaluation sub-library, the
validation, evaluation and other research findings about the innovations of the project are
included. A brief description of the search and find procedure follows:
All documents are indexed in four different catalogues. Every catalogue is defined
according to the specifications of the four sub-libraries. Every catalogue encapsulates all
the details needed to access and index the documents contained in corresponding sub-
library.
An enumeration mechanism identifies all the indexable files in the included directories
and appends them to a queue. A document filter opens each queued file and emits
properties and content of the document contained therein. The stream of text emitted by the
filter is fed to a word breaker, which recognizes features such as words and numbers
contained in the stream. Features that survive the stop list (noise word list) are eventually
compiled into a master index that is used to resolve queries.
The text extracted from a document is processed by a tool named: "word breaker",
which identifies words from the stream of text. As soon as a document is filtered and
processed by the "word breaker", the resulting words are stored in a word list. The master
index is the final destination of all the word lists.
Query formulation and result browsing can be accomplished using any standard web
browser. The user can perform searches in multiple sub-libraries using Boolean and
proximity operators. Also, the user can perform free text queries, which allow formulating
a query based on the meaning of a phrase rather than the exact wording.
The FRR Knowledge Base is considered as a quite dynamic environment that is
continually updated according to the new information gained in the project. While
developing it was tried to preserve its content and empower the gathered information. The
basic concern was to develop a user-friendly knowledge management tool and make it
available to all kinds of users. Finally, this tool was evaluated, in short periods, for its
comprehensiveness, content, functionality and coherency.
4. Discussion and Conclusions
The goal of knowledge management at FRR is to use the knowledge that resides in the
project in order to fulfil the FRR project mission which is to help the elderly people and
people with special needs to overcome the difficulties in their everyday life when using rest
rooms. The different categories of stakeholders, are primary users (people with different
categories of special needs, elderly people), secondary users (people that help and assist the
primary users to overcome the difficulties and restrictions of their physical problem in
everyday life, such as nurses, social workers, physiotherapists, ergo-therapists, etc.), and
designers and developers that will design and develop the friendly rest room. All
stakeholders that are related to the project have contributed information into the knowledge
base.
The three discrete steps taken in order to tackle the whole process of managing
knowledge in the project are [4]:
x Capturing knowledge and processes that are being used in the different categories
of stakeholders participating in the project.
x Consolidating these processes to provide an environment for cooperative problem
solving in the design and development of the friendly rest room.
x Implementing an integrated system to enable collaborative knowledge-intensive
processes.
The development and maintenance of a number of user guides, FAQS,

documentation and technical papers, illustrations, questionnaires, reports, will serve the
needs of managing FRR knowledge base.
A short evaluation that was performed according to some guidelines provided us with
quite accepted results. A group of experts that tested our facilities concluded that this kind
of knowledge management could help us fulfil our purposes. They agreed that in the new
era of health informatics, not only the knowledge extraction but also the knowledge
organisations are very crucial issues. According to their suggestions some new features
could be added; in this direction they proposed the automated summary extraction from the
documents and the inclusions of interactive training systems. Finally, they advised that
more documents should be added in the library and that the FRR Lexicon should be
enriched with more terms.
After experiencing several EU-projects we can conclude that an effective and user-
friendly share workspace is essential for such a large project with so many partners. Such a
system like the BSCW downsizes the email stream and makes the participant confident that
the results from day to day are stored in a stable system that gives access 24 hours a day.
Further it gives important feedback about the frequency of use by whom.
References
[1] Fayyad U, Shapiro G, Smyth P. Knowledge Discovery and Data Mining: Towards a Unifying Framework.
In: KDD-96. Proceedings of the Second International Conference on Knowledge Discovery and Data
Mining; 1996 Aug 2-4; Portland, Oregon.
[2] Appelt W. What Groupware Functionality do Users Really Use? In: Proceedings of the 9th Euromicro
Workshop on PDP 2001; 2001 Feb 7-9; Mantua, IEEE Computer Society, Los Alamitos.
[3] Klckner K. BSCW - Educational Servers and Services on the WWW. In: Proceedings of the International
C4-ICDE Conf. on Distance Education and Open Learning "Competition, Collaboration, Continuity,
Change"; 2000 Sep 9-14; Adelaide.
[4] Tiwana A. The Knowledge Management Toolkit: Practical techniques for building a knowledge management
system. Prentice Hall PTR; 2000.
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-101
Rapid Prototyping of Interface and Control

Software for an Intelligent Toilet
Charlotte MAGNUSSONa,1, Norman ALMb, Georg EDELMAYERc,
Peter MAYERc and Paul PANEKc
a
Certec Rehabilitation Engineering Lund University, Lund, Sweden
b
Applied Computing University of Dundee, Dundee, UK
c
fortec Research Group on Rehabilitation Technology Vienna University of
Technology, Vienna, Austria
Abstract. In the Friendly Rest Room (FRR) project a series of paper sketches and
computer implemented prototypes were designed to obtain information about user
preferences with regard to the user interface. The first stages in the process were
performed with the help of the user group, while later prototypes were tested in
end user tests. The results point to the importance of a combination of visual,
audible and tactile information as well as underlining the importance of
incorporating real end users in the design process. In parallel to the user interface
software design also a control program to steer the FRR prototypes was
implemented and successfully tested in laboratory settings and partly also in real
life environment.
Keywords. Toilet, Assistive Technology, Rest Room, Human Computer Interface,

Elderly
1. Introduction and Aim
As the Friendly Rest Room (FRR) system provides much more functionality than an
ordinary toilet, a new type of user interface is needed to present information about what
can be altered in a flexible, yet understandable way to the user. The following chapter
describes the development and tests with this new type of user interface. As a second
part, a brief overview on the overall FRR system software concept is given.
2. Development of the Human Computer Interface (HCI)
2.1. Early Stages of the Design Process
To obtain user feedback in the early stages of the design process both scenarios and
paper sketches were used. Scenarios are stories that describe potential future use
situations. They are extensively utilised throughout design processes for purposes such
as user-requirements elicitation, interaction design, and usability testing (see e.g. [1]).
1
Corresponding Author: Charlotte Magnusson, Certec, Lund University, LTH, P.O. Box 118, S-221 00
Lund, Sweden; Tel: +46 46 222 40 97; Fax: +46 46 222 44 31; Email: charlotte.magnusson@certec.lth.se;
Website: http://www.english.certec.lth.se/
102 C. Magnusson et al. / Rapid Prototyping of Interface and Control Software for an Intelligent Toilet
Our reason for working with paper prototypes (so called lo-fi prototypes) was that
they are known to allow the designer to focus on the design instead of technical issues
[2]. The scenarios were designed to illustrate typical usages of different hypothetical
usage situations. One scenario illustrating an interface where the user directly controls
the FRR station is explained in the following:
Ivan moves up to the FRR system. He logs in and the door opens. The toilet is
changing so that Ivans initial settings are adopted. The voice says: Welcome. You
may lock the door by saying LOCK DOOR or move the handle. To open the door
please say OPEN or press the handle. Please say INSTRUCTIONS to receive further
voice instructions. Say HELP to call for help. Say INFORMATION to repeat this
message. Ivan moves the handle to lock the door. He then moves over to the toilet and
gets on. He grabs the control interface and presses the toilet symbol. He then presses
UP to move the toilet seat up. He presses the handles symbol and then OUT to move
the handles out a bit. He does not want to change the initial settings, so he does not
press SAVE. When he is ready he presses TOILET and then FLUSH. While having
TOILET active he also presses UP to move the seat further up. He leaves the toilet and
moves to the sink to wash his hands. He unlocks and the door opens. He leaves.
Figure 1. Display arrows by the objects. The arrows indicate the possible changes that can be made.
Figure 2. Select object in the image but select actions from buttons shown separately.
C. Magnusson et al. / Rapid Prototyping of Interface and Control Software for an Intelligent Toilet 103
The scenarios illustrated fully automatic, sequence based and direct control type of
interfaces. The fully automatic interface assumes the system knows what the user does
and automatically controls all the devices in the room. The sequence based interface
assumes that there is a sequence of actions a user may want to perform and the user
initiates changes between these different states. In the direct control type interface the
user controls everything directly (although there is a pre-programmed initial state
which is saved for each user).
The users were also shown a set of preliminary interface sketches which illustrated
different principles for organising the interface. Figure 1, 2 and 3 show three such
sketches.
Figure 3. Make selection of objects from a range of images or icons. Then a new screen is shown indicating
object, available actions and a return button (note that the screens above are shown after each other, not
simultaneously).
The feedback from the user board showed that the users preferred the direct control
type of usage, where the system has a set of saved settings, but where all changes are
initiated and controlled by the user (including saving of new preferred settings).
Comments on the images and on the icons led to a first interface design which made
use of the fact that actions were easier to interpret if you saw them related to the object
as in the tilt forwards icon in Figure 4.
Figure 4. A tilt forwards icon which shows both the action and the object.
Since the users did not want to see too many icons at the same time, the interface
was organized hierarchically (Figure 5). This first implemented version of the interface
was tested at a second user board meeting, and since the results from this first test were
promising it was decided to continue developing this interface for the first round of full
user tests.
Figure 5. Overview mode. Main menu (left), toilet sub menu (middle) and light sub menu (right).
Figure 6. A screen shot from a sub menu in the large mode interface.
2.2. First Round of User Tests
For testing purposes a hand held computer on base of a PDA (Personal Digital
Assistant) was used as an input device, as it has the size of a hand held device and
allows for touch input as well as both visual and auditory output. The user interface
was developed through a sequence of paper prototypes into two basic versions:
x Overview mode (giving overview, but showing fairly small icons, Figure 5)
x Large mode (showing only few icons, but allowing for the use of big icons,
see Figure 6)
Both modes allowed for the use of a scanning function, where the PDA changed
images automatically after a pre-defined interval. Pressing a button generated auditory
(speech) feedback, and in the large mode every time a new icon was shown on the
screen it was accompanied by the corresponding speech feedback.
The PDA devices were positioned in the FRR room to allow for the testing of
suitable locations of this type of device. Two positions (by the door and by the toilet)
were used, and at each location the users were asked to perform relevant tasks. At the
door the users were asked to change the level of light and turn off the sound feedback,
and at the toilet the users were asked to change toilet position and tilt as well as change
the distance between the grab bars and then finally to flush the toilet (Figure 7).
Figure 7. The two iPAQ locations. One by the door and one by the toilet.
Figure 8. Discussing the interface in more detail.

The interface was also discussed in more detail on a table outside the FRR station
(Figure 8). Users with severe visual impairments performed the whole test at this
location to make it easier for them to bring the device close to the eyes with full
intensity on the screen (the iPAQ reduces the light of the screen when it is removed
from the cradle).
This first round of user tests performed with eleven users showed in general that
the users that could see the interface could also use it (success rate 8 or more of 11 for
15 out of 22 tasks). Unfortunately the loudspeaker in the iPAQ generated only quite
low sounds, and most of the visually impaired users could not hear the voice feedback.
The one visually impaired user that could hear this feedback could also operate the
interface in the scanning mode. The menu navigation caused some initial problems for
several users, but it appeared to be quite easy to learn how to operate it as most users
could navigate from the grab bar menu to the toilet menu in the final task.
The icons appeared in general to be clear and easy to understand. The exceptions
were the main menu or back button, the save button, the left/right buttons and the
sound on/off button. It was also interesting to note that the black ring around the flush
icon which was intended to make this icon more visible instead appeared to make it
harder to find for some users.
The size of the device was commented on by a few users. If possible a somewhat
larger screen may be chosen for the final system. This would also make it easier to
provide tactile information about the button locations, as it would be possible to show
both the main menu and the sub menu on the same screen.
Figure 9. The iPAQ hand held Figure 10. The toilet and sound sub menus in the normal mode.
computer showing the main menu The feedback icon in the top left corner is replaced by a restore
in the normal mode. The save button. In the sound menu two different buttons indicate on and off
button has a new icon, and a restore (instead of the previous toggle type button). The main menu button is
button is added (the icons are also changed to work better with the large version on the interface.
intended to indicate
saving/retrieving data from the
Radio Frequency Identification -
RFID card)
This way it would be easier to keep fixed button locations (although the content of
a button may change depending on the sub menu) and with fixed button locations it
would be possible to use transparent plastic with relief to indicate a button position.
In the overview interface there was an image in the top left corner that provided
feedback about which sub menu the user is in. Many users pressed this image when
attempting to get to the main menu.
Figure 11. The large mode version of the interface. Buttons are always in the same position on the screen to
make it possible to use a tactile overlay. The save and restore buttons can be found at the top, while the
buttons for menu navigation are placed at the bottom of the screen.
2.3. Second Round of User Tests
The test results led to a re-design of the interface intended to allow for additional touch
feedback for the large mode interface. The basic menu layout was the same as during
the previous test. Some changes had been introduced however (Figures 9,10,11 and
12):
x The feedback icon in the top left corner in the sub-menus was removed
x The save icon was changed and a restore button was added
x The main menu button was changed to work better with the large mode
x The on/off buttons showed both options (on and off) instead of the toggle type
of button used previously.
x A tactile overlay was used for the large version of the interface to indicate
button positions
x The large interface was reorganised so that buttons always were placed in the
same locations to allow for the use of the tactile overlay
x Auditory feedback was programmed to synchronize better with the visual
feedback in the large mode (there were some problems in the previous
version)
These new versions of the interface were tested during the second round of user
tests performed in the autumn of 2004. This time external loudspeakers were used for
the sound, which allowed all users to hear the sound. During the test three different
versions of the tactile overlay (figure 12) were tested, and the users were asked for their
preferences. The actual interface testing was then performed with the preferred tactile
overlay.
Ten users tested the interface. Four of these users failed to complete the whole test.
One user was unable to use this type of small interface due to motorical problems (very
limited reach and tremor that got worse the harder the person tried to use the device).
Another could not see nor feel the buttons on the tactile overlay (higher relief needed).
During another session the PDA hardware crashed and was impossible to repair during
the time allocated for the test. Six users completed the full test.
All users but one preferred the dotted version of the overlay (all ten users tested
this). Two users that saw very well said it did not help, while four users commented on
its usefulness. As was stated above the test indicates that it would be better with higher
relief. The sound on/off button was now easier to use since it showed both possibilities
Figure 12. The three different versions of the tactile overlay.

(sound on and sound off) compared to the previous version of the interface that used a
toggle type button where you only saw the current state (on OR off). The save icon in
the previous version had gotten comments for being hard to understand, but the new
version was not appreciated as well.
2.4. Conclusion
In general though, both tests show that this type of interface is possible to use with this
user group. As always, care needs to be taken with interface design, and it is clear that
for many of these users a larger interface (allowing the use of the overview mode type
design) would have been better. The tests also show the importance of making
information available through more than one sensory channel. Not only vision, but also
hearing and touch should be used. A simple way of achieving touch feedback by using
transparent tactile overlays was suggested, and the test showed this approach to be
useful.
3. Development of the Control and System Software
3.1. Software Concept
The control software is part of the general software concept that was developed for the
FRR system. The system software consists of several modules that work together
(partly via a defined XML message structure) to provide all necessary functionality.
The software also provides the interface structure to connect to dedicated hardware
(Figure 13). Within the project the FRR control and system software was realized
partly. It was only used for those five iterative prototypes which were evaluated at the
user test site in Vienna [4]. A modified version of the FRR control software was used
for the real life test [3] in Vienna.
Figure 13. FRR Software Components and Sub-Components including external hardware, third party
software, control unit hardware, Interface software and control software (bottom to top rows).
Figure 14. FRR system software v2.1c with integrated remote access via http (laboratory stage, to be used
only by engineers), September 2003.
The system software modules were tested implicitly during user tests, as the FRR
system software provides the internal interfaces to those parts of the whole system that
actually are the interface to the user (like the HCI described above). Thus the system
software was tested implicitly while not being directly visible for the test participants.
During life time of the FRR project (2002-2005) several iterative versions of the
system software were developed and tested according to the test set up of the different
tested toilet hardware modules. In general the control software provides the following
functionality:
x Measuring position including scaling to units of cm

x Moving toilet to certain positions
x Storing / recalling user profiles
x Semi-automatic calibration of system
x Continuous logging of sensor data
x Compensation algorithm (height/tilt)
x Graphical User Interface (GUI) for technician
x Semi autonomous control via ultra sonic seat sensor
x Acoustic prompting
x Basic safety routines
x Environmental control: switching on/off room light, spots, occupied indicator,
alarm indicator
x Interface to user recognition unit (RFID reader)
x Remote maintenance service
x Emergency call (only simulation)
3.2. Human Computer Interface for Control Software
The HCI of the control software is implemented as graphical user interface (GUI) and
is only used by the technician to adjust the FRR system for the different tests. It also is
used for administrating a very basic user database where predefined settings are stored.
A screenshot of the GUI used by the technician during the laboratory tests in Vienna is
shown in Figure 14.
For the real life tests in Vienna [3] the control software was modified to provide
remote accessibility via the internet using a specific technological approach described
in [5] and an enhanced continuous logging functionality for 24/7 data logging. Further
to this, it is to note that the possibility to steer the FRR system actively (i.e. drive the
motors as in the laboratory tests [4]) was not used for the real life tests [3] for safety
reasons.
3.3. Conclusion
The software concept, although not realized in full, forms guidelines for an open and
extendable system so that future development can be easily supported. The used control
modules proved to work reliable in both laboratory and real life situations. Some parts
of the system are currently (June 2009) still in laboratory use for demonstration and
education purpose.
4. Summary
Prototypes of multimodal interfaces for end users were designed and tested in
laboratory environment. Multimodality of the interface (using vision, hearing and
touch) was judged as useful, while the used hardware device could be larger. A basic
implementation of the main control software was done which provides a framework
open for future extension. The software was used to steer the toilet prototype system
during end user tests in laboratory environment and part of it was used successfully
during real life evaluation in a day care centre.
References
[1] Carroll JM. Making use: scenario-based design of human-computer interactions. Cambridge,
Massachusetts: MIT Press; 2000.
[2] Rettig M. Prototyping for tiny fingers. Communications of the ACM. 1994 Apr;37(4):21-27.
Integrated Sensors for Enhancing Autonomy and Safety. This volume.
[5] Panek P, Beck C, Zagler WL. Giving Wings to the Service Delivery Process - New Possibilities by the
RESORT Tele-Service Approach. In: Craddock G, McCormack L, Reilly R, Knops H, editors.
Assistive Technology - Shaping the Future. Amsterdam: IOS Press; 2003, p. 405-409.
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-112
The Final FRR Components

Theo J.J. GROOTHUIZENa,1, Atilla RISTb, Marja H. VAN WEERENa, Dries
DEKKERc, Renate DE BRUINc and Johan F.M. MOLENBROEKc
a
Groothuizen Beheer bv, Rotterdam, The Netherlands
b
Clean Solutions, Debrecen, Hungary
c
Faculty of Industrial Design Engineering Delft University of Technology,
Abstract. The design challenge within the Friendly Rest Room project has been to
anticipate the needs of individual users, in particular older persons and people with
disabilities, and to combine this with serving the needs of a far less specific
audience, of secondary users (e.g. caretakers, cleaning personnel) and even tertiary
users (e.g. facility managers). From start it was clear that the participating project
partners did not all share the same view and expectations about how to approach
the big design challenge to and about the exact process to follow. The first
exploration of the use of a rest room by older or disabled users and additional
statistics on accidents showed that many problems occur while entering the rest
room, moving through the rest room and while preparing for toileting. The design
team focused strongly on finding feasible solutions aimed to improve physical
safety and the perception of safety. Ergonomic variables related to the use of a rest
room played a central role. For that, the design team explored the use of a rest
room by the target user groups and analysed the relation between functions in the
rest room and potential user problems and risks. Based on those findings, it was
proposed to distinguish three functional areas in a rest room: the access, the
transfer and the toilet area. In 3 and later in 5 countries prototypes were built and
tested. Finally the integrated version was user tested in a nursing home in Vienna
during 3 months. The resulted knowledge was disseminated in a conference, in this
book and several conference papers and a in a commercial version produced by
Clear Solution, Debrecen Hungary.
Keywords. Smart Toilet, Smart Home, Design, Assistive Technology
1. Introduction
The design challenge within the Friendly Rest Room project has been to anticipate
the needs of individual users, in particular older persons and people with disabilities,
and to combine this with serving the needs of a far less specific audience, of secondary
users (e.g. caretakers, cleaning personnel) and even tertiary users (e.g. facility
managers). Even the unanticipated healthy visitor of our Friendly Rest Room should
not feel handicapped when he or she enters, a feeling which is easily called upon by
the stigmatizing robust design of most assistive aids for elderly and disabled. For the
latter group the final Friendly Rest Room (FRR) should contribute to a greater
individual autonomy and independence, hopefully adding to improved dignity and self-
esteem. In brief, its goal is an improvement of quality of lives for many [1].
1
Corresponding Author: Theo Groothuizen, Design Consultant, Groothuizen Beheer bv, Rotterdam, the
Netherlands; E-mail: theogroothuizen@gmail.com
T.J.J. Groothuizen et al. / The Final FRR Components 113
It is clear that even for experienced industrial designers, product developers,

engineers and researchers it is hard to imagine the possible outcome of such a project.
This chapter will show how the industrial designers, product developers, engineers and
researchers involved in the FRR project have mutually worked together to develop a
prototype and to test it with the help of representative users, in order to learn, adapt and
re-develop. To illustrate this learning path, this chapter will describe the consecutive
steps in the development and industrial design process. The results and some critical
considerations during the development process will be presented along the way.
2. Integrated Design Process
It all started with a rough beginning. From start it was clear that the participating
project partners did not all share the same view and expectations about how to
approach the big design challenge to and about the exact process to follow. How to
achieve a greater independence and autonomy for elderly? How to develop a rest room
for European elderly, with so many different cultures? Where to start?
The initial problem description and research was focused on the adjustability of the
toilet, arm supports etc. and did not include the rest room environment. Upon advice
from the involved industrial designers and excerpting from a proven design
methodology [2], it was decided to study all variables related to using a rest room and
to broaden the problem description accordingly.
The first exploration of the use of a rest room by older or disabled users and
additional statistics on accidents showed that many problems occur while entering the
rest room, moving through the rest room and while preparing for toileting [3, 4 and 5].
To avoid these problems users need assistance. This is in conflict with the wish to be
independent and with their dignity.
How to get all participating disciplines, engineers, industrial designers,
sociologists, ethical specialists and business oriented partners, on the same track?
Agreement was reached on trying to find solutions for those people who could move
independently of others, also including persons using a walker or wheelchair, and to
find safe and reliable solutions based on the principles of "Design for All". This means
trying not to exclude people from using the FRR.
An integrated development and user-centred process was followed, assuring that
all disciplines and end-users were involved in all stages of the development process.
3. Design Approach
The design team focused strongly on finding feasible solutions aimed to improve
physical safety and the perception of safety. Ergonomic variables related to the use of a
rest room played a central role. For that, the design team explored the use of a rest
room by the target user groups and analysed the relation between functions in the rest
room and potential user problems and risks.
Based on those findings, it was proposed to distinguish three functional areas in a
rest room: the access, the transfer and the toilet area (see Figure 1). These areas all
represent a specific group of usability problems, risks and complexity.
Further findings of user involved research in the URBs (User Research Bases) and
by the design team resulted in a list of problems to be solved and recommendations for
114 T.J.J. Groothuizen et al. / The Final FRR Components
additional research [6]. It was in fact this list of problems to be solved that focused
the design activities:
x Difficult to locate toilet and to see whether toilet is in use

x Difficult to open door and difficult to manoeuvre through door opening
x Difficult to lock the door
x Difficult to store personal belongings (bag, coat)
x Distinction (white) sanitary from (white) environment, or distinction floor
from wall difficult, due to diminished sight
x Difficult to move to the toilet; either too little manoeuvring space or too much
space without any support
x Difficult to undress, turn around and sit down, due to balance problems or in
case of wheelchair-users difficult to undress and transfer to toilet
x Difficult to sit stable on toilet and difficult to clean intimate body parts
(balance problems)
x Difficult to stand up and dress (balance problems)
Figure 1. Three functional areas in the toilet environment

Figure 2. Top view of the cantilever door and its movement
4. Access Area
4.1. The Door
Standard doors cause serious problems for many elderly or people with disabilities. In
particular, in case of lack of force in arm or hands, of using a walker or wheelchair,
doors can be frustrating barriers.
A cantilever door (see Figure 2) was tested at project partners CERTEC in Lund
and at the Delft University of Technology. A cantilever door rotates in such a way that
only a part of the door moves towards the user and the other part away from the user.
This removes the need for the user to "step back", because of the limited space the door
needs. The door hardly requires force to open and close.
The cantilever door improves the accessibility substantially, particularly for users
with a wheelchair or walking aids. For them, this type of door makes it possible to
close the door without extremely rotating their body or grabbing for the door handle
behind them.
The door, manufactured by project partner Clean Solution (CSO), proved to satisfy
the needs of the users, in particular in combination with the newly designed door
handles. The door is prepared for an electronic lock mechanism and an unlocking
option in case of emergency.
4.2. The Door Handles
Traditional door handles often are problematic for elderly and disabled persons, mainly
because of the force needed to rotate them. Based on user tests new door handles were
designed by project partner Landmark. Larger and smaller versions of the door handle,
both mounted on a cantilever door, were successfully tested in Lund and Delft.
The handles, (see Figure 3) are considerably larger than standard and have a
triangular shape. The shape offers users the possibility to use a hand, arm or elbow, a
high or low grip or even a vertical grip. The large dimensions mean that a very low
force is needed.
Figure 3. Door handle with lock indicator in locked and open position
Figure 4. The door with communication unit

The handle was designed to accommodate people with less strength, in case hands
cannot be used and for manipulation from a low or sitting position. The door handle
was rated very satisfactory for many subjects in the test groups.
The door handle is prepared for an automatic lock/unlock sign which is also visible
from the outside. This makes it possible for users to recognise whether the toilet is
available or occupied from larger distances.
The design is prepared to activate a light switch as soon as the door handle is used.
4.3. The Communication Unit
The Communication Unit is the central module of the FRR. The core function of this
multifunctional component is to identify a specific user and to adapt the rest room to
the specific, individual needs of that user. The unit is mounted on the outside vertical
post of the doorframe, at the side of the door handle (see Figure 4).
The following functions are integrated in this unit:
1. A contactless card reader which can identify the FRR user by Radio Frequency
Identification (RFID) technology
2. An intercom-function in order to communicate from outside the rest room with
somebody inside in case of emergency
3. An (optional) numeric keypad (digits 0-9), including an indication for acceptance
or rejection of a code
4. An alarm indicator, which can double as an indication for an occupied toilet
5. A sensor for indicating whether persons enter or leave the room steers the light
switch.
6. A sensor for a closed-door position to lock the door and activate the lock/unlock
signs
7. An activator to unlock the door in case of alarm/emergency
Only in case of alarm a two-way communication is made available. By pushing the
"speaker button", authorised assistive personnel can talk with the person inside and
check the situation before entering the restroom. The person inside does not need to
activate a button. Inside the rest room a speaker and microphone are mounted. The
keypad offers tactile, visual and aural feedback. The lock mechanism can be unlocked
from the outside by helpers after receiving an electrical signal from the alarm system.
The unlock indicator on the inside of the door will then change from red to green.
4.4. The Alarm Indicator
An alarm indicator is positioned at the top of the communication unit and is visible in a
180 angle. The alarm indicator has a double function. It can present a blinking red
light in case of emergency/alarm as well as a continuous red light to indicate an
occupied rest room, or green when available.
4.5. The Accessibility Sign
Different designs for an accessibility sign to indicate that the rest room is a "Friendly
Rest Room" were made (see Figure 5). The first design concepts were rejected by some
of the expert users, because there was no recognisable relation with known and
accepted signs for accessibility. A new design was made which was tested and
approved by the project partners in Athens.
Figure 5. Final design of the accessibility indicator tested in Athens
5. Transfer Area
5.1. The Wall Mounted Grab Bars
Observational studies of elderly users in rest rooms [7] clearly showed, that particularly
people with mobility problems grab anything in order to maintain balance or to feel
more secure. This is not only the case when close to the toilet itself, but also during the
transfer from entrance to toilet area. This made clear that many target users fear losing
balance when they move or stand in a rest room. Besides having grab bars in the toilet
area, it was concluded that they are needed along all walls in the rest room.
Standard grab bars offered in the market are limited in size and expensive. In order
to make it feasible, and affordable for users, to apply them along all walls, a design is
needed which can be mass-produced, reducing the costs for consumers (see Figure 6).
The wall grab bars mainly function as a "balance" providing support. The bars
will combine continuous support availability, an integrated mounting functionality,
optimum cleaning and an integrated, non-stigmatising look.
The continuous rounded inside shape (without sharp, dirt-holding corners) and the
lack of external mounting points, makes it very easy to clean the inside in almost one
stroke. Corners are open for ease of removal of dirt or moist.
The design proposal is based on extruded aluminium profiles and offers several
integrated added values, such as fraction strips or retro reflective lines.
Handmade prototypes of the grab bars were used for testing in the FRR project.
Figure 6. Main part of the wall mounted support bar, manufacturable by extrusion
6. Toilet Area
6.1. Body Support Bars: Horizontal and Vertical
In the Netherlands, horizontal body support bars at the left and right of the toilet are
very common in rest rooms for persons with mobility problems, both in private as well
as public areas. The design team concluded from observations and research that vertical
supports however might be a better alternative, mainly because they offer a better
support for users when standing in front of the toilet bowl, or for sitting down and
getting up.
Besides testing the horizontal bars extensively in the URBs, this project also
focused on comparing, via testing in Delft, of horizontal and vertical oriented body
supports [8]. From the results of this study, it was concluded that elderly test users tend
to prefer using vertical bars.
A design oriented study [9] pointed out that a combination of both horizontal and
vertical supports can be visually attractive. Of course care was given to avoid a
stigmatising image of the overall interior, which is opposite to what the design team
wanted to achieve.
Engineering models of vertical grab bars were produced and tested. These
prototypes aimed to offer the user help to find balance while sitting down or standing
up.
In order to prevent obstructing the user, in case they do not need vertical supports,
the bars can be rotated in a horizontal direction to the sidewalls of the rest room. The
distance between the vertical supports can be adjusted to the needs of the user (see
Figure 7). By pushing a button the bars can be moved, and when released the position
will be locked. The grab bars move up and down with the height of the toilet seat.
A complete redesign was realised for the horizontal grab bars, which were
originally developed and manufactured by partner Clean Solutions (CSO). The
redesign engineering models offer a friction function in any bar position (to prevent the
bar from falling down), a release button, an additional grip (at right angles with bar)
and an improved side grip (see Figure 7).
Figure 7. The toilet with the vertical bars in two positions and the horizontal supports by CSO
6.2. The Lift Toilet
The CSO Lift WC, which was the basis for this project, offers height adjustment from
46 cm above the floor to 81 cm, in order to accommodate a large variety of users. In
combination with a tilted position, it can assist users to sit down or get up and can
function as a urinal in its highest position.
Ergonomic research at the Delft University of Technology indicated that standard
toilet bowls and seats do not satisfy the needs of the target users of this project.
Dissatisfaction not only concerns comfort, but aspects related to personal hygiene as
well, particularly in (semi) public spaces.
It is strongly recommended to initiate a research project to study this subject,
aiming to develop and design a better and affordable toilet bowl for older users or
people with disabilities, as this subject lies outside the scope of the FRR project.
6.3. The Toilet Seat
User involved studies indicated that many elderly users and people with disabilities
complain about the lack of space offered by a standard toilet seat and even experience
serious discomfort. Assistive solutions as offered in the market, such as an "add on" to
increase the height of the seat, do not offer an integrated solution and have a poor
visual quality, thus contributing to a stigmatising image.
The design team has put much effort in studying the usage problems and proposed
three new concepts for seats. Different principles were developed resulting in three
functional models of seats, which were tested in several URBs [10].
The users almost unanimously preferred the functionality of the so-called Transfer
Seat. This seat consists of two parts: on the one hand a "normal" toilet seat and on the
other hand a transfer surface, on the left and/or right side of the seat (see Figure 7).
The transfer surfaces are meant to offer wheelchair users a large and flat surface
for transfer. The surface is smooth and allows easy sliding. The design also offers user
the possibility to use the surface to put aside some personal belongings needed during
toileting (for example a catheter or incontinence diapers) or to give support when
sitting down, adjusting body position or standing up.
The initial design included an adjustment of the width of the toilet seat. This was
left out in the new designs, because the risk of physical injury could not be excluded.
The toilet seat itself was redesigned in a later stage into a so-called comfort seat, in
order to offer more support and stability to the user, as result of additional ergonomic
research and user tests. The seat and transfer surface are connected with the height
adjustment and tilting mechanism of the toilet bowl. The width of the transfer seat will
be based on the available width of the rest room but is limited to a maximum of 40 cm
left and right of the toilet seat.
6.4. The Comfort Washbasin
During the exploratory phase of the FRR project, many target users mentioned the
necessity of being able to cleanse themselves during toileting, in particular in case of a
reduced physical mobility and in case of particular hygiene operations (i.e. changing
diapers or catheter). A washbasin out of reach does not offer a comfortable solution.
Therefore, it was suggested to develop a small washbasin, which offers the
possibility to cleanse hands and or body parts while seated on the toilet (see Figure 8).
The basin is mounted close to the toilet area on the wall or floor. The basin can be
pulled close to the person while seated. By pulling the handle at the front the basin
releases the brake function and allows movement in all directions in the vertical and
horizontal plane. After releasing the handle, the basin is locked in its position.
The washbasin can thus be moved in all directions into a most comfortable
position close to the user: "comfort washbasin".
The washbasin is equipped with a faucet with two integrated functions: water and
soap. The water sensor is located underneath the faucet outlet and the one for soap
above. Users will be instructed by pictograms. Additionally, a hand shower can be
mounted for comfortable cleansing of intimate body parts. Underneath the basin, an
additional light source is foreseen in order to improve visibility while cleansing the
intimate body parts.
The design was granted a patent [11] and additional R&D activities will be
planned.
Figure 8. View of total FRR toilet environment including comfort washbasin
7. Conclusions
After prototyping this design in 3 and later 5 countries, the integrated version was built
together with the company Clean Solution and tested 3 months in a nursing home in
Vienna. This evaluation was organised by fortec, a research group on rehabilitation
technology of the Vienna University of Technology, Austria. The recommendations
followed from these tests were announced in the final conference in Vienna and written
down in this book, in several conference papers [12] and in a commercial version of the
toilet produced by Clean Solution in Debrecen, Hungary.
References
[1] Technical Annex, Project QLRT-2001-00458, Friendly Rest Room for Elderly People. Quality of Life
and Management of Living Resources, Key-Action 6: the Ageing Population and Disabilities. FRR
Project document; 2003.
[2] Roozenburg NFM, Eekels J. Product design: fundamentals and methods. Chichester: John Wiley &
Sons Inc; 1995.
[3] Buzink S, de Bruin R, Groothuizen TJJ, Haagsman EM, Molenbroek JFM. Fall Prevention in the Toilet
Environment. This volume.
[4] Buzink SN, Molenbroek JFM, Haagsman EM, de Bruin R, Groothuizen TJJ. Falls in the toilet
[5] Kira, A. The bathroom. New York: Viking Press; 1976.
[6] Molenbroek JFM, de Bruin R. Overview of the FRR Project; Designing the Toilet of the Future. This
volume.
[7] Plante, R.A. Toilet customs of the elderly; an exploration to find problems caused by the symptoms of
old age and injury into the problems that exist when using the raised toilet seat [Student research report,
in Dutch]. Delft: Delft University of Technology, Faculty of Industrial Design Engineering; 2002.
[8] Dekker D, Buzink SN, Molenbroek JFM. User Preferences Regarding Body Support and Personal
Hygiene in the Toilet Environment. This volume.
[9] Buzink SN. De ontwikkeling van een product ter preventie van valongevallen in toiletruimten [Master
thesis, in Dutch]. Delft: Delft University of Technology, Faculty of Industrial Design Engineering;
2004.
[11] Groothuizen TJJ, inventor; Delft University of Technology. Wasbak. NL patent NL1027416. 2006 May
8.
[12] Fortec homepage. FRR - Friendly Rest Rooms for Elderly People / Intelligent Toilet. [Internet] 2011
[cited 2011 Mar 15]. Available from: http://www.is.tuwien.ac.at/fortec/reha.e/projects/frr/frr.html
Section 3
FRR Case Studies and User Tests
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-127
Elderly and People with Disabilities -

Limitations in their Everyday Life
Panayota SOURTZIa,1 and Terezinha MENEZELLOb
a
Hellenic Association of Gerontology and Geriatrics and Faculty of Nursing
University of Athens, Athens, Greece
b
Physiotherapist Centro di Bioingegneria, Fondazione Don Gnocchi Onlus.Milano,
Milano, Italy
Abstract: The proportion of older people (65+) in the population is increasing

steadily worldwide due to longer life expectancy and decreasing birth rates. The
ageing population often presents with chronic diseases that result into limitations
in the activities of daily living. People with disabilities, either congenital or
acquired, also face various degrees of limitations and need some form of
assistance. Disabilities in general and limitations that are common in old age,
including epidemiological data, are discussed. Indubitably, the need for adapting
the living environment of this population becomes apparent. Three case studies
with older people and people with disabilities in different situations are presented
as examples of adaptation of the bathroom area. Concrete solutions that have been
proposed with respect to their limitations and the way they successfully solved
their problems by means of home adaptations using mostly low-tech solutions are
described. Overall, these three cases encompass typical situations encountered by
aging and disabled persons.
Keywords: Elderly, Disabilities, ADL, Toilet, Observational Studies
1. Introduction
It is a fact that the demography of our world changes rapidly following the Second
World War. The synthesis of the population in the developed countries, but
increasingly in developing countries, too, has been altered in such a way that the most
common comment in the news today is the ageing of the worlds population.
In the European Union (EU) almost all countries show a decrease in birth rates,
with the average been 1.5 children per woman, while there should be 2.2 children per
woman for natural growth of the population. At the same time life expectancy of the
populations grows steadily. The average life expectancy of men in EU has reached 76
years and of women 82. Therefore, it is expected that the natural growth rate for most
European countries will diminish and it is predicted to become negative by 2010,
although in some countries it already is. The result of this development is that the ratio
of older people in the total population is expected to increase from 17% that is the
average today for the age group 65+ to 30% by 2060. Similarly, the proportion of the
1
Corresponding Author: P. Sourtzi; Address: 123 Papadiamantopoulou street, 11527 Athens Greece;
Email: psourtzi@nurs.uoa.gr
128 P. Sourtzi and T. Menezello / Elderly and People with Disabilities
very old people, aged 80 or more, is expected to rise from 5% today to 12% in 2060
[1,2].
The ageing of the population is a phenomenon that comes with many problems for
the society, the family and the health and welfare systems. Although ageing is a natural
biological fact, it is also strongly correlated with increased morbidity, especially of
chronic diseases, which very often cause various disabilities.
Similarly people with disabilities carried on from younger ages will have even
greater limitations as they become older. Dependency rates therefore, are expected to
increase greatly and will impact on health care systems as well as on the social and
economic structure.
The prevalence of chronic disease and disability is an important factor for any
populations health and quality of life. However, not all EU countries collect such data
and existing statistical reports are based on different sources, therefore cross-country
comparisons are difficult to find. In most countries relevant data are based on health
surveys, but in others they are estimated from the list of people receiving social
insurance disability pensions [3]. It is estimated that 10% of the EU population are
disabled, while 40% have reduced mobility [4].
Cross-cultural variation was noted in self-reported disability adjusted for
performance score. These differences may be due to sociocultural and physical
environmental factors [5].
1.1. Definitions
Old age is widely accepted today at least in the developed countries of our world -
that starts at 65 years of age, while very old age refers to persons of 80 years old or
older.
Disability is defined by WHO as a loss or abnormality of body structure or of a
physiological or psychological function.
Dependency is measured by the need for assistance in the activities of daily life
(ADL) [6] and instrumental activities of daily life (IADL) [7] as reported by the
individuals themselves (Table 1).
Table 1. Definitions of self reported activities of daily living.
Basic ADLs Instrumental ADLs

Bathing Using telephone
Dressing Grooming
Transferring (moving from chair to bed or toilet Laundry
and vice versa) Shopping
Toileting Housework
Feeding self Taking medicine as directed
Ambulating Managing ones own money
P. Sourtzi and T. Menezello / Elderly and People with Disabilities 129
2. Older People with Limitations in Every Day Life
People, in the vast majority, remain independent until their old age. People aged 65 or
older that are able to perform the essential activities that help them remain independent,
are considered healthy and they do not need any form of assistance, although they may
have developed some chronic health problem, such as high blood pressure or diabetes
type II. Therefore, old age does not mean disability and consequently limitation in any
ADL or IADL.
However, as old age advances the possibility for impairments emerges and
increasing deterioration is a common pattern. This is even more common for the
persons older than 80 years old, who are also in their majority women, a result of
longer life expectancy in comparison to men. Strauss et al [8] have found that women
have more limitations, according to basic ADLs, than men as age advances.
According to the report The social situation in Europe [9], the old age
dependency ratio has increased from 21.6% in 1990 in the 15 EU countries to 24.3% in
2001 and it is expected to rise to 27.3% in 2010. In 2000 in the EU-15 the average ratio
of people receiving disability benefits was 8.1%, while the older people accounted for
46.4% of the total number of people receiving any kind of benefits [9].
2.1. Most Common Problems That Lead to Limitations in Everyday Life
The main causes of death in older ages are diseases of the circulatory system, cancer,
diseases of the respiratory system and external causes such as injury (including car
accidents) and poisoning. Morbidity however, presents a different picture in older ages.
x Neuro-degenerative diseases such as dementias are becoming a severe

problem that increases with age and results into increasing dependency until
the individual becomes invalid and die. It is estimated that 4% of people
between 65 and 74 will develop some form of dementia, while this proportion
rises to 20% for persons 75 or more [10].
x Cardiovascular diseases are also a severe problem, with high incidence in
almost all EU countries and has been found to lead to various degrees of
disability [11].
x Musculoskeletal disorders lead into limitation in movement and are one of the
main causes of dependency in that age group. The most common age related
health problems that contribute to both musculoskeletal disorders and
accidents are osteoporosis and arthritis.
x Injuries, caused by a pathological condition, either in the home or in the
external environment are becoming more frequent and result into disability.
x Visual impairments among adults in the US account for 0.78% blindness and
1.98% of low vision, with the most common causes being macular
degeneration, cataract and glaucoma [12]. Similar prevalence and causes have
been found in Denmark [13].
x Hearing impairments are also a largely age-related problem and although it is
not disabling as such, when it coincides with other conditions, then limitations
are becoming even more severe.
2.2. People with Disabilities
A disability can affect any person regardless of sex, age, race, ethnic group or social
class. A disability is defined as any limitation in physical, mental or intellectual health
and result in different levels of need of care or assistance. A disability could be
congenital or established later in life following an accident or a chronic disease.
According to a recent report disability is defined in different ways in different
countries especially in terms of socioeconomic status [14]. In the characterization of
disability one refers, very often, to persons younger than 65, which is the average age
of retirement in Europe. However, once a person is characterized with a permanent
disability, this classification usually remains for the rest of his/her life. In 1996, when
the total EU-population was 300 Million, 40 million persons or 13% had some sort of
disability and of those 50% were of working age [15]. According to the report
compiled by EIM Business and Policy Research [3] the percentage of persons aged 16-
54 years with self-reported disability was 14.3% in the 15 EU countries.
Disability is much more prevalent as age advances, because the health condition
that is responsible for it usually deteriorates with age. Disabilities that start early in life,
are lifespan and not likely to be cured, are often due to:
x Congenital and chromosomal defects,

x Learning disabilities,
x Injuries at birth or other perinatal complications,
x Accidents at work, traffic accidents,
x Acquired disabilities related to chronic diseases such as asthma, juvenile
rheumatoid arthritis, cystic fibrosis, cancer,
x Neuro and muscle degeneration diseases, with more prevalent multiple
sclerosis, are also becoming more prevalent with age, as well as more
disabling.
Statistical data from the USA show that injuries cause 13.4% of all disabling
conditions, while orthopaedic impairments account for half of all disabling conditions.
According to ICD classification, diseases of the musculoskeletal system and connecting
tissue account for 17.2%, while circulatory system diseases for another 16.7% [16].
From the same data set it is also shown that the rate of people with at least one ADL
limitation was 14.4% in 1994. Older people experience disability at roughly twice the
rate of those in the older working ages (45-64) and four times the rate of the younger
working-age group (18-44). A still smaller fraction of children have disabilities.
2.3. Conclusion
It is clear from the above that dependency rates in the general population from both
ageing and disability are increasing in the EU countries. Because of this trend more
services will be required in the future in order to respond to the needs of older people
and persons with disabilities. These services include mainly traditional health and
social care.
Assistive technology that will increase accessibility, equity and independence,
however, could play an important role and could additionally free the services from
some of the costs induced by the need for traditional care. Therefore, the study -
according to the needs that emerge from users, their family and health care
professionals -, of products innovation looking for new solutions, in terms of technique
and use, is essential. For existing products, the aim is to assess and optimize the
application of new components. It is also important to improve the functionality of the
devices and their comfort, by developing new designs, applying new materials to
increase safety, autonomy and dignity in the restroom. [19,20,21].
Therefore the need for adaptation of the home environment is indispensable, if
there is a possibility for older people or persons with a disability to stay at home
independently or with some assistance for as long as possible.
3. Three Case Studies
The following case studies2 illustrate how the bathroom, one of the most important
rooms in the house, can be adapted with the amenities and assistive technology that are
currently available in the market, in order to contribute to the aim of helping people to
stay at home, and to provide them with an acceptable quality of life. In addition, these
case studies show how important it is to study new ways of making the life of old
and/or disabled persons easier and better.
3.1. Luigi and His Wife
The actors: Luigi (96 years old) and his wife (82 years old) live on their own in an
apartment on the 4th floor, in a big city. Luigi has slowness in his movements, it is
difficult for him to get up from his seating, he feels back pain and also has oedema in
his legs. In spite of their advanced age, the couple lives alone without needing any help
in the activities of daily living. Luigi and his wife have a lucid mind and they are
looking for assistive devices to support the independent living for them.
The main purpose of the intervention described here, was to find out facilitation in
the bathroom, to make it possible for Luigi and his wife to carry out their every days
sanitation activities without additional help.
3.1.1. The Bathroom

The room is 160cm wide and 350cm long (see Figure 1). The door entrance is 70cm
wide and all elements are localized on the left side, in the following order: Bathtub
(170x70x90cm), washing machine (60x60x85cm), sink (70x50x85cm), bidet and toilet
bowl (height 42cm). The distance between toilet bowl and bidet is 40cm. Near the
toilet bowl there is a window and on the right side, along the wall there are two pieces
of furniture that contain their personal things.
2
Although the case studies are based on real life problems, actors names are fictional.
Figure 1. The Rest Room
3.1.2. The Every Day Activities in the Bathroom

Luigi moves independently inside his home. He uses a walker to support shifting.
When he comes near the bathroom door, he leaves the walker outside and uses different
support points (the door handle, the washing machine, the sink, the drawer handle) to
move to the toilet bowl. The height of toilet is lower than standard; it is including the
toilet seat- only 42 cm high. As the problems related to growing old increase, like
sitting down and getting up from the toilet, Luigi becomes more dependent on his wife;
she is pulling him with both hands, with the consequence of forcing her back and
risking to fall down together. Following a discussion with the couple about possible
solutions for these problems, it was decided to install a raised toilet seat, fixed on the
toilet bowl and with support bars alongside.
When Luigi gets up from the toilet bowl, holding on the radiator or supported by
his wife, he moves towards the sink, in order to continue his personal hygiene
activities. He sits down on the commode chair, equipped with a cushion, because the
hard surface causes pain and leads to skin problems in the sciatic region. The long
support bars of the chair allow for autonomy to get up alone. Luigi adopted this
solution about two years ago, when standing up became difficult for him.
When taking a bath, Luigi used to sit on the edge of the washtub, with his wife
sitting in front of him in a small chair; she took off his shoes, and helped him turn
inside the wash tub; he then turned himself hanging on to the water tap and she helped
him to lift his legs one by one and put them inside the washtub. On the bottom of the
washtub an anti slippery carpet had been placed. Supported by his wife, Luigi used to
get up and sit down on a fixed stool placed 15 cm below the edges of the washtub.
When finished bathing, they used the same procedures to get Luigi out of bathtub. For
the last six months Luigi has not used the washtub anymore, because he does not feel
safe due to the increased difficulties for him to move.
3.1.3. Adopted Solutions

The solutions that were discussed with Luigi and his wife and eventually installed in
their bathroom were:
1. Raised toilet seat with fixed support bars (Figure 2) to allow for stability and safe
sitting down and getting up.
2. Swivel washtub chair (Figure 3), suitable to overcome difficulties of positioning
inside of washtub. Characteristics:
x Seat width 46 cm.

x Swivel 360 with blocking option each 90
x Support bars
x Maximum weight 130 Kg.
Figure 2. Raised toilet seat Figure 3. Swivel chair
3.1.4. Experts Evaluation

At the first meeting, the couple was looking forward to find solutions to support their
daily activities in the bathroom, so it was necessary to understand their way of doing in
order to solve their problems. Therefore, the solutions that were proposed were based
on their expressed needs. It was very important for Luigi and his wife not to make
structural changes in the bathroom. The solutions should fit in the actual restroom for
instance by using innovative products or assistive technology.
Specifics: The toilet: Luigi considers the choice of a raised toilet seat 10 cm higher
to be perfect; it allows for maintaining the foot contact with the floor, but is easier to
get up from. The side handles, made of anti-slippery material and appropriately
designed, provide sufficient support for independent transfer to and from the toilet
bowl. He does not use the urinal anymore and his overall mobility has improved.
The sink: By using a commode chair placed near the sink, Luigi sits down to carry
out the daily morning activities of personal hygiene; he washes his face, brushes his
teeth, combs his hair and shaves without help. The use of the sink is considered
satisfactory by the couple.
The washtub: By using a swivel chair mounted on the washtub, Luigi is able to
wash himself with minimal assistance from his wife. They now feel safe and are
satisfied with this solution.
3.2. Silvias Bathroom
The actor: Silvia is a 59 years old woman. In July 2002 she has had a hemorrhagic
aneurysm resulting into compression of the brain with consequenting hemiplegia.
Following discharge from a Rehabilitation Center, she lives at home with her family.
The bathroom is for her currently the main problem to be addressed in order to take
control of the hygiene activities independently and without assistance.
Silvia is not able to walk and uses a wheel chair to move inside her home. She is
able however, to make transfers with a minimum of help (she needs somebody aside to
feel safe).
The apartment has two bathrooms; a small one, with a not accessible shower box
(Figure 4), and a larger one with a wash tub (Figure 5). After a thorough study Silvia
and her family decided to change the main bathroom to create an accessible room for
her and her needs.
3.2.1. Description of the Bathrooms

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

The toilet has a double function; as a normal toilet and as a bidet. It is about 50 cm.
high and it is provided with a front opening in order to allow for the washing
operations through the use of an external shower. The baked clay washbasin is
provided with rests for the elbows, splashboard borders and it has a particular hollow
shape which allows an easier approach for people on wheel chair. The washbasin has a
mixer with clinical lever. The box shower has a shower tray floor edge and a folding
seat with back and arms. An adjustable tilting mirror is fixed on the wall above the
sink. The room is spacious enough to move around inside it for a wheelchair user and
an assistant. Silvia now is able to use the bathroom safely and comfortably.
Figure 4. The small bathroom
Figure 5. The main bathroom

Figure 6. The adapted shower
Figure 7. The adapted toilet and washbasin

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

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

Table 2. Tinas bathroom
Part Success Failure Action Suggested

Sink Tina considers the No further action suggested.
accessibility, the
size, and height
adequate. The
mixer tap is easy to
handle and safe.
Light point It is located too high (150 cm) and Transfer the light point and
and it is not accessible. To turn on the electrical outlet at 100 cm high
electrical light she uses a walking stick but and at the left side of the sink
outlet the electrical outlet is not usable. because access is easier.
Toilet bowl The access is impaired on the left The wheelchair should be
side by the sink and on the right positioned transversally to the
side by the shower box. There is no WC to make it possible to slide
place to install support to the up to e from the WC. The height
transfers and it is too high for the of WC should be the same as the
user. The bowl has an opening at wheelchair. It is important the
the front side, designed to help support of handles during the
with cleaning, however, it creates transfers. WC without the front
instability. Tina has spastic legs opening. The bidet system
and the transfer can produce would be functional with a
contractions and she does not feel handle shower.
safe; she fears the empty space in
front of her while attempting
transfer. The back hole for the
delivery of cleaning water (the
bidet system) is not functional.
Shower Inability to enter the shower box The user decided to eliminate
box with the wheelchair because the the upsetting chair; alternatively,
floor of the shower box is lower 2,5 shes trying out a shower chair
cm. than the bathroom floor and with the big wheels to be able to
connected to the latter by means of manoeuvre on her own. By this
a short ramp. It was initially way, the transfer will be done in
designed to accommodate a plastic the bedroom (bed to shower
or a wooden carpet, but it has been chair and shower chair to bed).
not yet installed (when Tinas tries On the floor a plastic carpet will
to get in the wheelchair she tends be installed.
to tilt forward with the front wheels
pivoting side wards thus creating
instability). Tina feels like falling
and cannot make it without help.
Basket It is situated at the right side of the There should be 2 baskets
sink and the access is difficult (it is installed at both sides of the sink
too near to the corner). at the same high (100cm) but not
too far as it is now.
Door It is too narrow (60 cm.). It should be 10 cm. wider to
make the entrance and the exit in
the restroom easier.
Floor The user is happy No further action suggested.
with the non-
slippery tiled floor
Figure 9. Reaching for the light point and electrical outlet
4. Conclusions
From the viewpoint of 'adding life to years', studying socioeconomic inequalities can
give us clues about how much 'life' can still be added to the 'years' of elderly people
and persons with disabilities that are in a socioeconomically disadvantaged position
[22].
To finally conclude, the following part from an EC report [9] illustrates current
needs and future developments:
It is a feature of human life that the number of functional disabilities of all kinds tends
to increase with age. Sickness, risky lifestyles, accidents and socio-economic factors all
combine to create a 'disabling' process, which accumulates overtime. It is not
surprising, therefore, that young people make up 5% of the people with disabilities,
while people of working age constitute 46% and the remaining 49% of the people
declaring disability are over 60 years of age (ECHP Data). With increasing life
expectancy, prevalence of visual and hearing impairments also increase, as well as
neurological disorders such as Alzheimers disease and dementia. However, future
trends in age-specific risks of becoming hampered will be a key factor in the number of
elderly people that will be in need of assistance and care.
References
[1] World Health Organisation. Atlas of health in Europe. WHO Europe; 2003.
[2] European Commission. The 2009 Ageing Report. Underlying assumption and Projection
Methodologies. European Communities; 2008.
[3] EIM Business and Policy Research. The employment situation of people with disabilities in the
European Union. EC Employment and Social Affairs; 2001.
[4] European Disability Forum. Facts and figures about disability [Internet] 2009 [cited 2009 Jun 10].
Available from: http://www.edf-feph.org
[5] Brink CL van den, Tijhuis M, Kalmijn S, Klazinga NS, Nissinen A, Giampaoli S, Kivinen P, Kromhout
D, Bos GAM van den. Self-reported disability and its association with performance-based limitation in
elderly men: A comparison of three European countries. Journal of the American Geriatrics Society.
2003;51:782-788.
[6] Katz S, Downs TD, Cash HR, Grotz RC. Progress in development of the index of ADL. Gerontologist.
1970;10:20-30.
[7] Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of
daily living. Gerontologist. 1969;9:179-86.
[8] Strauss E von, Aguero-Torres H, Kareholt I, Windblad B, Fratiglioni L. Women are more disabled in
basic activities of daily living that men only in very advanced ages: A study on disability, morbidity,
and mortality from the Kungsholmen project. Journal of Clinical Epidemiology. 2003;56:669-677.
[9] European Commission. The social situation in the European Union. European Communities; 2003.
[10] Mougias A. Handbook on Alzheimers disease and other dementias [Greek]. Mendor Publications;
2003.
[11] Kattainen A, Koskinen S, Reunanen A, Martelin T, Knekt P, Aromaa A. Impact of cardiovascular
diseases on activity limitations and need for help among older persons. Journal of Clinical
Epidemiology. 2002;57:82-88.
[12] Congdon N, OColmain B, Klaver CC, Klein R, Munoz B, Friedman DS, Kemben J, Taylor HR,
Mitchell P. Causes and prevalence of visual impairment among adults in the US. Archives of
Ophthalmology. 2004;122:477-485.
[13] Buch H, Vinding T, La Cour M, Appleyard M, Jensen GB, Nielsen NV. (2004). Prevalence and causes
of visual impairment and blindness among 9980 Scandinavian adults: the Copenhagen City Eye Study.
Ophthalmology. 2004;111:53-61.
[14] Brunel University. Definitions of disability in Europe. A comparative analysis. Report. European
Commission, Employment and Social Affairs; 2002.
[15] European Commission. Employment-HORIZON; Better Employment Opportunities for People with
Disabilities [Internet]. 1996 [updated 2010 Jun 30]. Available from:
http://ec.europa.eu/comm/employment_social/equal/index.cfm
[16] LaPlante MP. Health Conditions and Impairments Causing Disability. Disability Statistics Abstract.
1996; No 16.
[17] Kaye HS, LaPlante MP, Carlson D, Wenger BL. Trends in Disability Rates in the US, 1970-1994.
Disability Statistics Abstract. 1996; No 17.
[18] Kennedy J, LaPlante MP, Kaye HS. Need for Assistance in the activities of daily living. Disability
Statistics Abstract. 1997; No 18.
[19] Jensen L, editor. Go for it! A user manual on assistive technology. Milano: Eustat Consortium,
European Commission; 1999.
[20] Andrich R, Besio S, editors. Assistive technology education for end-users - guidelines for trainers.
Milano: Eustat Consortium, European Commission; 1999.
[21] Andrich, R. Being informed, demanding and responsible consumers of assistive technology: an
educational issue. Disability and Rehabilitation. 2002;24:152-159.
[22] Huisman M, Kunst AE, Mackenbach JP. Socioeconomic inequalities in morbidity among the elderly; a
European overview. Social Science and Medicine. 2003;57:861-873.
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-141
Experience of Testing with Elderly Users

Gunilla KNALLa,1, Panayota SOURTZIb and Joseph LIASKOSc
a
Certec University of Lund, Lund, Sweden
b
Hellenic Association of Gerontology and Geriatrics and Faculty of Nursing
University of Athens, Athens, Greece
c
Laboratory of Health Informatics Faculty of Nursing University of Athens, Athens,
Greece
Abstract: The experiences and knowledge gained from user tests with primary
(elderly) and secondary (caretakers) users carried out at two of the five different
User Research Bases (URBs) in the FRR Project, located in Lund and Athens,
have been analyzed for commonalities and differences. Aim of the tests was to
actively involve users in all the phases of development of the FRR, including
needs assessment, actual measurements, reporting of requirements, and evaluation
of designed components. Working with people with different abilities proved to be
a challenging research experience in both URBs. In-depth understanding about
what test persons need, think and feel about their difficulties in daily life was only
possible through recognition of the importance of the role of test persons in this
interaction. Valuable experience was gained about how to manage difficulties
during interaction with test persons and prototypes as well as working in a
multidisciplinary team and in collaboration with other URBs from different
scientific and cultural backgrounds. It is concluded that rest rooms of today are
often unnecessarily inaccessible and the test results of the FRR project have
increased the knowledge on how to improve the design of toilets; and this,
comparing the results from the different URBs, does not really seem to differ from
culture to culture.
Keywords. Elderly, Toilet, Observational Study, Laboratory Testing
1. Introduction
The User Driven research model has been instrumental in the FRR project as in all
projects funded by the EC Quality of Life Programme [1]. The primary end users in
this project were older people and people with disabilities; secondary end users were
health care professionals and caregivers. Experts were also asked to participate in the
different stages of the research and development in order to enrich the data collected
from users and the proposals made by the researchers.
User Research Bases (URBs) were developed in order to actively involve users in
the participating countries [2]. These bases included the research team and
representatives of the users primary, secondary and experts. The FRR prototypes,
which were tested each time were the invaluable material part of each URB.
1
Corresponding Author: Gunilla Knall, Certec, LTH, P.O. Box 118, S-221 00 Lund, Sweden; Tel: +46 46
2220195; Fax: +46 46 2224431; Email: gunilla.knall@certec.lth.se; Website: http//www.english.certec.lth.se
142 G. Knall et al. / Experience of Testing with Elderly Users
Primary users in this project were older people with various limitations in activities
of daily living and persons with disabilities [3]. Primary users were all volunteers,
although recruitment followed different approaches in each URB.
Secondary users were caregivers of older people and persons with disabilities, as
well as professionals who provided direct care, such as nurses, physiotherapists,
occupational and therapists. In most cases, secondary users came from the same
institutions from where each URB recruited their primary users and very often they
were instrumental in informing and supporting primary users.
Users in this project were actively involved as equal partners and influenced the
prototype design and development not only by presenting their needs and evaluating
the components presented to them, but also by their insightful comments during all
research stages. Special means and techniques with the intention of enhancing user
participation and contribution were tested, developed and implemented, in the process
and are described in other chapters [4, 5].
Ethical reviewers ensured that all steps recommended for recruitment and
participation of users were seriously taken into account, especially because the issues
involved in this project are of a very sensitive nature for the participants [6].
The aim of the tests was to actively involve users in all the phases of development
of the FRR, including needs assessment, actual measurements, reporting of
requirements, and evaluation of designed components.
In this chapter the experiences gained from two of the URBs, one from the north of
Europe and one from the south, are presented and discussed in order to give useful
information for future similar efforts.
2. Experience of Testing with Elderly Users in Sweden
2.1. Why Testing?
You cannot know until you have tried! This is the truth in any project, so also in our
FRR project aiming at an intelligent toilet specially designed for elderly and disabled
people. See figures 1 and 2 for an impression of the test environment.
2.2. How Did We Choose the Test Persons?
One of the partners in the FRR project, EURAG, (European Federation of the Elderly)
is an umbrella organisation for elderly people in Europe. They have a wide network of
contacts in most European countries but not in Sweden. So we had to think of another
way to find testers in our geographical neighbourhood. Our concerns were to find
testers who represented a wide range of disabilities as well as different lengths, weight
and gender. It was also important that they were not dependent on us in any way. Our
test station in Lund, Sweden was the only one where the consortium was able to test
different kinds of illumination; therefore we were particularly interested in people with
visual impairments. At this stage we had created the User Board consisting of a group
of people with both professional and personal experiences in the field of disabilities.
We asked them to provide us with possible test persons. The criteria were: elderly with
some kind of disability and preferably good verbal skills. When our User Board
members found these people they asked them if they would be willing to participate in
G. Knall et al. / Experience of Testing with Elderly Users 143
a research project like ours. If the answer was yes, we then contacted them and this is
how we found our 12 test persons.
All contacted persons answered that they were willing to participate in the trials.
Some of them expressed their happiness that somebody wanted to take this issue about
toileting seriously and carry out research on the topic, and thus they were pleased if
they could contribute.
Figures 1 and 2. Pictures form the tests in Sweden
2.3. Information about the Project and the Tests
All five URB test stations used the same kind of information. It was sent out at least 2
weeks in advance and contained:
x Project presentation; images of the test station (in this case, Lund)
x The testing procedure
x A city map with directions
x Instructions for the test persons
x An informed consent form.
The explicit purpose of the informed consent form was to ask the expected test person
if they felt fully informed and if they agreed to participate in the research or not. Later,
when the testers arrived for the first test trail, we also read through it together to make
sure that they agreed to the contents.
The information kit was highly appreciated by the test persons. The official FRR
logo on the front page and the way the information was organized looked nice and gave
a confident impression.
2.4. Preparations
To carry out these tests, we had to build the station and equip it with the test objects.
We also had to prepare ourselves mentally for the procedure. To give ourselves the best
chance of success we had to be very thorough when deciding how the testing should be
done. Our test persons were generally old and frail and therefore the tests should not be
too physically or mentally demanding.
2.5. Atmosphere
It was of paramount importance that the test persons felt at ease in the physical
environment of the test area and with people around them, so their thoughts and
reactions could be as natural as possible. To create the relaxed atmosphere we required,
we met all the test persons at the main entrance and walked casually with them to
where the lab is located enjoying some idle small talk along the way. To show that we
were in no hurry we always had fruits and drinks available whilst they were in the
laboratory and the test persons were encouraged to help themselves during their visit.
2.6. Security
In a test situation there is always a risk of component failure. To reduce that risk we
were very careful when assembling our equipment and it was always double-checked
before being put in use. During the tests the area used was kept free from unnecessary
tools and equipment to avoid accidents. As en extra precaution we took out an
insurance policy to cover our volunteers against injury. This covered the entire visit
including time in transit.
2.7. Influence on the Testing
Carrying out tests like these requires objectivity from the test leader; on the one hand
he/she must create a pleasant atmosphere and on the other he/she must not be so
personally involved that the test persons results are affected. We really think the risk
that the test persons eagerness to please by giving the right answers should not be
underestimated and feel that we should emphasised this as a possible source of error.
2.8. Did They Come Back?
We were impressed by the effort made to attend our test sessions but were forced to
increase the number of test persons by 4 to achieve the numbers we desired.
2.9. What Did We Learn?
x We learned that our method for choosing test persons was very successful. It
resulted in a fantastic mixture of testers who had a lot to tell us. They were
unbiased and were capable of communicating their opinions on all the topics they
were asked.
x We experienced that the two hours testing time was just right. We never had the
feeling that they were stressed or that two hours was too much for them.
x The test persons seemed to be very engaged in the project and they also seemed to
look upon their own contribution as important for the research, and they liked to be
asked.
x We also learned that the way we carried out the testing, by not interrupting the
testers but following their thoughts as they came during the session, gave us more
input than the questioning afterwards.
x Sometimes the test persons had a need to concretise their opinions and they were
then given paper and pens. It would have been much better if we had had small
models of the test items that could be moved around.
x It would also have been much better if we in advance had thought of providing
them with coloured images of the whole FRR station to take with them in order to
facilitate their creative ideas when they were back home.
Without the test persons we would never have discovered that a divided toilet seat
is very uncomfortable and even dangerous for paralysed people, because it was
possible for their legs to fall into the gap.
We thought it would be of interest for people who use a catheter for urinating to
have a good spotlight above the toilet, but none of our testers really needed that.
We thought that adjustable lighting was very important, and it was. However, we
did not realised just how important. The very bright light was actually painful for one
of our test persons, while others really appreciated it.
Most of our test persons appreciated the adjustable toilet as expected. What we
learned was that they did not understand that it could be used as a raising help if you
have weakness in your legs. When we pointed this out to them it was greatly
appreciated.
Small things like a place to put your cane or your handbag are as important as the
technically advanced aspects of the toilet. Support bars are essential and they must not
be forgotten in a project like FRR. Spontaneous comments we heard from the testers
when entering the test room were more often about the nice, clean appearance rather
than the high tech utilities.
There should be at least three persons from the research team present at each test
session: one test leader guiding the test person through the procedure; one who is
responsible for all technical equipment including documentation through photography
and video recording and one expert observer.
3. Experience of Testing with Elderly Users in Greece
3.1. User-Driven Research Base in Athens
In the framework of the FRR project a user-driven research base [7,8] was established
in Athens. Its aim was to recruit testers potential users of the friendly rest room being
developed and organise for them the appropriate procedure for using and testing the
components of the different FRR prototypes installed in the research base. The FRR
prototypes, i.e. the models of the friendly rest room with the different components
provided by the designer and manufacturing partners of the consortium, were installed
in the building of the Faculty of Nursing of the National and Kapodistrian University of
Athens [8,9] The decision to install the prototypes in that building was made mainly for
two reasons. On the one hand, the Faculty of Nursing is an educational institution that
educates and trains nurses, who are one of the major groups of the secondary users
interested in this project, and an important link with the primary users of the FRR,
which means that they can be easily informed, activated, and recruited for the aims and
needs of the FRR research base. One the other hand, that building is the working
environment of the researchers of two of the partners of the consortium, which means
that the testing procedure for the users could be more efficiently prepared, organised
and implemented.
The tests carried out in the research base followed different phases, according to
the different FRR prototypes installed. The testing station of the initial tests was
different from that of the following ones. The first station was installed in a relatively
small room with little space for the users, but with the installed prototype being fully
functional, due to its connection to the water supply and drainage. On the contrary, the
location of the second station, where the next prototypes were installed and tested, had
dimensions large enough for the toileting needs of the users, but the water supply and
drainage were absent. This meant that the tests conducted at the second station more
resembled laboratory conditions [9,10,11]. See figures 3 and 4 for an impression of
the test environment.
3.2. Recruitment of Users
One of the initial aims of the research base was the recruitment of primary and
secondary users who would visit the FRR station, and test the different prototypes that
were installed. A User Board was created in order to facilitate user recruitment. It
consisted of a small group of people who were professionally engaged in the provision
of care to elderly and people with disabilities, or they also experienced limitations as
elderly or people with disabilities themselves. The User Board played an important role
in advising the research team and counselling in aspects of the prototypes installation
and the testing procedure followed. It also assisted in the recruitment of primary users,
at least in the first phases of the tests. It was decided that the primary users were to be
mainly elderly users, at least 65 years old and older, with limitations in mobility, either
walking with aid or not. Moreover, the primary user group included younger people
with visual limitations, mobility disabilities and use of a wheelchair. The test persons
participate on a voluntary basis since they could not be paid for their contribution, apart
from the expenses of their transfer to the test station and back home [9,10,11 12].
Most of the older people participating in the tests came from the KAPI network.
KAPI is a centre where elderly people can assemble, socialise, work creatively, and be
entertained. These centres are widespread in Greece, where a significant percentage of
elderly people prefer to visit them and actively participate.
All the users who were requested to participate in the tests responded positively
and they were very willing to participate. Most of the users who participated in the first
phase of the tests were asked to participate in the following ones as well. Thus, some of
the users participated in all phases of the tests, some in two or three, and others in only
one. Taking into account that four phases of tests were conducted in total, each of them
tested different components of different FRR prototypes. In all testing phases around
40 different persons participated.
3.3. Informing Users about the Tests
A new primary user was requested to visit our station and participate in the test, usually
through the nurse, physiotherapist, or occupational therapist that was taking care of him
or through the administration staff of the KAPI. An information kit accompanied by a
formal invitation letter to participate in the tests was sent to the user, and his/her visit
was scheduled for the following one or two weeks. The information kit included brief
information about the FRR project; information about the Athens FRR research base
with an map of the area; a floor plan of the building and the place of the testing station;
images from the installed prototype with a short description of its functions; description
of the testing procedure, its steps and instruction for the test persons. The transfer of
most of the test persons to the testing station and back to their residence was arranged
for the scheduled day and time and a taxi or the car of one of the participating
researchers was used. Before the user started the testing, a consent form was also
signed, in order to ensure that the tester had been informed sufficiently about the
projects aims, the prototypes functions, the testing procedure, and that he fully
accepted to participate in the test.
Figures 3 and 4. Pictures form the tests in Greece
3.4. Preparing and Conducting the Tests
Each test was conducted by the test person, with or without the attendance and or
assistance of his physiotherapist or occupational therapist, while 2-3 members of the
research team were giving the instructions, observing the test and interviewing the user.
The new users also answered the two questionnaires developed in the project: the first
one included questions about their personal health condition, and the common
problems they had to face when using an ordinary toilet; the second one was about their
personal hygiene habits while using the toilet [7,12,13,14]. Each test lasted around two
hours in most cases.
The researchers had to be prepared in such a way as to keep an objective attitude
towards the user and the test, guide the user effectively throughout the testing
procedure, make the appropriate questions and observations to the user, and help the
user avoid difficult, insecure, or even dangerous situations (e.g. potential accidents
during the test). In order to avoid such insecure situations the installed prototype had
been thoroughly checked at its time of installation, and carefully inspected before each
test conducted. Sharp surfaces were rounded, or additional soft materials were used to
cover them.
It was very important that the researchers create a friendly, warm and relaxing
atmosphere for the participants. The users were given attention and time by the
researchers to feel relaxed, express themselves and talk about their health conditions,
while being offered refreshments during the test. The test persons appreciated the
friendly manner, and hospitality of the researchers, the detailed instructions provided,
and the well-organised process of the tests. Most of them agreed to be photographed or
videotaped for research purposes as was planned in the different phases of the project.
3.5. Lessons Learned
We gained important knowledge about what the participating older people need, think,
and feel about their difficulties in daily life and daily toilet usage. We developed and
also helped the test persons to develop a positive attitude towards their problems and
needs, and especially towards the private and sensitive matter such as using a toilet.
This was mainly achieved through the discussions and interviews with the users, while
trying to keep as open-minded as possible, objective, and unbiased towards the
sensitive issues of toileting habits. In this issue, the advice and guidelines of the ethical
team participating in the project played an important role.
The elderly users were willing to participate in the testing process, and helped us to
find ways and solutions for their needs. There were practically no refusals by any of the
users to our invitation to participate in the tests; no reluctance at all by them to comply
with any instructions, prompts and rules during the test; and a great willingness to
answer to any question we asked. Most of the participants did not have any objections
to answering the questionnaire about their personnel habits while using the toilet, even
though some questions might be considered too private or might place the user in an
uncomfortable situation.
The users, who tested the different installed prototypes, had a great range of health
problems and limitations, mainly in mobility but also in vision and hearing abilities.
There was an effort to view each test person and each disability as a special case, which
requires a different approach, care and provided solution by the prototype tested. The
test persons helped us to realise uncomfortable, poor, insufficient, unnecessary, useless
or unsafe situations and parts of the prototypes components. This realisation led to
specific efforts for the improvement or adjustment of these unsuitable conditions in the
tests of the next phases.
Most of the users found the testing procedure very interesting. In general, the
prototype they tested seemed to be very interesting, with many features, very helpful,
very innovative and up-to-date; but perhaps a bit complicated in some of its functions
for the elderly people, since it would be necessary for them to be trained first. They
also expressed their doubts with regard to the probable purchase and installation of
such a prototype at their home due to the high price they thought it would cost.
We learned to work with older users and persons with various disabilities in an
environment where professionals from different specialties (nurses, physiotherapists,
occupational therapists, sociologists, designers, engineers, manufacturers, etc.) were
cooperating towards a common aim: to improve the toilet facilities according to the
multifaceted needs of older people and persons with disabilities. Of course, in such an
environment, where many people had to cooperate and the contribution of each of them
was very important for the final result, obstacles, delays, or complaints were inevitable;
moreover external elements or unpredictable situations also negatively influenced the

scheduled work and tests. The most apparent example of such situations was bad
weather on some scheduled testing days, which made it impossible for the users to be
transferred to the testing station. Another example was unexpected cancellations of a
specific test by users due to health problems, holidays, etc.; or a delay in the delivery or
installation of specific elements of the prototype.
However, in all these unplanned situations all participants displayed a positive
attitude towards finding alternative ways to overcome them. Eventually, our
cooperation with all participating people in the process of the prototypes testing was
very effective, productive and successful. Moreover, our participation in this process
was a great experience, indeed.
4. Conclusions
Working with people with different abilities was a great challenge within the FRR
project for all participants, users and researchers alike. Researchers had the opportunity
to gather a huge amount of information regarding users needs and expectations, which
however, they needed to communicate efficiently to the other participants in order to
use it constructively. Users on the other hand had to overcome any difficulties they
faced in their every day life activities in order to participate in the tests, as well as to
bear with the researchers very detailed questions. Researchers who do not always had
much experience on how to respond to their specific needs, although they tried their
best in all instances. What we have nevertheless arrived at is that the fundamental
human needs are global or at least deeply human.
The starting point for the project was that people need physically accessible toilets
and when the bodys abilities diminish, this can to a certain extent be compensated for
with advanced technology. However, it must be highlighted that the need to feel secure
and safe, which can be achieved to a great extent with technical assistance as well, is
equally important as that a rest room is hygienic, comfortable and pleasing in
appearance.
In a project such as this with participants from so many different countries and
cultures, it is natural that there would also be different approaches and that
disagreements would arise in how to manage a research project that deals with such a
delicate topic as how people behave in a rest room. During the tests difficulties that
arose from the prototypes themselves had to be managed in order that the tests be
conducted according to the protocols decided inside the consortium. This was
necessary to facilitate data collected to be comparable among different centres and the
outcomes resulted from the collected data to be easily interpreted and used from
researchers from different professional and scientific backgrounds.
We have learned from our test persons that the rest rooms of today are often
unnecessarily inaccessible and through the results of the FRR project we have
increased the knowledge base for how to design as good a rest room as possible; and
this, actually, does not really differ from culture to culture.
Finally, the collaboration that was achieved through the FRR project, although it
was very challenging it was fruitful and a valuable experience for future activities for
all involved.
References
[1] Technical Annex, Project QLRT-2001-00458, Friendly Rest Room for Elderly People. Quality of Life
and Management of Living Resources, Key-Action 6: the Ageing Population and Disabilities. FRR
Project document; 2003.
[2] Svensk A, Nordgren C, Magnusson C, et al. FRR Deliverable 4.2.1. and 4.2.2.: Report on critical
design review Engineering prototype and draft requirements and definition report. FRR Project
document; 2005.
[3] Sourtzi P, Menezello T. Elderly and People with Disabilities - Limitations in their Everyday Life. This
Volume.
[4] Daye C, Teissl G. FRR Deliverable 4.1.4.: Report on Module Approval. FRR Project document; 2005.
[5] Alm N, Badon Ghijben N, Bruin R de, et al. FRR Deliverable 4.3.1. and 4.3.2.: Critical design review
on the alpha prototype. FRR Project document; 2005.
[6] Rauhala M, Wagner I. FRR Deliverable 4.1.2.: Guidelines and Report on Ethical Issues. FRR Project
document; 2005.
[7] Panek P, Neveryd H, Zagler WL. The FRR Project: Developing a More User Friendly Rest Room. In:
Craddock G, McCormack L, Reilly R, Knops H, editors. AAATE 03. Assistive Technology Shaping
the Future; 2003 Mar 8-9; Dublin, Ireland. Amsterdam: IOS Press; 2003. Vol. 11: p.678-682.
[8] Neveryd H, Molenbroek JFM, Panek P. FRR Friendly Rest Rooms for Elderly and Disabled Persons
A User Centered R&D Project. Gerontechnology 2002 The International Society for
Gerontechnology Conference. 2002 Nov 9-12; Miami Beach, Florida. Eindhoven: International Society
for Gerontechnology; 2002 [Congress issue]
[9] Sourtzi P, Panek P, Liaskos J, Mantas J. Friendly Rest Room (FRR): Developing the concept and the
product. Proceedings of 13th Alzheimer Europe Conference - 3rd Hellenic National Alzheimer Disease
and Related Disorders Conference. Sciences and Care. 2003 Jun 12-15; Thessaloniki, Greece.
[10] Liaskos J, Tolika F, Sourtzi P, Mantas J. Designing friendly rest rooms for the elderly and for the
people with special needs. Proceedings of the 5th Panhellenic Nursing Students Conference. 2003 Dec
12-14; Athens, Greece; 2003: p.42-43.
[11] Liaskos J, Tolika F, Sourtzi P, Mantas J. FRR Shaping rest rooms for older people and persons with
disabilities. Proceedings of the 8th National Conference of Gerontology and Geriatrics. 2004 Jan 22-24;
Athens, Greece.
[12] Liaskos J, Tolika F, Sourtzi P, Mantas J. Developing and evaluating prototypes of a friendly rest room
by elderly and persons with disabilities the FRR project. Proceedings of the 5th Panhellenic Nursing
Students Conference. 2004 Dec 10-12, 29.
[13] Panek P, Edelmayer G, Magnusson C, Mayer P, Molenbroek JFM, Neveryd H, Schlathau R, Zagler WL.
Investigations to develop a fully adjustable intelligent toilet for supporting old people and persons with
disabilities the Friendly Rest Room (FRR) Project. In: Miesenberger K, Klaus J, Zagler WL, Burger
D, editors. Proceedings of the 9th ICCHP Conference. Computer Helping People with Special Needs.
2004 Jul 7-9; Paris, France. Berlin Heidelberg: Springer-Verlag; 2004, Lecture Notes in Computer
Science Vol. 3118: p.392-399.
[14] Joel S, Alm N, Egger de Campo M, Gregor P, Hands K, Hine N, Panek P. Eliciting sensitive
information about toilet needs using a computer based interview [poster presentation]. Proceedings of
the 7th European Conference for the Advancement of Assistive Technology. 2003 Aug 31 - Sep 3;
Dublin, Ireland.
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-151
Laboratory Tests of an Adjustable Toilet

System with Integrated Sensors for
Enhancing Autonomy and Safety
Paul PANEKa,1, Georg EDELMAYERa, Peter MAYERa,
and Wolfgang L. ZAGLERa
a
fortec Research Group on Rehabilitation Technology
Institute integrated study Vienna University of Technology, Vienna, Austria
Abstract. This chapter describes the five different generations of toilet prototypes
which have been installed and tested in a laboratory environment in Vienna during
FRR (Friendly Rest Room) project. It outlines the data measured during tests with
older and disabled persons and their care persons. The FRR prototypes have been
equipped with a PC based control unit, voice input and output, contactless smart
card technology and several sensors for estimating the user's intention and for
recognizing potential falls of the user in the toilet area. The toilet components have
shown to be very useful for disabled and older persons during extensive tests in a
laboratory setting.
Keywords. Toilet, RFID, Older Persons, Assisted Transfer, Ambient Intelligence
1. Introduction
In the framework of the Friendly Rest Room (FRR) project the consortium has carried
out various research, design, development and evaluation activities following a user
centred approach [1,2,3]. Among these multidisciplinary tasks the user tests which
were done on a regular base at up to 5 user test sites in Europe have played a decisive
role. The test participants (older people, persons with a disability, carers) were asked to
interact with new components of the FRR toilet system and to comment on them.
Between September 2002 and February 2005 the FRR consortium has realised more
than 200 test runs in laboratory environment (see Table 1). Additionally, a field test [4]
in a day care centre with selected toilet components was carried out between December
2004 and February 2005. This chapter focuses on the FRR prototypes located in
Vienna, while four other test sites were active in parallel to Vienna [5]. The objective
of this chapter is to outline the iterative prototypes and to discuss the results gained
from the user tests in Vienna. The test site in Vienna focused on user groups of persons
with impairments in lower parts of the body. Thus, the selection of the FRR
components to be tested in Vienna was done according to the specific needs of this user
group. The overall aim was to develop and evaluate new methods and tools in order to
1
Corresponding Author: Paul Panek, fortec - Research Group on Rehabilitation Technology, Institute
integrated study, Vienna University of Technology, Favoritenstrasse 11/029, A-1040 Vienna, Austria;
Email: panek@fortec.tuwien.ac.at or fortec@fortec.tuwien.ac.at. Web site: http://www.fortec.tuwien.ac.at/frr
Tel: +43 1 58801 42913, Fax: +43 1 58801 42999
152 P. Panek et al. / Laboratory Tests of an Adjustable Toilet System with Integrated Sensors
enhance the autonomy and safety of primary and secondary users at the toilet. For more
details regarding the concept and the realisation of the user involvement please refer to
[6].
Table 1. Number of Person Tests per prototype and per test site carried out by FRR consortium 2002-2005
Prototype AT SE GR IT NL total person tests

Generation Vienna Lund Athens Milan Delft
1st 12 12 8 - - 32
2nd 19 14 9 - - 42
3rd 5 7 - - - 12
4th 12 11 10 8 15 56
2
5th + Real life test 41 10 33 10 19 113
Total Person Tests 89 54 60 18 34 255
2. Methods
The first prototype (PT1) was installed in a test booth which was set up in a laboratory
room (see Figure 1). This setting has been extended when enhanced prototypes arrived
for testing.
Figure 1. Left: First Prototype (PT1) tested in Sept 2002. Right: Third Prototype (PT3) tested in January
2004 in laboratory environment
2
Additionally to the laboratory test a field test with selected FRR components took place in Vienna. 29
primary users and 12 secondary users carried out 316 toilet sessions using a new toilet system in the daily life
of a day care centre over a period of two months [4,20,25].
P. Panek et al. / Laboratory Tests of an Adjustable Toilet System with Integrated Sensors 153
As mechanical base of the first prototype an existing award winning product from
commercial partner Clean Solution Kft. [7] was used. This base construction was
extended iteratively during the different phases of the project (see Table 2). In 2004 it
was replaced by a new construction which was tested as final research prototype by the
consortium. After completion of the FRR project (March 2005) it was made final for
production by Clean Solution Kft. A first basic commercial version [7] is on the market
since January 2006. In the following sections the main features of the research
prototypes (2002-2005) are being described.
Table 2. Adjustability of height and of tilt of bowl and of position of horizontal grab bars
Prototype seat seat seat seat bars min bars max bar bar
Generation min max min. max horiz. horiz. min max
height height tilt tilt distance distance height height
[cm] [cm] [deg] [deg] [cm] [cm] [cm] [cm]
1st 47 76 0 +7,5 63 85 80 149

nd
2 36,5 66,5 -12 +10 53 75 80 149
rd
3 36,5 66,5 -12 +10 53 75 80 149
th
4 44,5 77,5 -1,5 +9 69 77 78,5 111,5
5th 44,5 77,5 +2 +11,5 69 79 79,5 112,5
Table 3. Average velocity and duration for changing position of toilet seat and grab bars of PT1
Part Duration Average velocity Duration Average velocity (50kg

(no load) load on part)
Bowl up 27 s 1,07 cm/s 28 s 1,03 cm/s

Bowl down 26 s 1,12 cm/s 26 s 1,15 cm/s
Bowl tilt forward 6s 1,33 /s 6s 1,33 /s
Bowl tilt backwards 6s 1,33 /s 6,5 s 1,2 /s
Supporting bar up 52 s 1,35 cm/s 57 s 1,23 cm/s
Supporting bar down 49 s 1,43 cm/s 47 s 1,49 cm/s
2.1. Adjustable Position of Toilet Bowl and Grab Bars
Already the first prototype provided several degrees of freedom in adjusting the
mechanical properties of the toilet. It was possible to change the height of the toilet
bowl between 47 cm and 76 cm and to change the tilt between 0 and 7.5 degrees (see
Table 2). Additionally, the horizontal bars left and right of the toilet seat could be
moved up and down within the range of 80 to 149 cm independently from the position
of the toilet bowl. This adjustability was realised via actuators (motors) even with load
on the toilet (e.g. a person is sitting on the toilet bowl while position is changed). Table
3 shows velocity of the movement with and without load on the toilet bowl and the
average duration of the movement. Additionally, the horizontal distance between the
two bars could be changed within a range of 63 to 85 cm manually.
The later prototypes had some of the properties changed due to users' comments
and due to mechanical adaptations and modifications of the construction (see Table 2).
For PT2 and PT3 a mechanism for a manual tilt offset was used which extended the
possible range of tilt and allowed also negative tilt up to minus 12 degrees. This
mechanism was replaced in PT4 by a fully actuator driven mechanism with a range of
minus 1.5 to plus 9 degree. PT1, PT2 and PT3 provided a mechanism for changing the
horizontal distance between left and right bar manually. In PT4 the horizontal distance
between the bars was fixed, but new types of bars were introduced providing a larger
distance between the upper tubes of the bars and a shorter distance between bottom
tubes of the bars. The first 3 prototypes had a possibility to change the vertical height
of the bars via dedicated actuators independently from the height of the toilet bowl.
These dedicated actuators were removed in PT4, the vertical height of the bars can only
be changed synchronously with the height of the toilet bowl.
Figure 2. Three different types of seats of PT2 tested in June 2003, top view (top line), side view (bottom
line). CP indicates the virtual Central Point.
2.2. Adjustable Grab Bars
Horizontal bars are an important means for assisting transfers and for increasing
stability of ones own body. Several iterative versions were provided and tested. The
horizontal bars can be folded up, are automatically locked in the horizontal position
and are providing a friction hinge. Additionally, new types of vertical bars which can
be moved around a fixed axe were introduced as part of PT5 (see Figure 7).
2.3. Toilet Seat
Several types of seats were tested as part of PT2 (see Figure 2). A seat with integrated
transfer wings on both sides was developed further in PT4 (see Figure 4) and PT5 (see
Figure 7). The overall dimensions of the transfer seat in PT5 are; width: 120 cm, depth:
39.5 cm. The purpose of this seat is threefold: (a) to provided place for storing personal
belongings, (b) as means for transferring from / to wheelchair and (c) possibility to
hold one self in order to increase body stability.
2.4. Control Unit and Control Software
A standard desktop PC with 512 MB RAM and AMD XP2000+ processor with
Microsoft WindowsXP SP1 (later SP2) operating system serves as hardware for the
control unit. On this PC the FRR control and interface software is running. It is
equipped with special interface cards (counter card, ADC - analogue digital converter
card, binary input/output card) for reading various sensor data and for steering the
actuators. Additionally it interacts with other intelligent sub systems like the User
Interface demonstrator [8] and the RFID reader / writer. It provides continuous logging
functionality by saving all sensor data each 100 ms. This creates important data records
for analysis. The logged data can be synchronised with the video recordings of the user
tests in laboratory. Logged data also can be visualised as shown in Figure 3. Remote
maintenance functionality via the internet is available. Software modules for speech
input and speech output are included. For commercial product an embedded PC is
planned to be used.
2.5. Sensors
The prototypes in Vienna were equipped with several types of sensors serving for
different purposes. Firstly, it is necessary to measure the current position of the toilet
system, e.g. the current height and tilt of the toilet bowl. Secondly, it is important to
recognise potentially dangerous situations and thirdly it is interesting to recognise the
users intention when interacting with the toilet system.
2.5.1. Sensors for Measuring Toilets Position

The task of these sensors is to signal changes regarding actual height and actual tilt of
the toilet to the control unit. For the first prototypes shaft encoders were used, later they
were replaced by wire sensors. The sensors are connected to counter cards located
inside the FRR control unit. It is important to note that the sensors are providing
accurate relative information regarding height and tilt. This means that up to date
information regarding absolute height and absolute tilt needs to be calculated by the
control unit. The control unit also transfers the counter signals into units of cm and
takes care for the calibration of the sensor system after power up of the whole system.
Figure 3. Example of a visualisation of a log file showing the height and tilt during a user test run
2.5.2. Sensor for Measuring Distance to Users Back

An ultrasonic sensor measured the distance between the cover of the toilet system and
the back of the user. The sensor was fixed in the middle of the toilet, 40 cm higher than
the upper edge of the toilet seat. The motivation for introducing this sensor was to
analyse the changes in the measured distance regarding an automatic recognition of the
users intention to stand up. In this case, the toilet could optionally assist the user in
getting up by moving into a higher position.
2.5.3. Sensors for Measuring Distribution of Users Weight on Toilet

Strain gauge sensors were provided to measure the forces in the construction of the
toilet system due to the users weight. The purpose of these sensors is to gain more
insight into the distribution of weights during a toilet session. Furthermore, the analysis
of these data should allow deriving information of the users intention to stand up. In
addition to the strain gauge sensors 2 load cells were integrated in order to compare
data from load cells with the data from strain gauge sensors [9].
2.5.4. Sensor System for Fall Recognition

Falls are an important issue in the area of toilet, especially for fragile older people.
Therefore sensors which are able to recognise falls are of high interest, as such sensors
could play an important role for triggering emergency calls even in those cases where
the fallen person has lost consciousness or is not able to move herself / himself [10]. It
goes without saying that prior to fall recognition the prevention of falls has to be done
[11]. Unfortunately, falls can happen even if fall prevention has been implemented to
the most reasonable or feasible extent.
The FRR prototype provides an optical sensor which is able to recognise falls
which might have occurred. The fall recognition provides a binary output: a fall most
likely has happened or a fall most likely has not happened. The sensor signal needs to
be combined with the data from the FRR control unit which needs to know if
somebody is in the room or not. In contrast to pressure sensitive mats this type of
sensor can adapt itself autonomously to possible changes in the room.
2.5.5. Sensor for Triggering Alarm Calls

A voice level controlled sensor allows the user to trigger an alarm / emergency call by
shouting. This is language independent but requires a certain volume of speech which
needs to be exceeded.
2.6. Voice Input
In addition to the conventional hand held remote control and in addition to the touch
screen user interface demonstrator which is described in more details in [8,9] a voice
control input module [12] was integrated (see Figure 4). It is speaker independent and
was tested for German language. This feature allows controlling the toilet system via
spoken commands in the user's or care person's native language. A set of pre-defined
phrases is recognized and used to control functions of the toilet. Voice control is
providing an additional way of controlling the toilet. It is expected to be useful in
situations when the user does not have the possibility to press a button (e.g. when doing
a transfer) but also for care personnel while helping the user doing a transfer.
All voice commands to the toilet start with the word computer in order to
increase the length of the command which has a positive effect on the performance of
the recognition. Then the actual phrase for the part of the toilet system one wants to
change follows. It is necessary to make a small pause between the different command
words to enhance Speech recognition. Commands that are usable (currently in German
only):
x Computer Licht Ein / Computer Licht Aus: This turns the light on and off.
x Computer Klo hher / Computer Klo tiefer: This moves toilet bowl up and down
stepwise.
x Computer Neigung strker / Computer Neigung schwcher: This changes the tilt
of the bowl stepwise. Neigung strker means seat is tilted forward, Neigung
schwcher means tilt backwards.
x Computer Splen / Computer Alarm: This triggers the flush function and the
emergency call (nurse call).
x Computer Position 1 / Computer Position 2 / Computer Position 3: This moves the
toilet to one of the three predefined positions. These positions could e.g. be a
position for the transfer onto the toilet, one for transfer from the toilet and one that
is especially suitable for using the toilet. Positions which can be recalled using
speech recognition have to be stored in the control unit of the toilet. If no positions
are stored, the commands are ignored.
2.7. Voice Output
Pre-recorded personalised messages can be re-played optionally and pre-defined text

messages can be spoken by the FRR control unit. This can be triggered by the system
(e.g. when a pre-stored position has been reached, the system says: Position one has
been reached) or by the user (e.g. when entering the room the FRR card of the user is
being recognised and the user is being welcomed: Good morning Mr. X). Voice output
can be seen as additional output channel for information of the user but also for guiding
the user [13].
Figure 4. Fourth Prototype (PT4) tested in May 2004 in the laboratory in Vienna. Voice control was tested
successfully. The microphone was mounted on the right top corner seen from the person sitting on the toilet.
2.8. Smart Cards
Integration of smart card technology based on RFID [14] allows recognising the users
preferred toilet settings, which are stored on the FRR card (see Figure 5) in a contact
less way, when the user is approaching the toilet. The system detects the user and can
move the toilet automatically to the preferred height and tilt, can switch to the preferred
language and activate / deactivate the optional features of the system. For the
laboratory prototype the user profiles were actually saved on the control unit, using
RFID only to get the unique ID of the FRR card. For application in daily life the user
profiles are planned to also be stored on the RFID tag, which in future might be
integrated part of ones mobile phones, key, jewellery, etc.
Figure 5. Smart Cards (RFID) used during laboratory tests of PT4 and PT5
2.9. Safety and Emergency Call
Manual triggering of the emergency call (nurse call) is possible via pressing the
corresponding button on the conventional hand held control, via speech input and via
loudness sensor.
3. Test Settings
The user tests of the different prototypes described here have been carried out in the
laboratory. For details regarding used principles of user involvement including
informed consent, information kit, and ethical remarks please refer to [6,15,16]. It is
important to note that the tests have mainly been set up in order to gain qualitative
rather than quantitative data.
A booth-like structure was constructed with the geometric dimension (measured from
inner side) of the booth: length: 265 cm, width: 99 cm, height: 215 cm. On the right
side next to the booth a small control room was set up, where the FRR Control Unit
(currently a standard PC-system) is located. The size of the control room is: length: 117
cm, width: 146 cm, height: 215 cm. During the tests the responsible technician is partly
in this room to change parameters in the control software and for general supervision of
the control system. The equipment was not connected to water neither to sewer. Two
large emergency buttons were mounted on the booth for general safety reasons.
4. Results
Five prototype generations have been tested during a period of two and a half years.
About 50 user tests have taken place in the laboratory in Vienna. More than 200 test
sessions were carried out in all laboratories of the FRR consortium (see Table 1).
Duration of each laboratory test was about 2 hours, whereas the hands-on time was
about 1 hour [17]. Many of the tests have been recorded on video tape, additionally
continuous logging data of all sensor signals are available and provide valuable data
sources in addition to the ADL (activity of daily living) scores of the individual users,
the questionnaires and the interview data [6,18]. According to a user centred iterative
design approach each cycle of specification, prototype building and testing led to a
redesign of the specification following the comments received from the primary and
secondary users. The manufacturing of the last FRR prototype is described in [19].
Below some qualitative and quantitative results from prototype testing are outlined,
additional results from real life tests are documented in [4,20].
4.1. Adjustability of Toilets Height and Tilt
Being able to adjust the toilet to ones own preferred position regarding height and tilt
is one of the most important benefits from the users point of view. It brings benefits
not only during sitting on the toilet but also during the transfer phases, e.g. moving
from and to the wheelchair.
Data measured regarding preferred sitting height from the user tests with PT2 were
published in [21]. It was shown that the preferred sitting positions do not correspond
much with the anthropometric data (like popliteal height or body height) of older adults
[22]. Similar findings regarding the height of support bars were found in [23].
Nevertheless it is remarkable that most of the users were able to reproduce their
preferred height of seat very well [21].
Another important and very plausible finding is that this adjustability does not only
assist the primary but also the secondary users [24]. The range of adjustability was
extended during the lifetime of the project (see Table 2). The range in height and tilt
provided by the toilet is actually being used by users in daily life; this could be
confirmed by the findings from the real life validation documented in [4]. The current
minimum position (44.5 cm) should be lower.
Figure 6. Vertical Bars were seen to be useful add-ons, e.g. for assisting while dressing / undressing. Testing
the PT5 prototype
Figure 7. Fifth Prototype (PT5) tested in laboratory setting in Vienna in February 2005
4.2. Grab Bars and Seat
The improvements of the grab bars regarding fixation in the horizontal position in order
to avoid unintended folding up during transfer were seen as benefit, as well as the
introduction of the vertical bars as an additional support, e.g. for leaning against when
dressing / undressing (see Figure 6 and Figure 7). The fixation mechanism which
currently (May 2005) is implemented via a push button on the top of the vertical bar
needs improvement.
The new seat originally was introduced in order to facilitate transfer from / to
wheelchair via moving step by step from wheelchair to toilet seat sliding over on the
wings of the seat. Additional benefits are provided to the user by the fact that now one
can grip left and right of the toilet seat in order to increase ones own stability when
sitting on the seat. The wings also provide place for storing personal belongings. The
vertical bars need to be moved away far enough in order to allow access of wheelchair.
4.3. User Identification for Personalisation
According to the test persons one of the main advantages provided by the user
identification is seen in the automatic adaptation of the toilet to the individual
preferences. This saves times for the users, especially for those who, due to functional
impairments, would need more time than others to adapt the system each time again.
Additionally, the fact that the prototype toilet system offers many optional features
demands a method for customisation to the individual preferences which does not put
additional cognitive load on the user.
It is evident that a user could forget to carry his/her FRR smart card around all the
time. Therefore the RFID tags might not only be realised as smart cards in format of
credit cards but might also be integrated in objects of daily life like mobile phones,
keys, jewellery. Regarding privacy it might be reasonable to store personal preferences
regarding settings of FRR toilet on the users own card, a centralised database server
might be useful for backup but is not necessarily needed.
4.4. Touch Screen User Interface Demonstrator, Speech Input and Speech Output
The speech control feature was rated to bring benefits by approximately half of the test
participants. This is a much higher proportion than was expected before. The reliability
of the speech recognition system also was higher than expected. Nevertheless it does
not yet seem to be high enough to put it into a field test (see Table 4).
Table 4. Laboratory test of speech input system ASR 3200 (embedded system) from ScanSoft [12] with 3
subjects from research team. Entry marked with *) not 100% sure, details not known. Number of different
speech commands: 7.
Correct No Wrong Correct No actions Wrong

actions actions actions actions [%] [%] actions [%]
subject 1 83 15 1 *) 83,8 15,2 1,0

subject 2 85 10 0 89,5 10,5 0
subject 3 70 0 0 100 0 0
total 238 25 1 *) 90,2 9,5 0,4
Some problems exist regarding the minimum volume level which is necessary to
be exceeded in order to trigger the recognition process. Some test participants actually
were not in the position to speak loud enough to exceed this trigger threshold. It also
needs to be considered that there is a cognitive load required to be carried by the user,
as he / she needs to remember the exact command phrases. The speech input was said
to be of great value also for secondary users when assisting a primary user manually
during a transfer. In this situation both hands are used for assisting, the third hand for
adjusting the toilets height is missing and could be replaced by the speech input
functionality. Detailed results regarding the user interface demonstrator can be found in
[8].
4.5. Sensors
The sensors for measuring the position of the toilets height and tilt were found to work
stable and reliable. The sensitivity of these sensors is very high. Thus, even those
changes in tilt caused not by technical actuators (motors) but just by the movements of
the person sitting on the toilet, can be measured. Also the changes in tilt due to
standing up or sitting down of the persons can be recognised clearly in the sensor data.
When the person is sitting down, the load (seen from the toilet system) is increased by
part of the persons own weight (assuming that there is contact form the persons feet to
the floor) and thus the tilt of the toilet is increased due to the mechanically flexible
construction of the prototype. The increase of tilt can be measured by the sensors.
height of
toilet bowl
tilt force
height force
Figure 8. Exemplary visualisation of data from strain gauge sensors: A person of about 80kg weight sits on
toilet. The toilet moves from lowest to highest height position and back to the lowest. While doing this, the
feet of the person sitting on the toilet move from ground when the distance from toilet bowl to floor exceeds
a certain value. Missing contact to floor increases the tilt force on the tilting mechanism and the height
force on the height adjusting mechanism. Y-axis shows three curves: the relative height of the toilet bowl,
the height force and the tilt force, x-axis shows time.
The ultra sonic sensor for measuring the distance from the cover of the toilet to the
users back worked and could demonstrate the principle of deriving the users intention
to standing up. Nevertheless the weight sensors described in the following seemed to
be more promising.
The data delivered by the strain gauge sensors on the tilting mechanism and the
height adjusting mechanism showed compared with the data from the alternatively used
load cells a lower but still a satisfying level of accuracy. Figure 8 shows one typical
diagram which can be discussed as follows: The force on the tilting mechanism is
increased when the toilet height is increased. This is plausible as the users feet will
lose more and more contact to the floor which means that more force (due to users
constant weight) will be led to the tilting mechanism (and the height adjusting
mechanism). As soon as the feet leave the floor, tilt force and height force will deliver
constant values. The toilet then reaches its highest position. As soon as the toilet moves
down again, there is a step in the graph of the height force. This is assumed to be due to
the mechanical construction of the height adjusting mechanism of the toilet. The tilt
force is being reduced as the feet get more and more contact to floor and therefore take
over more and more force.
The fall recognition sensor was tested successfully in parallel to the laboratory
tests. No real falls happened, so the sensor could only be tested with simulated falls.
The alarm sensor triggered by shouting was tested successfully. It is multi lingual
and speaker independent as it only monitors the volume level. Some test persons could
not use it, as they were not able to exceed the loudness threshold. A better pre-amplifier
for the microphone might help here to overcome this problem.
5. Discussion
The tests of the prototypes described here were tests in a laboratory environment
carried out in the framework of the FRR project. The toilet was connected to electricity
but not to water and sewer. The users tested with clothes on, and only for
approximately one hour. Several test cycles of iterative prototypes have been carried
out and nearly all test persons have accompanied the tests through all the different
cycles which can be interpreted as a high level of interest and engagement.
Nevertheless the limitations of such tests in comparison to field tests cannot be
overseen.
6. Conclusion
Running laboratory tests also brings advantages, e.g. it is possible to evaluate new
concepts and ideas in an early stage of development. For example, hygienic needs are
not so strict in a laboratory settings with clothes on, reliability and safety requirements
can be fulfilled easier when a research team is participating in the test run and could
interfere in case of occurrence of a risky situation. It also is to note that the design of
the user tests followed the idea of exploring specific areas in detail by studying the
interaction of users with the prototypes [6] rather than collecting statistical data of a
large sample of randomly selected users.
Some of the results from laboratory tests could be validated in a real life test which
was carried out with some few selected components of the FRR project which were
mature enough regarding safety, hygiene and expected usefulness to put them into a 2
months field test in a day care centre [4]. The results of this real life test underline and
confirm some of the results gained in laboratory tests. This especially concerns
increased autonomy and safety of users which was stated by the users themselves on
their presentation [5] given during final conference of the FRR consortium held in
Vienna March 17, 2005.
Acknowledgements
We want to thank all members of the Austrian User Board and all persons who have participated in the
iterative prototype testing in our laboratory between 2002 and 2005 for your cooperation and for a huge
amount of very valuable information. Our special thank goes to Ramona Rosenthal and Christine Pauli from
Caritas Socialis Vienna and to Robert Schlathau from Austrian Multiple Sclerosis Society.
References
[1] Molenbroek JFM, Bruin R de. The Development of a Friendly Rest Room - A User Friendly Restroom
for Elderly and Persons with Limited Abilities. Presentation during FRR final conference.
Electronically available from [26,27]
[2] Bruin R de, Molenbroek JFM, Groothuizen T, Weeren MH van. On the development of a friendly rest
room. In: Coleman R, Myerson J, editors. Proceedings of the INCLUDE Conference 2003: Inclusive
Design for Society and Business. London: Helen Hamlyn Research Centre; 2003: pp. 14: 570-14:576
[3] Neveryd H, Molenbroek JFM, Panek P. FRR - Friendly Rest Rooms for Elderly and Disabled Persons -
A User Centered R&D Project. Presentation at Gerontechnology Conference; 2002 November 9-12;
Miami Beach, Florida. Printed in Gerontechnology. 2002; 2(1): 94.
[4] Gentile N, Edelmayer G, Day C, Mayer P, Panek P. FRR field test - Real life test at a day care centre.
Presentation during FRR final conference. Available from [26,27]
[5] Panek P. Overview about Iterative Prototype Generations at the 5 test sites in Athens, Delft, Lund,
Milan and Vienna. Presentation during FRR final conference. Available from [26,27]
[6] Day C, Egger de Campo M. User-Driven Research - How to Integrate Users' Needs and Expectations
in a Research Project. This volume.
[7] Clean Solution Kft., Debrecen, Hungary [Internet]. 2005 [cited 2005 May 16]. Available from:
http://www.cstechnologie.com/ and http://www.conplan.org
[8] Magnusson C, Alm N, Edelmayer G, Mayer P, Panek P. Rapid Prototyping of Interface and Control
Software for an Intelligent Toilet. This volume.
[9] Panek P, Neveryd H, Edelmayer G, Eftring H, Knall G, Magnusson C, Mayer P. Design of a Flexible
User Interface Demonstrator, Control Software and Sensors. Presentation during FRR final conference.
Available from [26,27]
[10] Sixsmith A, Johnson N. A Smart Sensor to Detect the Falls of the Elderly. IEEE Pervasive computing,
2004 April-June; 3(2):42-47
[11] Buzink SN, Bruin R de, Groothuizen TJJ, Haagsman EM, Molenbroek JFM. Fall prevention in the
toilet environment. This volume.
[12] Speech Pearl v8, ASR3200, Speech Control, embedded systems, ScanSoft [Internet]. 2005 [cited 2005
May 16]. Available from: http://www.scansoft.com/
[13] Mihailidis A, Barbenel JC, Fernie G. The efficacy of an intelligent cognitive orthosis to facilitate hand
washing by persons with moderate-to-severe dementia. Neuropsychological Rehabilitation.
2004;14(1/2):135-171.
[14] Radio Frequency Identification Systems, Texas Instruments Inc., USA [Internet] 2005 [cited 2005 May
16]. Available from: http://www.ti.com/tiris/
[15] Rauhala M, Wagner I. Ethical Review in the FRR Project A Continuous Process. Presentation during
FRR final conference. Electronically available from [26,27]
[16] Rauhala M, Topo P. Independent living, technology and ethics. Technology and Disability. 2003; 15:
205-214.
[17] Knall C, Sourtzi P, Liaskos J. Experiences of Testing with Elderly Users. This volume.
[18] Day C. The FRR-questionnaire - Assessing Who Needs What Where. This volume.
[19] Rist A. Engineering and Manufacturing of the final FRR Prototype According to the User Needs.
Presentation during FRR final conference. Electronically available from [26,27]
[20] Gentile N, Day C, Edelmayer G. Egger de Campo M, Mayer P, Panek P, Schlathau. Concept, Setting
up and First Results from a Real Life Installation of an Improved Toilet System at a Care Institution in
Austria. This volume.
[21] Panek P, Edelmayer G, Magnusson C, Mayer P, Molenbroek JFM, Neveryd H, Schlathau R, Zagler WL.
Investigations to develop a fully adjustable intelligent toilet for supporting old people and persons with
disabilities - the Friendly Rest Room (FRR) Project. In: Klaus J, Miesenberger K, Burger D, Zagler W
editors. Computers Helping People with Special Needs: 9th International Conference, ICCHP 2004;
2004 July 7-9; Paris, France. Proceedings (Lecture Notes in Computer Science), LCNS 3118. Berlin
Heidelberg: Springer-Verlag; 2004: pp. 392-399.
[22] Department of Trade and Industry, UK, publications@dti. Older adult data. The handbook of
measurements and capabilities of the older adult: data for design safety, anthropometric and strength
data on older people aged 60 and over. UK: Department of Trade and Industry; June 2000
[23] Dekker D, Buzink SN. User Preferences Regarding Body Support and Personal Hygiene in the Toilet
Environment. This volume.
[24] Knibbe JJ, Friele RD. Prevalence of back pain and characteristics of the physical workload of
community nurses. Ergonomics. 1996 Feb;39(2):186-98
[25] Adolf S, Fink B, Freist A, Rosenthal R, Pauli C, Schlathau R. Voices of the Users. Presentation during
FRR final conference. Available from [26,27]
[26] Presentations Final Conference of Friendly Rest Room (FRR) project consortium, Caritas Socialis,
Vienna, March 17th, 2005 [Internet]. 2005 [cited 2005 May 16]. Available from:
http://www.fortec.tuwien.ac.at/frr
[27] Web site of FRR consortium [Internet]. 2005 [cited 2005 May 16]. Available from: http://www.frr-
consortium.org and http://www.fortec.tuwien.ac.at/frr
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-166
Concept, Setting up and First Results from

a Real Life Installation of an Improved
Toilet System at a Care Institution in
Austria
Nadia GENTILEa,b,1 , Christian DAYa, Georg EDELMAYERc,
Marianne EGGER DE CAMPOa,b, Peter MAYERc ,
Paul PANEKc and Robert SCHLATHAUd
a
EURAG European Federation of Older Persons, Graz, Austria
b
Compass Institute for Social Research, Graz, Austria
c
fortec Research Group on Rehabilitation Technology, Vienna University of
Technology, Vienna, Austria
d
Austrian Multiple Sclerosis Society, Vienna, Austria
Abstract. The last phase of the Friendly Rest Room (FRR)-project was explicitly
dedicated to the validation of the conceptual and technical solutions developed
within the preceding years. Validation in this context means to assess whether the
project has reached its objectives. As FRR is a project within the Quality of Life
Programme, the main objective was to contribute to an enhancement of the quality
of life of old people (and people with disabilities). In order to be able to investigate
whether the quality of life of the target group could be improved by the toilet
system developed within the FRR-project, a prototype must be set up in an
adequate context, i.e., in an area where, in contrast to a laboratory situation, a
normal use is possible. This chapter describes the concept and the setting up of a
real life installation of an improved toilet system which was carried out at a day
care centre in Vienna, Austria. Furthermore, first results from this validation phase
(29 primary users and 12 secondary users carried out 316 toilet sessions over a
period of two months) are reported. It could be shown that the new toilet system
increases safety and autonomy from point of view of primary and secondary users
and that the toilet was more than well accepted in the day to day practice of the
day care centre.
Keywords. Toilet, Older Persons, ADL, Multiple Sclerosis, Day Care, Autonomy,
RFID
1. Introduction
Setting up the project, the Friendly Rest Room (FRR)-team decided that components of
the new toilet system developed during the project should be tested in daily use at the
Multiple Sclerosis (MS) day care centre of the Caritas Socialis (CS) in Vienna. Over a
1
Corresponding Author: Nadia Gentile, Compass - Institut fr Sozialforschung; Adress: Flosslendstrasse
18, A 8020 Graz, Austria; Tel: +43 316 68 71 41- 0; Fax: +43 316 68 71 41- 41; Email: office@compass-
org.at or n.gentile@compass-org.at or gentile@easyentrance.at; Website: http://www.compass-org.at
N. Gentile et al. / Concept, Setting Up and First Results from a Real Life Installation 167
longer period of time (2 months, from December 2004 to February 2005), clients and
employees of this day care centre should be invited to use components of the FRR-
system in order to evaluate them on the base of daily life experience. Only some
selected parts of all the developed components and concepts [1-7] were used in order to
ensure reliability, security and hygiene and also not to confront the clients of the day
care centre with too many new things".
Contact to the Caritas Socialis was established through the MS-Society who
intensively supported the development of the FRR system right from the beginning of
the project. Before starting to plan the real life installation, some of the guests of the
day care centre already tested previous FRR-Prototypes that have been built up in the
laboratory of fortec at the Vienna University of Technology [1, 2]. Both the guests and
their care personnel took part in expert discussions and delivered an important and
valuable contribution for further development of the FRR system. The preparation
phase of the real life installation was done in close cooperation with CS and the
personnel there. The planning documents were updated and discussed on a regular
basis and provided to all persons involved.
2. Setting the Scene
2.1. Description of Day to Day Life in the MS Day Care Centre
The opening hours of the MS-Day Care Centre are Monday to Friday from 8.00 a.m. to
4.30 p.m., except holidays and weekends. Its clients are people with MS syndrome and
different physical/motoric and/or cognitive restrictions. The goals of the day care centre
are to provide an ambulant management of a follow-up treatment instead of stationary
rehabilitation, to provide preventive measures against social isolation and improving
domiciliary treatment and extending it through specific relieve of relatives. The
services offered to achieve these goals are manifold, e.g. rehabilitative neurological
care, physiotherapy, MS-specific therapy, walking training, occupational therapy (self-
help training, computer-assisted cognitive training, sensitisation training) music
therapy, continuous specialized medical care, creative activity etc.
The number of day guests is approximately 60 to 65, approximately 20 guests per
day. They visit the centre twice a week on average but some guests visit the day care
centre more often and make use of the whole weekly program. Nearly all visitors have
a therapeutic indication. Many of the guests are using their visits to take a shower,
because they need help with personal hygiene, or for medical treatment like changing
bandages. The other time is spent in the lounge or in the dining room, after lunch some
go to the cafeteria on the ground floor. The staff (nurses, nursing auxiliaries, civil
servants, trainees) helps to support the guests if needed. For discussion rounds, games
and other creative activities (e.g. painting) an animator/reactivation assistant is in
charge. Apart from the therapy units another fixed time is lunch at noon.
Concerning toilets, daily guests use those toilets suitable for them. For one it is the
bigger space, for others the more suitable door handles, etc. Sometimes they just
choose the one which is empty. What all guests have in common is that in their every
day life toilets play really a crucial role. Thus many daily guests are experienced in
developing strategies to avoid going to the toilet, which means not drinking enough or
even taking tablets to dehydrate.
168 N. Gentile et al. / Concept, Setting Up and First Results from a Real Life Installation
2.2. The FRR System
The toilet system was built up in an already existing toilet room in the day care centre
(Figure 1). The original toilet was dismantled and the test system was built up after
some adaptations of the room. The personal computer (PC) running the FRR-software
[1,2] for data gathering was hidden in a cavity in one of the side walls (Figure 2).
The actual toilet system consisted of a LiftWC700 from 'Clean Solution Kft.' [4]
with actuators for changing tilt and height, two horizontal support bars which can be
folded up and a handheld remote control to steer the toilet and to activate the alarm call.
Additionally a new type of a door handle developed within the project [3,5] was
installed on the outside of the entrance door.
Figure 1. Toilet room in the day care centre before (left) and after (right) modifying and installing the FRR
system. The traditional toilet bowl in the left corner was removed and the wall in the back was adapted to
mount the adjustable toilet system. A 360 degrees view is available on [8].
For user detection an RFID mid range module (similar to what was used in
laboratory environment, cf. [1]) was installed and the antenna of the module was
hidden behind the toilet back cover (Figure 2). 'Smart Cards' with unique identification
numbers were given to each test participant so that identification of persons using the
system was possible. A box-like cavity was built into one of the walls to provide space
for keeping a PC running the FRR control software and doing data logging. The
necessary electronics was put next to the PC. For data collection position sensors for
height and tilt were installed. Binary sensors were used to read the status of the six
different buttons (pressed/released by user) on the hand held remote control (height
up/down, tilt forward/backwards, toilet flush, alarm call) as well as of the entrance door
(open/closed) and the status of the local nurse call system (nurse call active / not active).
Remote maintenance of the PC as well as downloading daily sensor data was possible
via an internet connection using the LAN of the care institution.
2.3. User Description
Of the 60 daily guests at the MS day care centre, 29 actually participated in the real life
test. According to the definitions of target groups they are called "primary users (PU)"
of which 22 were female and 7 male. All participants were MS patients living with
many different kind of impairments and therefore offer the opportunity to explore a
very large range of individual needs. The age of the PU ranged from 39 years to 79
years with an average of 57 years. 14 persons were wheel chair users, 3 used crutches,
6 a so called Rollator, 2 used a so called Rollmobil, 4 walked without any aid, 7 of the
PU made the transfer with help from 1 or 2 persons from the nursing staff ("secondary
users", SU).
Figure 2. A personal computer (PC) for automatic documentation of toilet movements and user activities
(technical logging) was installed next to the toilet (left) including also electronics for RFID system; RFID
antenna for the FRR Card detection was mounted behind the back cover of the toilet (right).
Beneath simple demographic characteristics like gender and age, the well-known
method of ADL (Activities of Daily Living) staircases2 was applied to describe aspects
of the test person's dependency in daily life [9,10]. The average grade of disability or
2
ADL staircases are a common tool that enables therapists as well as researchers to evaluate the range of
care a person needs. Literature describes many ways to design an ADL-staircase there are different
opinions about which items to include and about how to put the different items in order. We decided to
include 8 common ADL-items and we used an adapted version of Sonns staircase. Description of steps: Step
0, Step 1 Heavier housework, Step 2 Grocery shopping, Step 3 Going out, Step 4 Light housework, Step 5
Bathing & dressing, Step 6 Walking in the home, Step 7 Going to bed, getting up, Step 8 Eating and drinking.
The higher the score, the higher is the grade of dependency.
use of care respectively of the participants was middle to high. On the ADL-scale the
participants ranged between 0 (min) and 8 (max) with an average of 4.5.
3. Expected Benefits
The main expectations or goals of the field test were that the users should be satisfied
at the end of the tests and for all participants usefulness should be noticeable. The
satisfaction and the safety of the users (e.g. avoiding of problems and accidents) were
the top priorities. Before the onset of the real life test phase, the local FRR-project team
agreed that the ideal scenario would be if the day care guests would like to use the FRR
toilet as "normal" part of their daily life (meaning, not to consider at it as test object):
as a useful, comfortable and functional object that helps them and makes them more
independent. One objective was also to get hints with regards to future improvements
and developments of the system.
4. Methods
4.1. Data Collection
To ensure the validity of our findings different methods and data from different sources
have been combined in a process of data triangulation 3 to give a more complete picture
of the FRR real life case study [11].
x Participant observation (Interaction between users and the FRR system)

x Statistical data (ADL score, age, gender)
x Expert knowledge of service provider(s) (in-depth interview with head nurses,
occupational therapist, physiotherapist, etc.)
x Observation sheets and notes from nurses
x Feedback of experts, PU and SU
x Comparison/reference to technical log files
x Questionnaire on users degree of satisfaction
Participant observation is a method of research used in qualitative social research

[12,13,14]. The scientists try to get answers to their questions by going into the field
and get into interaction with the people, talk to them and when it is possible or
necessary, take part in their daily life [15,16,17]. People interact with objects and other
people on the basis of the meanings that the objects have for them [18]. In the real life
field test this was of relevance as it turned out very soon that context knowledge
generated with the help of the PUs was indispensable to understand how the toilet was
used and accepted by the daily guests [19]. These data have been compared and related
to technical log files gathered by the computer [1,2]. Finally a questionnaire was used
to assess the users' degree of satisfaction with the FRR [20,21]. Data were collected
from the middle of December 2004 to the middle of February 2005. Photography was
used as additional means of documentation [22,23].
3
According to [13] and [24].
4.2. Data Collection Log File
All sensor data that were taken up by the system (information about height and tilt of
toilet, status of buttons on the remote control, status of the emergency call system,
status of door and the identification numbers of the recognized FRR smart cards) were
logged in a dedicated log file on the monitoring PC. Each day at midnight a new log-
file was automatically created by the FRR software. The existing log files were
downloaded manually the following days for data storage, backup and off-line
evaluation. The log files contain, besides some header information, all sensor data and
additionally data for plausibility checks. Before the data are evaluated the files undergo
consistency checks. After that the logged data are transformed to make visualisation
with diagrams easier (Figure 7). The diagrams are then used to extract single toileting
events. Additional tables of events (door open/close, button presses, tag detections etc.)
are generated to support detailed investigation of the data.
4.3. Ethical and Safety Considerations
4.3.1. Informed Consent Procedure

Like in all other project phases, the users (both SU and PU) received written
information about the project and its purpose, about the researchers involved, about the
functions of the prototype and the test [25]. Also a signed form of informed consent
from participants was collected. Verbal information and training of the employees
followed the written information. During this theoretical and practical training the SU
showed great enthusiasm even if their prime work in the day care centre was affected
by it (see Figure 3). The training of the PU was done in some steps over a period of a
few days. The PUs were mainly instructed by the staff of the day care centre since they
are better trained to explaining the contents in a simple and clear way (see Figure 4).
Figure 3. Primary and secondary users during the initial training with the FRR-Toilet in December 2004.
Left: View into the toilet room from outside. Right: Entrance door seen from inside the toilet room. 360
degrees views from inside and outside the toilet room are available on [11].
4.3.2. Safety of the Toilet

A real life test requires a high level of safety and hygiene; therefore it is reasonable to
concentrate only on few components that absolutely fulfil these requirements. From a
technical point of view, the safety of the system was ensured by the fact that a standard
product was used as a basis and that technical changes did not influence the safety level
of the system. Sensors used for measuring were only passive ones, the PC used for data
gathering and storage was passive, i.e. only measuring and not actively steering the
system. Therefore possible malfunction of the PC would not influence the toilet. The
electrical safety of the used RFID system was ensured by the supplier. Personal data of
the participating users were not stored. The used FRR-Cards only held a unique
number that could be detected by the system when using the toilet; no additional data
were stored on the cards.
Figure 4. A training situation which happened unplanned and spontaneous, out of the interest of the day
guests (left); a guest with the FRR-Card (RFID) around her neck (right).
5. Preliminary Findings and Outlook
5.1. Preliminary Findings from Observations and Interviews
In the time before the tests actually started, the day care centre management and the
employees were not sure whether the FRR would be accepted or even appreciated by
the day guests. It was supposed that the guests interest in testing something new could
be quite limited. Routine activities and habits are difficult to abandon, because they
give you security. However, the status transition of the FRR from being "news" to
getting used in a rather economical and un-commented way happened in a faster and
more seamless way than it was expected. At the end of December 2004 the presence of
the FRR was already evident for the external observer, as many guests wore their FRR-
cards.
Nevertheless, in the communication among the guests, the FRR was not a big issue.
For what reason ever, this changed in the second week of January, when the
participants started to wait in front of the FRR until it was free/accessible. In an
interview on this phenomenon, a nursing auxiliary reported "The people are highly
motivated; they already ask in the morning whether they can have their cards. Its
unusual, because normally they keep forgetting things".
However, some of the guests in the day care centre did not like to participate at the
test. The use of a modern technology like the FRR, respectively the use of assistive
tools in general can be an indicator for the grade of dependency. For some of the guests,
the participation in the FRR test would have meant to admit a higher degree of
"dependency" than they actually have and/or than they want to admit to themselves and
their environment. One guest said that she does not use the FRR, because it is "work",
she would have to learn something and it is easier with the known, commonly used
toilet.
5.2. Preliminary Findings from Log Files
Due to the tremendous amount of data gathered, only some first findings are presented
here. However, they provide a good overview of the capability (and usefulness) of the
system. The toilet was used on 39 days during the testing period. The remaining 20
days were holidays or weekends where the day care centre was closed. During this time
316 toilet usages were detected giving an average of about 8 toileting events per day.
The maximum was at 14 events on a single day, the minimum at 2 usages per day
(Figure 5). Of these events 149 (approximately 47%) could be assigned to specific test-
persons via the FRR-card. The remaining 167 events are those where no FRR-card was
detected by the system.
Figure 5. Number of toilet usage per day during real life validation in the MS day care centre at Caritas
Socialis in Vienna, Austria, between 22.12.2004 and 18.02.2005.
Figure 6. Comparison of possible and actually used values of height (left) and tilt (right) of the adjustable
toilet bowl. Height was actually used between 43.6 and 67.9 cm (possible adjustability is between 43.6 and
75.8). Tilt was used between 0 and 6.5 degrees which is the full range of possible tilt values.
(1) Height of bowl

[43.6 to 75.8 cm]
(2) Tilt of bowl

[0 to 6.6 deg]
(3) Entrance Door

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

open (curve top)
closed (curve down)
Figure 7. Example of data gathered during a day (subset of available data). Four curves over time axis show
(from top to bottom): height position of toilet bowl between 43.6 and 75.8 cm (1), tilt position of toilet
between 0 and 6.5 degrees (2), status of entrance door (3) open/closed and flushing of toilet (8) as binary
event. The four curves are shown between approx. 8 and 17 o'clock when the day care centre is open (on a
working day).
A total of 23 different PU and 6 SU were detected by their FRR-Cards. The PUs

used the toilet between one and 29 times each. Although not all users were detected
very often, 43% of them were identified at least 10 times. The available range of height
and tilt was extensively used, only the maximum possible height was not used to full
extent; however it was set to values that are far higher than a standard toilet (Figure 6).
Toilet usage differs of course each day and with each user. An example of
visualized sensor data gathered during one day is shown in Figure 7. It can be seen, that
tilt and height are changed in the morning mainly, and the toilet was then used in the
afternoon with no changes. The flush events can be related to single toileting events
each. From daily diagrams, the different single toileting events can be extracted and
evaluation of toileting events of identified users can be done. These data will then
accompany the sociological evaluation of the tests. Only a limited set of possible
enhancements which were tested in laboratory (see for example [1,2,5,6,7]) was
presented to the users and tested by them during the real life evaluation. However, it
can be stated, that these features actually have improved toileting for the target group
of users. The results which are outlined below in more details show, that adjusting
height and tilt of the toilet is not only accepted very well by the test persons but also
provides great benefit for both primary and secondary users [11,26]. This is outlined in
the following sections.
5.3. Preliminary Findings from Data Triangulation
The documented results were very satisfying. Some of the users, the CS management
and staff members were very happy having been included as experts in this project: it
was time to ask those who in their everyday life and work are confronted with such
situations and problems stated for instance a staff member. Even if some functions
have to be adapted, all the participants stated that the FRR was able to improve the
quality of life of the daily guests and to relieve the staff. The transfer is easier and safer
(see Figure 8 and 9), the remote control and the possibility to adjust the toilet high and
tilt is very useful and increases autonomy: some users with a high degree of
dependency now are able to flush independently or to touch the ground with their feet
while sitting on the toilet. This provides more stability and in general the feeling to be
more autonomous and safer. The users also stated that the contact with the floor will be
helpful to activate the belly musculature when defecating.
There is indication that FRR enables persons who are completely depending on
help to discover resources that might increase autonomy; further, it helps MS patients
to maintain independence for a longer time. A daily guest (wheelchair user) who cannot
use the toilet alone because of the transfer, stated at the end of the test: Such a toilet
could have postponed the decrease of my autonomy. Another test participant added
The autonomy in pressing the nurse alarm button makes me happy!!!.
Figure 8. Closing the door as wheelchair user requires a lot of efforts (left, view from inside of the toilet
room); A Secondary User accompanied a Daily Guest in the FRR (right, seen from outside).
Despite the positive and encouraging evaluation so far, there are still some things
to be improved. A user recognition system that is able to rapidly adjust the toilet
according to the user needs would be good and bring many advantages, e.g. because
everything goes much faster 4 . In general, we have to remember that people with
impairments, particularly with wheelchair, often have to search for a long time before
they find an adapted toilet. When they finally find a proper toilet, they need to use the
toilet very urgently. The future development must absolutely consider this aspect. We
also have to take into account that every automatic function, (including the automatic
door ) that some of the users would appreciate, can be a disadvantage for people with
cognitive impairments or older people who have problems to understand new
technology. As regards the horizontal bars, they were assessed as very helpful, in
particular for the transfer. The transfer is faster and safer and many of the users now
can make the transfer without any help. This reduces the stress, makes happy and
the transfer back easier, also for the secondary user. The adjustability of the handles
in height and in width would be important because some people need them shorter, the
other ones longer.
The door handle [5] was assessed as being very useful, despite the fact that some
users refused to test the toilet because the door handle was too large, looks unfriendly
or like a safe5. In general we observed that doors are actually the first barrier for
people who are going to use the toilet many of the daily guests have quite some
problems in opening and closing the doors. The new door handle at the FRR door has
brought improvements for them. It is very helpful for persons using crutches, because
you can operate it also with your elbows. For wheelchair users there was however no
evident improvement especially closing the door requires long to and fro
manoeuvres. The door currently opens to the inside. The new door handle was useful
but it should be implemented in a whole concept (also a bigger room would be helpful).
Most of the users benefit from the transfer with the FRR, but not all of them. This
can be illustrated by two very opposed cases. We observed a female wheelchair user
who several times was waiting 5 to 10 minutes in front of the FRR door, undertaking
complicated manoeuvres to go to another toilet if she had to wait longer, only to
reverse everything when the FRR was free again. Why did she undertake all those
efforts to get into the FRR? Because of her sense of duty or does she believe in the
benefits of using it? How significant must the benefit be to compensate the efforts
made? The question could not be answered by comparing this observation with the
pure technical log files data collected by the embedded PC. From the technical point of
view these data show that one user used the toilet without changing anything.
Afterwards she was interviewed and she said that for her the long waiting period was
nothing unusual because the FRR is simply perfect for the transfer and she would
love to take that toilet home with her. Most of the time she finds the toilet in the right
height/angle, which suits her needs, which means she does not have to change anything.
4
Please note that for safety and other reasons the RFID system used during the field trial served only for
identification of the current user in the toilet room. During field trial FRR smart cards (RFID) were not used
for automatic adjusting the toilet parameters (e.g. height and tilt) to the individual preferences. This was
implemented and successfully tested only in laboratory environment as described in [1].
5
A safe is something that can be locked hermetically, you can only enter if you know the combination
(i.e. eventually too complicated, strenuous) and perhaps you might have problems in leaving the room
afterwards. Such fears were also expressed in the course of previous test phases, in general in the context
with automatically controlled devices/functions (dependence, you have no influence on it, you have to rely
on the technology) and also with doors that can only be opened and closed automatically.
If she does not need to go to the toilet urgently, she prefers to wait instead of using
another toilet.
The second example is a guest, also a wheelchair user, who stopped going to the
FRR because she cannot manage the transfer alone in there. She normally drives close
to the wall, supports herself with her legs at the wall and uses the vertical handle to
move her body up. At the FRR it is not possible to do that and thus she uses another
toilet which meets her demands. The high benefit for the first user (as described before)
especially with the transfer corresponds 1:1 to the high effort of the second user.
Figure 9: Guests waiting in front of the FRR (left). A test participant demonstrates the best transfer position
for her (right).
6. Discussion
As we reported at the beginning, the main goals of the field test were that the users
should be satisfied at the end of the tests and usefulness should be noticeable for all
participants. The response of the users proves that we have reached these expectations.
The FRR is an advantage for both primary users and secondary users and the daily
guests welcomed that the FRR-Toilet in the future will remain in the MS-Day Care
Centre.
Despite the fact that both, the technical and the sociological data are so rich that it
is necessary to continue evaluation, the implementation of the results that were gained
so far form the basis for future developments and should also lead to compulsory
implementation of findings from the FRR project on local, national and European level.
And, as one of the users stated at the final conference [26] (see Figure 10), the FRR
would bring a win-win effect both for users (longer autonomy) and caring staff (relieve
in their health condition) which is equal to a benefit for national economies!
Figure 10. Voice of the Users at the final conference of the Friendly Rest Room (FRR) project organised
at Caritas Socialis in Vienna; March 17th, 2005 [26].
7. Conclusions
Even simple features like height and tilt adjustability of the toilet system were found to
be of high value and usefulness for primary users and carers in the daily activities of
the day care centre. Over a period of 2 months 316 toilet sessions were recorded with
29 primary users and 12 carers being involved. It could be shown that the adjustability
of height and tilt of the toilet bowl, the remote control of the toilet flush and the call for
nurse actually were used in daily routine and were considered as very useful from point
of view of the test participants. Observations from sociologist and interviews with
primary and secondary users have confirmed these findings. Personal statements from
participants were given during the final conference of the FRR project and are
documented in [26,27,28].
Some selected examples from primary users perspective: The transferring from
the wheelchair to the toilet and back again is supported significantly. The adjustment of
height of the toilet ensures that feet have contact with floor which increases safety.
Such a toilet would have delayed the limitations that my independence suffers from!
The independence in pressing the alarm button (call for support) increases the
autonomy and feeling of personal independence. Important benefit is that it reduces
stress when using the toilet [26].
From the care team it was noted that the physical workload of the care personal is
reduced by the height adjustment of the toilet. FRR offers persons who, in my point of
view, are dependent on help, the possibility to discover own resources which mean
independence for the person and it also provides the possibility to keep resources
and independence for a longer time (rehabilitation) [26].
It also can be concluded that most but not all users found their needs met by the
toilet system. The experience and satisfaction of the users can be quite different or even
opposite and apparently these are depending on the different coping strategies the
individual user has.
By the time of final revision of this chapter (June 2009) the toilet system installed
at the day care centre in December 2004 still is in continuous and successful use. The
real life evaluation of the FRR toilet system 2004-2005 is an example of successfully
transferring an innovative system into daily life and ensuring the necessary technical
maintenance work by engaged local companies. It is worth noting that functional and
technical specifications similar to those of the installed toilet system were included to
the tender of the Vienna International Airport terminal extension (skylink) project
where the reader might be able to use such toilets in near future [29]. Some of the
wishes for the future are the integration of speech control and automatic adjustment via
RFID cards into the system. These features were tested successfully under laboratory
conditions (cf. [1]) but were not yet included in the field evaluation reported about here.
Acknowledgements
We gratefully acknowledge the intensive contributions provided by all the persons who have participated in
the prototype testing phases and in the real life evaluation of the toilet system at the day care centre. Special
thanks to all clients and nursing staff, especially to Christine Pauli, Ramona Rosenthal and Franziska Sonntag
from Caritas Socialis Pflege und Sozialzentrum Rennweg in Vienna and to Robert Schlathau from the
board of the Austrian Multiple Sclerosis Society. Without their extraordinary support and engagement the
FRR real life test in the day care centre would not have been possible.
References
Integrated Sensors for Enhancing Autonomy and Safety. This volume
[2] Magnusson C, Alm N, Edelmayer G, Mayer P, Panek P. Rapid Prototyping of Interface and Control
Software for an Intelligent Toilet. This volume
[3] Design Partner of the FRR Consortium: Landmark Design Holding bv [Internet] 2005 [cited 2005 May
16]. Available from: http://www.frr-consortium.org
[4] Manufacturing and engineering partner of the FRR Consortium: Clean Solution Kft., Debrecen,
Hungary [Internet] 2005 [cited 2005 May 16]. Available from: http://www.cstechnologie.com/ and
http://www.conplan.org
[5] Groothuizen TJJ, Rist A, Weeren MJ van, Dekker D, Bruin R de, Molenbroek JFM. The Final FRR
Components. This volume.
[6] Sourtzi P, Menezello T. Elderly and People with Disabilities: Limitations in their Everyday Life. This
volume.
[7] Knall G, Sourtzi P, Liaskos J. Experience of Testing with Elderly Users. This volume.
[8] Panorama View (360 degrees) from inside the FRR toilet room in the day care centre in Vienna [image
on the Internet]. 2009 [cited 2009 June 20]. Available from:
http://www.is.tuwien.ac.at/fortec/reha.e/projects/frr/panorama/inside.html
[9] Sonn U. Longitudinal Studies of Dependence in Daily Life Activities among Elderly Persons.
Methodological development, use of assistive devices and relation to impairments and functional
limitations. Scandinavian Journal of Rehabilitation Medicine. Supplement. 1996;34:1-35.
[10] Strainer DL, Norman GR. Health measurements scales: A practical guide to their development and use.
Oxford: Oxford University Press; 2004.
[11] Real Life Validation of FRR prototype system at MS day care centre of Caritas Socialis [Internet]. 2009
[cited 2009 June 20]. Available from:
http://www.is.tuwien.ac.at/fortec/reha.e/projects/frr/frr_reallife.html
[12] Cicourel AV. Method and Measurement in Sociology. London: The Free Press Glencoe, Collier-
Macmillan Limited; 1964.
[13] Denzin N. The Research Act: A Theoretical Introduction to Sociological Methods. New York: Aldine
Publication Company; 1970.
[14] Strauss A, Corbin J. Basics of Qualitative Research. Grounded Theory Procedures and Techniques.
Newbury Park, CA: Sage Publications; 1990.
[15] Glaser A. Basics of Grounded Theory Research Analysis. Mill Valley, CA: Sociology Press; 1992.
[16] Goffman E. Relations in Public. Basic Books; 1971.
[17] Strauss A, Corbin J. Grounded Theory Methodology: An Overview. In: Denzin NK, Lincoln YS,
editors. Handbook of Qualitative Research. Thousand Oaks, CA: Sage Publications;1994. p.273-285.
[18] Blumer H. Symbolic Interactionism, Perspective and Method. Berkeley, Los Angeles, London:
University of California Press; 1969.
[19] Jnsson B, Malmborg L, Svensk A, Anderberg P, Brattberg G, Breidegard B, Eftring H, Enquist H,
Flodin E, Gustafsson J, Magnusson C, Mandre E, Nordgren C, Rassmus-Grhn K. Situated research
and design for everyday life [Internet]. 2004 [cited 2005 May 16]. Available from:
www.arkiv.certec.lth.se/doc/situatedresearch/
[20] Demers L, Weiss-Lambrou R, Ska B. Development of the Quebec User Evaluation of Satisfaction with
Assistive Technology (QUEST): A new outcome measurement. Assistive Technology. 1996; 8(1): 3-13.
[21] Weiss-Lambrou R. Satisfaction and Comfort. In: Scherer MJ, editor. Assistive Technology. Matching
Device and Consumer for Successful Rehabilitation., Washington DC: American Psychological
Association; 2002. p.77-94.
[22] Becker HS. Photography and Sociology. In: Becker HS, editor. Doing Things Together, Selected
Papers. Evanston: Northwestern University Press; 1986. p. 221-271.
[23] Collier J, Collier M. Visual Anthropology. Photography as Research Method. Albuquerque: University
of New Mexico Press; 1986.
[24] Yin RK. Case Study Research, Design and Methods. 3rd ed. Thousand Oaks: Sage Publications; 2003.
[25] Day C, Egger de Campo M. User-Driven Research - How to Integrate Users' Needs and Expectations
in a Research Project. This volume.
[26] Adolf S, Fink B, Freist A, Rosenthal R, Pauli C, Schlathau R. Voices of the Users. Presentation during
FRR final conference, Caritas Socialis Sozialzentrum Rennweg; 2005 Mar 17; Vienna, Austria.
[Internet] 2005 [cited 2005 May 16]. Available from: http://www.fortec.tuwien.ac.at/frr and
http://www.is.tuwien.ac.at/fortec/reha.e/projects/frr/conference/1630_Voices_of_the_users_en.pdf
[27] Presentations Final Conference of Friendly Rest Room (FRR) project consortium, Caritas Socialis;
2005 Mar 17; Vienna, Austria [Internet]. 2005 [cited 2005 May 16]. Available from:
http://www.fortec.tuwien.ac.at/frr
[28] Press Release of Caritas Socialis. Mehr Selbstndigkeit durch Toilette mit Hirn - More independence
provided by a toilet with brain [Internet]. 2005 [cited 2005 May 16]. Available from:
http://www.cs.or.at/presse-detail.asp?ID=19
[29] Egger de Campo M, Day C, Panek P. Creating Friendly Rest Rooms by Involving Older and Disabled
Users in the RTD Process. Invited presentation at Research Benefits for the Ageing Population -
Dissemination Conference for European Research Results, STAKES and the European Commission
under the Finnish EU Presidency; 2006 Sep 14-15; Helsinki, Finland [Internet]. 2005 [cited 2006 Nov
23]. Available from: ftp://ftp.cordis.europa.eu/pub/life/docs/egger_de_campo_session_4.pdf
Section 4
Aspects of Human-Product Interaction
in the Toilet Environment
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-183
Fall Prevention in the Toilet Environment

Sonja N. BUZINKa,1, Renate DE BRUINa, Theo J.J. GROOTHUIZENb, Eva M.
HAAGSMANa and Johan F.M. MOLENBROEKa,1
a
Delft University of Technology Faculty of Industrial Design Engineering
Section Applied Ergonomics and Design, Delft, The Netherlands
b
Groothuizen Beheer bv, Rotterdam, The Netherlands
Abstract. This study was carried out to determine the need for more appropriate
fall preventive measures and create a knowledge base for design criteria to be
implemented in the Friendly Rest Room project. Literature research and interviews
with users and caretakers were used to create the FRiTA Model, which was used to
identify basic toilet activities with an increased fall risk within the Dutch toilet
ritual. Next, a new toilet support was developed which provides a fine-tuned all-in-
one support solution with an inviting appeal, representing luxury, serenity and
hygiene. Several elementary aspects have been implemented in FRR prototypes.
The results of usability tests with these functional FRR prototypes look affirmative
and promising.
Keywords. Slips, Trips and Falls, Inclusive Design, Toilet, Support, Assistive
Devices
1. Introduction
Statistics show that people are getting older and in the near future, elderly people will
represent an increasingly larger group of the population. Social structures are changing
and many elderly people expect to enjoy a more active lifestyle and benefit from better
living conditions [1,2,3]. Fall accidents are responsible for the majority of serious
injuries amongst the elderly in the category of home accidents. More than one out of
three people over 65 and about 50% of the elderly over 85 years of age fall at least once
a year. The consequences of these fall accidents for elderly people are diverse and can
affect the mental, social and physical condition of the elderly individual. That is why
falls often have a strong impact on daily life [1-7]. The prevention of falls in the toilet
environment is an important theme within the FRR project.
2. Investigating Fall Accidents in the Toilet Environment
The research project was started with the general aim to help prevent fall accidents of
elderly people when they visit a public or semi-public toilet. The first phase existed of
a profound literature investigation on related aspects in the multidisciplinary field
including the geriatric process, falls and fall prevention, Dutch legislation and
1
Corresponding Authors: Sonja Buzink and Johan Molenbroek, Faculty of Industrial Design Engineering,
Delft University of Technology; Address: Landbergstraat 15, 2628 CE Delft, The Netherlands; Email:
s.n.buzink@tudelft.nl, j.f.m.molenbroek@tudelft.nl
184 S.N. Buzink et al. / Fall Prevention in the Toilet Environment
standards on rest room design and the toilet routine in general. This was complemented
with a set of investigations on current available assistive devices for the toilet
environment, the present-day situation for Dutch (semi-)public toilet environments for
elderly people and the handicapped, the view of elderly people (n=10) and nursing
professionals (n=6) on falls and fall prevention by interviewing them [2].
This knowledge was used to develop the FRiTA model for fall risks assessment in
toilet routines [2]. The model was used to identify toilet activities with an increased fall
risk within the Dutch toilet routine and reveal potential problem areas (locations and
actions) within the toilet environment and ritual. This resulted in a set of
recommendations for fall preventive measures in the toilet environment as a whole
[1,2,3], preliminary design criteria and a refined design assignment focussing on
physical product interactions in one specific problem area and aesthetic experiences.
Additional research focussed on area-specific aspects of fall prevention,
ergonomics, usability, aesthetics, and stigmatising design aspects [1,2,3]. Input on the
latter aspects was obtained by literature, using collages and by means of a
questionnaire filled out by seniors (n=19) on their perception of toilet environments.
2.1. The Consequences of Falls for Elderly People
For elderly people falls are, more often than in other age groups, the cause of severe
physical injury and rank high on lists of causes for accidental death [2,6,8]. In the
group of elderly people, 25-50% of falls cause some kind of physical injury [2,5].
Although less than 10% of all falls lead to a fracture, about 52% of fractures in the
older age group are caused by a fall, with hip fractures as most frequently occurring
type of fracture [7]. According to Spirduso [6], more than half of the elderly
hospitalised due to a fall die within one year, and Fuller [8] additionally reports that
approximately 25% of the elderly with a fractured hip as result of a fall die within six
months. In general, elderly women appear to fall more often than elderly men do,
whereas elderly men have a higher mortality rate due to falls.
The fear to fall alone can affect the daily life of an elderly person significantly.
Next to the fear of falling again, elderly people are often afraid of their first fall
accident. Many consider the occurrence of falls a sign for the beginning of the end [6].
Fall-related fears repeatedly result in stiffened locomotion, loss of self-confidence, and
subsequently lead to self-inflicted functional limitations. This, unfortunately, mostly
brings about an increased risk of falling and growing social isolation [2,6,7].
The fear to fall (again) often makes elderly people decide not to lock the rest room
door, not even in a public or semi-public environment. The anxiety of ending up
injured inside a toilet booth, helpless or even dying after a fall is stronger than the
potential embarrassment of a complete stranger entering while using the toilet [2,9].
2.1.1. Risk Factors in General

A broad variety of intrinsic (individual/personal) and extrinsic (external/environmental)
factors influence the extent and presence of the risk to fall for elderly people. These
affect either the stimulus responsible for the initiation of a loss of balance, the
capability to recover a loss of balance or, in some cases, have an effect on both. Most
often though, falls are caused by a combination of several intrinsic and/or extrinsic
factors [2,6,7,10].
S.N. Buzink et al. / Fall Prevention in the Toilet Environment 185
Falls themselves are, apart from any fall-related fear, also responsible for
increasing the risk to fall, especially when multiple falls occur within one year [2,5]. A
repetitively falling person does not necessarily fall due to a similar combination of
factors each time. And while many single risk factors by themselves do not entail a
notably increased fall risk, interaction between risk factors can intensify the fall risk
significantly. Many times, they create a vicious circle, eventually leading to a fall
accident [2,6,8].
Decrease of physical activity and difficulties during the execution of movements
are important contributors to the in intrinsic causes for fall accidents, while physical
limitations together with a more cautious performance of movements reduce the
exposure to extrinsic fall risk factors. This subsequently causes a further decline of the
capability to act in response to danger and risks [5,6].
3. Preventing Falls When Using the Toilet
Everybody has their own toilet ritual, which includes a variable number of relatively
small movements and tasks. In early childhood, one is trained in these activities and the
tasks unite to become, as it were, one activity to be performed almost automatically,
without thinking. This changes when people get older. The ageing process often affects
some of the movements and postures that are part of the toilet routine. This causes the
ritual as a whole to disintegrate, and a task within the toilet ritual previously without a
significant fall risk can suddenly change into a hazardous activity [2,11,12]. In most
cases, people will first try to compensate and slightly adjust their ritual, or use already
present objects for support to accommodate geriatric complaints, before relying on any
additional assistive device [2,9,10].
3.1. Current Fall Prevention Strategies
Currently, a diverse range of fall prevention strategies is in use, which all attempt, by
following various paths, to reduce the occurrence of falls, also for the toilet
environment. The first major step in almost all of these prevention programmes is to
create awareness of fall risks present in the surroundings of an elderly individual.
Multi-faceted approaches tailored to the elderly individual, assessing and modifying
both intrinsic and extrinsic fall risk factors, appear to be the most successful in
reducing the number of fall accidents [2,6,7].
Fortunately, the use of assistive devices in toilet environments seems to be less
affected by the reluctance often shown with other assistive devices [4,11]. Supports in
the toilet environment are the second most frequently used type of assistive devices
after ambulatory aids. For various reasons, their presence, though, does not always
imply (correct) usage. Some elderly people state they not always recognize grab bars as
such. In some cases they are thought to be a towel rack [10], in other cases the user
lacks the necessary strength to use a particular type of support [2].
Proper installation of assistive products in toilet environments is determinative for
the suitability and amount of support offered in real use [1,2,3,10,12,13]. The design of
public or semi-public toilet facilities generally follows a minimal set of accessibility
regulations and guidelines, which are mostly based on average dimensions. In many
situations, anthropometrics guidelines based on averages are acceptable; applying these
guidelines in assistive products for elderly people though, will result in excluding a
considerable number of people from (comfortable) use, since elderly people are,
anthropometrically speaking, far from average.
3.2. Risk Factors within the Toilet Environment
Implementation of a broader range of fall-preventive measures in building regulations,

for instance, should be considered as very important to bring down the number of falls
in toilet environments. Extrinsic aspects of toilet environments can be divided into two
categories: fixed toilet environment (the floor, toilet bowl, etc.) and additional
objects (towels, floor carpets, etc.). Both categories entail a varied, though different
range of risk factors. As the Friendly Rest Room project concentrates on public and
semi-public toilet environments, the fall risk factors incorporated in the fixed toilet
environment will be focussed on.
The layout and interior design of the toilet environment has to be spacious,
practical and clear to be easily accessible for elderly people. The space to manoeuvre in
many toilet environments is very limited, which hinders many, especially those using a
mobility aid like a rollator [2,11]. In a confined, narrow rest room it is easy to find
support against walls; getting up after a fall, though, becomes almost impossible.
A toilet environment accessible for people using a mobility aid like a rollator
should at least have the dimensions of a rest room plus, see Figure 1. Non-elderly
users will most likely appreciate this relatively new type of spacious public toilet
environment as well, for example obese people and people with infants. This set-up
simultaneously removes the first barrier for many elderly to visit a public toilet, as they
no longer will depend on the stigmatised toilet for the handicapped [1].
The nature of the floor surface influences the fall risk strongly. The level of slip
resistance should be sufficient, both in dry and wet circumstances. Various gaits and
types of shoe wear should be taken into consideration in the assessment of the floor
surface as well, as combinations suitable for some can be hazardous for others [2,6].
Figure 1. Dimensions of a toilet room plus Figure 2. The toilet bowl as object to trip over (upper left),
lack of contrast (lower left), visual support and a
deceptively continuing floor (both on right)
The floor should be level, without any thresholds or other trip objects. Wall-
mounted toilet bowls are preferred over floor-mounted ones, as feet or rollator wheels
easily hook behind them [2], see Figure 2.
Elderly people often experience visual difficulties. For this reason sufficient
contrast between all objects in the toilet environment, including walls and floor, is
indispensable, see Figure 2. Clear visual support as in contrasting vertical or horizontal
lines, at or above eye height, will help many elderly people to maintain postural
balance [1,2], also see Figure 2. Usage of wall plinths in the same colour as the rest
room floor should be avoided. They complicate the assessment of the environment for
the visually impaired by creating a deceptively continuing floor [2], see Figure 2.
Blinding or disorientation due to glare or reflections should be avoided. Sufficient
lighting is essential for elderly people to assess the interior of the rest room properly,
but light transitions should be gradual to avoid dizziness or disorientation when
entering the room [2].
Figure 3. Manikin Mathilde demonstrates the basic toilet activities with the highest fall risk (by Landmark
Design Holding BV)
The style and ambience of a toilet environment can be of influence on the possible
risk to fall. Activities connected to urination and defecation are generally considered
very intimate and private [11]. Thoughts about our own toilet ritual already raise some
negative, uncomfortable feelings; those of strangers are seen as even more unpleasant.
The more publicly accessible a toilet is and the less familiar the people are who use it,
the more important it becomes that the environment appears hygienic and as if never
used before. In different ways, this is connected to the perception of the toilet
environment and the behaviour of people during a toilet visit [11]. The way people
perceive the environment determines their well-being, which in turn influences the use
of the facilities and therefore the potential fall risk. Hygiene, privacy and a safe,
comfortable surrounding should therefore also be considered as essential attributes

within the overall toilet environment design to avoid fall accidents [1,3]. Elements, like
assistive devices, bearing a stigma should be banned or redesigned to become an
integral part of the environment.
Figure 4. Several preliminary scale models in different stages of the design process
3.3. Risk Factors within the Toilet Ritual
Transfers onto and from the toilet are well known as one of the most difficult personal
care activities to perform for elderly people [2,10,11]. Many elderly people also
experience difficulties when rising, standing, turning, (un)dressing and reaching [9,13].
Heightened toilet seats can cause constipation problems and prolonged sitting can
cause legs to fall asleep [2,11]. To obtain a complete and proper impression of the
potential risks within the toilet ritual of elderly people, a process tree of the Dutch
toilet routine was created. A broad range of over 40 activities was identified with
changing movements and postures [2,11]. The basic toilet activities, which were
always performed by nearly all users, are most important to focus on when designing a
public or semi-public toilet environment.
An evaluation of hazardous movements within the toilet ritual was performed
which revealed that the activities of opening and closing the door, manoeuvring
through the rest room, turning in front of the toilet, (un)dressing, sitting down,
performing perineal cleansing, rising and checking clothing after dressing were the
basic toilet activities with the highest fall risk [1,2,3,5,11]. In Figure 3, Mathilde, a
manikin designed by Landmark Design Holding Bv for the FRR project, illustrates
these activities.
4. The Design of a New Assistive Product to Prevent Falls
The study above was used as an outline to describe the need for an assistive product to
prevent falls in toilet environments, and to define a design assignment for such a
product. To design a support for a (semi-)public toilet environment with an as large
assistive effect as possible, the design phase focuses on basic toilet activities, as those
activities are performed almost every time by nearly all users. The largest number of
fall-riskful basic toilet activities is performed by Dutch elderly people in the vicinity of
the toilet bowl [2]. Therefore, the design focuses on assisting elderly people properly
during their movements and postures while standing still and manoeuvring in front of
the toilet bowl, (un)dressing, sitting down, performing perineal cleansing and standing
up. The target group consisted of people older than 60 years of age that are able to visit
a public toilet autonomously (whether or not using a simple mobility aid like a walking
stick or rollator) and use the facilities in it without the help of another person. The
product should in no way (physically or mentally) hinder or complicate the use of the
toilet environment by any user, including secondary and tertiary users.
The semi-public environment the product is designed for implies a setting with
durable products, used by multiple users with varying demands and styles of usage.
This also means a relative high level of cleaning and maintenance by specialised staff
(and not/less by the primary user self), and makes a product with a relative higher level
of luxury, compared to a fully public situation, possible.
The emphasis in most current assistive products is on technical functionality and
reliability in assistive behaviour. The new design should distinguish itself from those
products by taking also the usability, ergonomic functionality and aesthetics into
account as equally important.
Through a creative design phase, involving various design techniques, a broad
range of ideas was generated. The most promising ideas were combined to form
interim conceptual solutions. Next to additional research and design sketches,
preliminary scale models played an important role during the following design process,
see Figure 4.
In subsequent design phases, the conceptual design was further developed to a
more detailed level, mapping experiential aspects to physical properties. Design
decisions were made based on aspects of usability and perception of hygiene. The
limited space of toilet environments and the potential big influence of an assistive
device on the perception of the whole environment require the manifestation of the
design to be simple, open, and inviting.
Next to a 3D computer model (see Figure 5), a full-scale visual model of the grab
bar section (see Figure 6) was made as well to evaluate the manifestation of the grab
bar in full scale [1,3].
4.1. Swing
The final support proposal, named Swing, consists of several specially designed
components (see Figure 5): a toilet lift module, a toilet seat and two grab bars alongside
the toilet [1,3]. Each component provides users assistance when performing their toilet
ritual and helps them prevent fall accidents. When applied collectively, though, they
reduce the fall risk even further, as they intensify and supplement each others fall-
preventive qualities.
Figure 5. The 3D computer model of Swing
The design of Swing facilitates a varied range of support to choose from for
elderly users. The design enables sufficient support and assistance for elderly people
between the 5th (often a small female) and 95th (often a tall male) anthropometric
percentiles during various activities of the toilet ritual.
The toilet seat and grab bars are height-adjustable because they are mounted on a
lift module. Ergonomic research during the design process showed that when choosing
for such a type of adjustability, anthropometric needs could be met with a design that is
more compact and less visually present in direct sight. Next to a less complex product
to use for the elderly, this helps to avoid a potentially deterring and stigmatising effect
caused by the dimensions of the supports. The curved surface of the toilet lift module
also includes a back support to provide extra stability while seated.
The toilet bowl applied is a wall-mounted type. The fact that it hangs free from the
floor decreases the fall risk by tripping. The design of the toilet seat is trapezoidal.
Together with the enlarged and slightly concave curved surface this shape ensures
(more) stability while seated. This also reduces the hazard of sliding off the seat, while
sitting on one side for wiping ones buttocks, for example. Furthermore, it eases sitting
down and standing up as it offers enough space to place both hands on the seat next to
the upper legs.
Swing offers various types of support and can be used in many different ways,
according to the wishes of each individual toilet visitor (see Figure 7). When a user
enters the toilet environment without a FRR personified data carrier, the grab bars will
be in the position shown in Figure 5, this way the user will know that at least two
positions are possible.
When rotated backwards, the support bars present a grip to grasp while sitting
down, as well as an armrest to use when seated. When rotated upwards Swing offers
grip in front of the toilet seat, and can also be used to lean against with the hip. The
design of Swing gives the user options to store a walking stick or small bag while
toileting, for example by placing it through the V-shaped opening in the grab bars or
hanging it over the vertical grab bar. In the backwards position, they present a grip to
grasp while sitting down, as well as an armrest to use when seated.
The support and grab bars can be rotated between an upward (vertical) and
backward (horizontal) position and fixed in in-between positions. To change the
position of a grab bar the user grasps and squeezes the button on the lower arch and
give it a slight push or pull in the desired direction until the preferred position is
reached. During this, the mechanism inside carries the largest part of the weight. To
lower or raise the whole toilet unit (including the grab bars), to flush or call someone
for help, the user can use the buttons on top of one of the grab bars.
In the described version of Swing, the handles are adjustable and actively rotated
by the user. The seat can be adjusted in height and tilt, but still provides a static type of
support. In a more elaborate design, Swing could offer dynamic assistance. Sitting
down and standing up could be actively assisted by a rotating movement of the support
bars, for example. This would help the user to initiate and coordinate these motions.
Moreover, a more simplified edition could be marketed, which for instance only
offers the grab bar(s) without the toilet lift to be installed at a personally defined, fixed
height.
The colouring and use of materials is chosen such that it helps to increase the
perception of hygiene and serenity. In most sanitary situations, light/pale blue appeals
as more fresh and new to a user, as it is less sensitive for visual contamination and
yellowing due to cleaning chemicals than white, for instance. Parting lines, surface
curves and edges are designed such that they will not collect dirt, and if minimal
amounts of dirt might collect, it will be out of the line of vision for users. Materials to
be used will conduct heat sufficiently to maintain a relatively cold and fresh feeling
when touched by human skin.
Figure 6. Computer-simulated usage examples by a small elderly female, a tall elderly male and an average
elderly person
Figure 7. The visual full-scale model of the grab bar and some details
5. Conclusions
The fall risk present in toilet environments is determined by the combined action of a
variety of factors. When applying fall-preventive measures in the toilet environment,
the most important thing is to assess and modify the environment as a whole, taking
both intrinsic and extrinsic factors into account. It is possible to reduce the influence of
these factors by applying a full set of appropriate fall-preventive measures.
The conceptual support developed during this graduation project, offers an
innovative and appropriate solution to prevent falls in the toilet environment. Its
components together form a fine-tuned whole with an inviting appeal representing
luxury, serenity and hygiene. In various ways, it offers an enormous improvement
compared to existing assistive products for the toilet environment.
Elderly toilet visitors will no longer be forced to alter their toilet behaviour to
obtain suiting support, as it offers an integrated mix of different types of support. This
ensures that the number of users excluded from usage is minimal.
6. Recommendations
The next step should be the development of a fully functional prototype of the
conceptual design as a whole for usability testing. Only this way it will be possible to
actually verify the design decisions that have shaped the design.
Additionally more fundamental research on topics that have not thoroughly been
studied before would create a better basis to determine the genuine value of the new
design. This includes research into support preferences of elderly, interaction patterns
with different types of support within the toilet environment, as well as a more
elaborate study into the perception of toilet environments by elderly people. This will
create a profound basis for further developments in the field of fall prevention in the
toilet environment.
Finally, it is advisable to re-evaluate current accessibility regulations and
guidelines for toilet environments in detail to include a broader range of criteria
concerning fall prevention.
References
[1] Buzink SN, Molenbroek JFM, Haagsman EM, Bruin R de, Groothuizen ThJJ. S'wing; a fall prevention
product for the toilet environment. Development of a product to prevent falls in the toilet environment
[in Dutch]. Tijdschrift voor Ergonomie. 2004;29: 4-11.
[2] Buzink SN, Molenbroek JFM, Haagsman EM, Bruin R de, Groothuizen ThJJ. Falls in the toilet
[3] Buzink SN, Molenbroek JFM, Bruin R de, Haagsman EM, Groothuizen ThJJ. Prevention of falls in the
toilet environment. In: Pikaar RN, Koningsveld EAP, Settels PJM, editors. Meeting diversity in
Ergonomics. Proceedings of the 16th Triennial Congres of the International Ergonomics Association,
IEA2006. 2006 Jul 10-14; Maastricht, The Netherlands. Elsevier Ltd.; 2006.
[4] Aminzadeh F, Edwards N. Exploring seniors' views on the use of assistive devices in fall prevention.
Public Health Nursing. 1998;15:297-304.
[5] Bueno-Cavanillas A, Padilla-Ruiz F, Jimnez-Molen JJ, Peinado-Alonso CA, Glvez-Vargas R. Risk
factors in falls among the elderly according to extrinsic and intrinsic precipitating causes. European
Journal of Epidemiology. 2000;16:849-859.
[6] Spirduso WW. Physical dimensions of aging. Champaign: Human Kinetics; 1995.
[7] Til J van, Michels PH, Delobelle M. Priv veiligheid: voorkmen van vallen. In: Handboek lokaal
ouderenwerk voorkomen van vallen [in Dutch]. Amsterdam: Stichting Consument en Veiligheid; 2003.
[8] Fuller GF. Falls in Elderly. American Family Physician. 2000;61:2159-2168.
[9] Plante RA. Toilet customs of the elderly; an exploration to find problems caused by the symptoms of
old age and injury into the problems that exist when using the raised toilet seat [Student research report,
in Dutch]. Delft: Delft University of Technology, Faculty of Industrial Design Engineering; 2002.
[10] Aminzadeh F, Edwards N, Lockett D, Nair RC. (2000). Utilization of bathroom safety devices, patterns
of bathing and toileting, and bathroom falls in a sample of community living older adults. Technology
and Disability. 2000;13:95-103.
[11] Kira A. The bathroom. New and expanded edition. New York: Viking; 1976.
[12] Crawford J. Design regulations and bathroom accessibility for the elderly. In: zok AF, editor.
Advances in Applied Ergonomics, ICEA96. West Lafayette: USA Publishing; 1996. p. 724-727.
[13] Bosman J. Toilet usage in the living environment of elderly, research into preferences of grips and grab
bars (in Dutch). Tijdschrift voor Ergonomie. 1999;24:36-41.
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-194
User Preferences Regarding Body Support

and Personal Hygiene in the Toilet
Environment
Dries DEKKER , Sonja N. BUZINK and Johan F.M. MOLENBROEK1
Abstract. In the development process of the friendly restroom, information was

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

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

x To determine the range of preferred positions of supports for sitting down on
and standing up from a toilet, both relative to the body and absolute,
x To determine the preferred type of support and the usefulness for each type for
standing up from, sitting down on a toilet and during wiping of the buttocks,
1
Corresponding Author: Johan Molenbroek; Address: Delft University of Technology; Address:
Landbergstraat 15, 2628CE Delft, The Netherlands; Email: j.f.m.molenbroek@tudelft.nl
D. Dekker et al. / User Preferences Regarding Body Support and Personal Hygiene 195
x To verify whether familiarity with supports in the toilet environment is related

to the preference for a particular type of support,
x To gain insight in the attitudes towards several methods of perineal cleansing,
both in private and semi-public toilet environments,
x To determine the need for the newly-designed washbasin, both in semi-public
and private situations,
x To gain insight in the use of the newly-designed washbasin for washing hands
x To determine the range of positions of the washbasin for washing hands
comfortably.
2. Method
2.1. Subjects
In order to gain insight in the use of the washbasin and supports and to fine-tune the
test set-up, a pilot test was done with five students of the Faculty of Industrial Design
Engineering of the Delft University of Technology. During this test, the students wore
an old-age simulation kit (see Figure 1). The pilot test was held with students, because
students are more readily available than the actual target group of seniors and to avoid
exposing the seniors to unknown risks of the test equipment.
Figure 1. Student wearing the old-age simulation kit

196 D. Dekker et al. / User Preferences Regarding Body Support and Personal Hygiene
The main study was held with fourteen persons from 58 to 78 years of age after the
test was fine tuned and evaluated in the preliminary test. The senior subjects were
asked to fill out a questionnaire about their experience with supports in the toilet and to
record their home situation. The subjects of both studies were asked to demonstrate
several specific activities of the toilet ritual in the simulated toilet environment.
2.2. Equipment and Environment
The test equipment consisted of a toilet bowl, several adjustable supports and a
prototype of the washbasin for both tests. The toilet bowl was hydraulically height-
adjustable over a range large enough to accommodate all subjects, thereby eliminating
the possible influence of a fixed toilet height. The students in the pilot test wore an old-
age simulation kit during the test.
2.2.1. The Old-Age Simulation Kit

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

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

The usage and acceptance of a new washbasin design was investigated by testing a
wooden prototype. Afterwards the test users were interviewed with a questionnaire,
especially made for this purpose. Use situations, often regarded awkward for toileting
and cleansing is a sensitive topic, were represented in this questionnaire by friendly
drawings. In this way test users were not confronted with blunt text or the need the
phrase themselves, just pointing would suffice.
The washbasin prototype was adjustable in height and horizontal position, however
was not connected to the water supply.
Figure 2. The toilet environment and its adjustability in laboratory at TU Delft

The students were asked to show how they would cleanse themselves after
defecating, how they would clean a small plastic bag (representing a stoma), how they
would wash their hands seated as well as standing. They had to do this using the
washbasin including the sprayer and the dryer. The student test revealed that the
washbasin prototype needed more detail for usability testing. After the students test,
the focus of the test set-up was changed from usability to acceptance and the attitude
towards the newly-designed washbasin. The students had to find out how to use the
washbasin on their own to verify whether they understood the functions and given use-
cues.
Before the test with the elderly subjects, all the functions of the washbasin were
explained to the subjects. By ensuring that the elderly subjects understood all the
functions of the washbasin and its aids in their test, it was possible to ask the subjects
their opinion on these functions.
The elderly were asked to pretend to cleanse themselves after defecation with the
available equipment on the washbasin. Following they were asked to pretend to wash
their hands, both while seated and standing (see also height-adjustable washbasin in
Figure 2). Finally, the elderly were asked for their opinion about the washbasin, for use
at home as well as in a semi-public toilet environment.
After the prototype tests, all subjects were asked to fill in a questionnaire about
their experience with different cleansing methods and their attitude towards these
methods, both in private and semi-public situations. The elderly were also asked to fill
in a questionnaire concerning common postures and cleansing methods in a semi-
public toilet environment.
3. Results
In general, all subjects used the supports two-handed with a power grip (see Figure 4) .
The most common way of applying force was by pulling or hanging, except for the side
supports to which a pushing force was more frequently applied. The difference is
illustrated in Figure 3.
Figure 3. Common way of sitting down using the vertical supports by a senior (a) and a typical sequence for
standing up with the side supports by a senior (b)
Figure 4. Power grip, thumb grip and hook grip respectively

Figure 5. Body-related preferred heights of support for the elderly subjects
3.1. Vertical Supports
The subjects most frequently grasped the vertical supports at elbow height while
standing. The elderly showed a lot of variety in grip posture, as can be seen in Figure 5.
Generally, the subjects did not change the positions of their hands between sitting
down and standing up.
3.2. Front Support
For the front support, most of the subjects considered a position slightly lower than
elbow height while standing as most comfortable. The range was a bit narrower than
for the vertical supports, as can be seen in Figure 5. As with the vertical supports, most
subjects prefer to pull or hang to stand up and sit down using the front support. The
support was held at about shoulder height while sitting by all subjects.
From comments by and observation of the subjects, the front support appeared to
have some practical and psychological disadvantages. Some subjects nearly bumped
their heads against it, while others said to feel confined by it.
3.3. Side Supports
Most students liked the side supports best when they were placed at elbow height while
sitting. The elderly mostly preferred them to be at buttock height while standing, as can
be seen in Figure 5. This is lower than the heights considered comfortable for the other
types of supports. In contrast to the other types of supports, a pushing force was used
more often for sitting down and standing up with the side supports, as illustrated in
Figure 3b.
3.4. Correlation of Preferred Positions of the Supports and Anthropometrics
The subjects were asked for the optimal heights of the three types of support for sitting
down on and rising from the toilet. The heights of all supports were adjustable. The
depths of the vertical and horizontal front supports were adjustable only in the test with
the elderly subjects. The depths were measured from the front of the toilet seat and the
heights from floor level. No strong correlations were found between the measured
anthropometric dimensions and the preferred positions, as is illustrated in Figure 6.
3.5. Preferred Type of Support
When subjects were asked to choose between the different types of support, both
students and elderly preferred the vertical support most frequently for standing up and
sitting down, as shown in Figure 7. If stability is needed during use of the toilet, for
example for wiping, the side supports also provide a good solution according to many
elderly subjects.
3.6. Relation between Familiarity and Preference Supports
The elderly were interviewed at home prior to the experiment in order to investigate to
what extent they were familiar with supports in the toilet environment and to record
their home toilet situations.
Familiarity with supports was mapped in order to verify whether there are relations
between the familiarity with and the preference for a specific type of support. The
results show that familiarity has a significant relation with preference as the five
subjects familiar with supports favour the vertical supports for standing up and sitting
down.
depth of vertical supports (mm) height of front support (mm) height of side supports (mm)
1400
500 1000
400 1200
800
300
1000
200
800 600
600 700 800 900 700 800 900 380 420 460 500 540
comfortable reach (mm) fist height standing (mm) popliteal height (mm)
senior student
Figure 6. The preferred depths are measured from the toilets front and the preferred heights from floor level
Figure 7. Preferred type of support for three phases in the toilet ritual
Figure 8. Different postures of elderly wiping their buttocks with toilet paper
Figure 9. Different postures while cleaning with the hand sprayer

3.7. Personal Hygiene
Both the student and elderly subjects were asked to pretend to cleanse themselves with
the aids available on the washbasin prototype. This resulted in a lot of different
postures, as illustrated in Figure 9. As the washbasin prototype was not functional, the
illustrated postures are only valid to indicate the variety of postures that will be used.
On three moments during the test, the fourteen elderly subjects were asked to
demonstrate how they would apply toilet paper for cleansing after defecation.
A total of seven combinations of postures and approaches for application were
identified, which are represented in Figure 8.
16 urinating 16 defecating
bidet
14 14
toilet
paper
12 12
humid
tissues
10 10
Count
bottle of
8 8 water
6 6 shower
toilet
4 4
2 2
public private public private
Figure 10. Seniors preferences for cleansing aids after urinating and defecating
Figure 11. Different strategies for raising the washbasin
3.8. Preferences for Perineal Cleansing
Although the aids for perineal cleansing on the washbasin were accepted better than
expected, the answers given by the subjects show that more traditional methods of
cleansing (in the Netherlands, toilet paper or wet tissues) are still most preferred by the
subjects, see Figure 10. Some elderly prefer a combination of dry toilet paper and wet
tissues, while others prefer the bidet or hand-sprayer for perineal cleansing. Wet tissues
are especially popular after defecating.
All students stated to prefer toilet paper for perineal cleansing after defecation and
urination, although almost all of them say to use the hand-sprayer when no alternative
is at hand.
Figure 12. Positions of the washbasin chosen by the elderly for washing hands while seated
Unexpectedly, it seems that students are not as open to new concepts for perineal
cleansing as the elderly. The students state only to want to use a sprayer-dryer
combination when no alternative is at hand. The difference could be explained by the
fact that the students were only asked about their attitude in semi-public situations and
that the elderly were questioned about both private and semi-public situations.
3.8.1. Using the Washbasin for Washing Hands

The subjects were asked to pretend to wash their hands, both while seated and standing,
and to put the washbasin in the most comfortable position for this activity. The
washbasin was considered somewhat small, and the sprayer and the dryer on the sides
limited the space to move the hands.
In the students test, the most frequently used method for moving the washbasin up
is by manipulating the handle in front of the washbasin see also Figure 11. The rubber
buttons, originally intended for this operation, were used as well, and one subject tried
to lift the whole of the washbasin to elevate it. The students test also revealed the lack
of sufficient contrast between the washbasin parts. This will create problems especially
for the visually impaired.
All subjects were able to find comfortable positions for washing the hands, both in
sitting and standing posture. Some students stated to be too impatient to raise the
washbasin to a comfortable height for a short activity like washing hands. The total
heights range of the test of the elderly subjects varies between 470 mm and 1090 mm.
It was expected that the elderly would prefer to place the washbasin over their lap
or between their legs, as this position allows a more relaxed posture during hand-
washing. This appeared not to be true as can be seen in Figure 12.
4. Conclusions
The studies resulted in several very valuable answers to questions of the designers on
the usage of supports within the toilet ritual, in addition to information on the
acceptance and usage of the newly-designed washbasin. The conclusions that can be
drawn from these studies are that the test users:
x Prefer vertical supports for standing up and sitting down,

x Consider the washbasin to be a valuable addition to the FRR toilet, but needs
further development.
5. Recommendations
One of the most interesting topics for future study is the description of comfort and
discomfort zones for the positions of the supports around the toilet, and whether there
is a relationship between the boundaries of these zones and anthropometry. In a similar
study, the influence of different types of support around the toilet on the sit-to-stand
and stand-to-sit motion could be investigated. An analysis could be made of the
influence on the trajectory of the centre of gravity, for example. This could eventually
lead to the developments of supports in the toilet environment that better suit the
variation of the human anthropometry for the sit-to-stand and stand-to-sit motion.
Another interesting topic for future study regarding the use of the washbasin and
its cleansing aids could be a real-life test of the functional cleansing aids on the
washbasin when used for perineal cleansing. Most subjects in this study were not used
to perineal cleansing using water. Therefore, it is also considered advisable to perform
a longitudinal study in which the washbasin design and the aids for perineal cleansing
are tested. This gives the usage of the new aids for perineal cleansing a chance to
evolve to a more automatic activity, like cleansing by toilet paper currently is for most
Dutch people.
The subjects in this study were mobile enough to come to the test facility.
Therefore, the difference in behaviour and opinion between elderly people with more
limitations and the subjects in this study could be verified.
At the same time, still more data needs to be collected on common toilet habits and
preferences concerning perineal cleansing, especially those of the elderly.
Finally, one of the challenging aspects of this study was the issue of ethics. It
would be very valuable to develop methods of user research in the toilet environment
or other taboo areas without compromising the privacy of the participating subjects and
the concept of informed consent. These methods should ideally yield the same
information as unobtrusive, observational user tests.
References
[1] Buzink SN, Molenbroek JFM, Haagsman EM, Bruin R de, Groothuizen ThJJ. Swing; een valpreventie
product voor de toiletruimte. Tijdschrift voor Ergonomie. 2004;29 (5): 4-11.
[2] Buzink SN, Molenbroek JFM, Haagsman EM, Bruin R de, Groothuizen ThJJ. Falls of elderly in rest
rooms: a study on influential factors. Gerontechnology. 2005;4 (1): 15-26.
[3] Buzink SN, Dekker D, Bruin R de, Molenbroek JFM. Methods of personal hygiene utilized during
perineal cleansing: acceptance, postures and preferences in elderly Dutch citizens. Tijdschrift voor
Ergonomie. 2006;31(3, Special IEA06 issue): 36-44.
[4] Dekker D, Buzink SN, Molenbroek JFM, Bruin R de. Hand supports to assist toilet use among the
elderly. Applied Ergonomics. 2007;38 (1): 109-118.
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-207
Biomechanical Aspects of Defecation with

Implications for the Height of the Toilet
Chris J. SNIJDERSa,b,1, Johan F.M. MOLENBROEKa and Rozemarijn A. PLANTEa
a
Department Industrial Design Faculty of Industrial Design Engineering Delft
University of Technology, Delft, The Netherlands
b
Department of Biomedical Physics and Technology
Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
Abstract. Study Design: Questionnaire on impairments, biomechanics of posture

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

Low Back Pain
1. Introduction
The coming 25 years predict an 88% increase in elderly of an age above 65 years,
resulting in 800 million elderly worldwide. Symptoms of old age can be classified as
follows: physical, psychomotoric, sensoric and cognitive. Decrease of balance, co-
ordination, muscle force and joint mobility interfere with the use of a toilet. Dizziness
and faint mean risk of falling which can also be provoked by a loose object on the floor
like little carpets. Therefore, risk analysis provides strict requirements for the design of
toilets. Standards are introduced for lay-out of toilets in relation to transfer from
wheelchair to toilet seat. Few, however, is known about usability issues as described in
other chapters. In the following we restrict ourselves to the height of the toilet seat
which has implications for sitting down and standing up, urination, defecation,
grasping of toilet paper and cleaning the buttocks and anal cleft. Special concern
herewith is the rationale of elevation of the toilet seat. No studies are known to us that
measured the advantages of toilet elevation. In contrast, squatting is supposed to be the
only natural defecation posture for a human being [1,2]. This lead to the idea that a
1
Corresponding Author: Chris Snijders; Email: c.snijders@erasmusmc.nl
208 C.J. Snijders et al. / Biomechanical Aspects of Defecation with Implications
sharp angle between thigh and trunk promotes defecation [3]. Therefore studies were
designed using cinedefecography for the measurement of parameters such as anorectal
angle, perineal descend and puborectal length in relation to patient position in sitting
[4,5]. The study of squatting would not be representative for the Western population.
The anorectal angle was found to be sharpened in the erect standing position and
significantly wider during pushing in sitting position. The length of the puborectalis
muscle sling was increased during pushing as well [4,6]. The puborectalis muscle is the
most important muscle of continence because of its sensitivity as well as its motor
activity. It contains sensory receptor organs which trigger off the rectal sphincter reflex
mechanism and produce a feeling of fullness. It is assumed that its contraction in erect
posture will cause the anorectal angle and with it the reflex and voluntary contractions
of the puborectalis. The internal anal sphincter has ambivalent properties because it is
the most important factor in maintaining the anorectal barrier to pressure at rest and at
the same time relaxation of the internal sphincter will initiate defecation [7,8].
Phenomenological studies are consistent with respect to the positive influence of
lowering seat height. Therefore, defecation may not be improved by raising the seat
height. Because this issue is not reported in literature we decided to study the use of a
toilet with special attention to elderly and higher seats than normal.
2. Methods
The present study consists of three parts, a questionnaire, a biomechanical study and an
anthropometric analysis.
A verbal inquiry was held among 14 elderly of which 12 were living independently
in a care institute. Two needed help for daily activities, including the use of the toilet.
The average age was 77 years (67-98). The average condition was considered poor as
compared with the peer group. This was particularly related to grip force [9].
In the biomechanical study the so-called click-clack movement was induced in 3
male and 3 female human bodies (age range 51-99 years), admitted for embalming at
the department of Neuroscience. The experiments were performed prior to embalming
since a pilot study showed that embalmed specimens were too stiff for this experiment.
The bodies were positioned on a specially designed apparatus which allowed for
control of postural change while seated. One forward-backward translation of the trunk
was performed with shoulder support only. This allowed for free backward tilt of the
pelvis combined with forward flexion of the spine (Figure 1). In the sagittal plane
needles (1.5 mm diameter) were inserted into the ilia (posterior superior iliac spine),
sacrum (the medium sacral crest of S1) and L5 (the spinal process). The backward
translation of the upper body was accomplished using a spindle, moving the shoulder
rest in steps of 1 cm. After each step, photographs were taken from the side view and
the top view. The limited experimental conditions excluded the use of video cameras
and markers. Angles were measured (all photographs by 4 persons) on a drawing table,
with an accuracy of 0.25. This study was approved by the Medical Ethical Committee
of the Erasmus MC, University Medical Center Rotterdam.
The third part of the study dealt with anthropometric data as reported in articles
and books, with special attention to popliteal height.
C.J. Snijders et al. / Biomechanical Aspects of Defecation with Implications 209
Figure 1. In sitting translation of the upright trunk from a forward position (right) to a backward position
(left) involves transition from one stable position to another. This transition from lumbar lordosis to lumbar
kyphosis is called the lumbopelvic click-clack movement [10,11].
3. Results
Problems with the use of a toilet were experienced by 8 of the 14 elderly. In their
homes an elevated toilet was installed. All respondents used the hand grip when
standing up whereas all women experienced problems with reaching the ground with
the feet. Four elderly reported constipation while 3 of them had a toilet raiser. This
meant that problems with defecation arise with a seat surface 4-6 cm above normal (8-
10 cm above 39 cm standard bowl height). The opening of the toilet raiser was
considered insufficient because it necessitates shifting forward for cleaning and shifting
backward for urination. Shifting forward to achieve foot contact can dirty the seat with
faeces.
With the view on defecation Figure 2 shows the result of the rotations of L5, sacrum
and ilium with respect to each other. Backward movement of the trunk widens the L5-
sacrum angle. During ventral flexion of L5 the sacrum rotates in opposite direction
with respect to the ilium (counternutation, see also Figure 3). The model becomes
three-dimensional and complete by adding Figure 4. It illustrates the agonist-antagonist
action about the sacroiliac joints of the pelvic floor muscles and the deep back muscles
which attach to the sacrum (sacral part of multifidus). This relates back muscle
dysfunction with pelvic floor muscle dysfunction [12,11] which was verified in a
clinical study [13]. Furthermore, Figure 4 illustrates the action of transverse oriented
muscles in the abdominal wall.
Figure 2. Stepwise backward movement of the upright upper body progressively widens the L5-sacrum
angle dorsally (grey line), while the sacrum rotates backward with respect to the iliac bones (counternutation,
black line). Horizontal axis: estimated horizontal position of centre of gravity of upper body in cm with
respect to the ischial tuberosities. Vertical axis: average values of relative rotations of L5, sacrum and ilium
in the sagittal plane of all specimens (n = 6) in degrees. SD values at 10, 0 and +10 are respectively 0.5, 0
and 1.44 for sacrum-ilium, 0.95, 0 and 0.60 for L5-sacrum.
In particular the transversus abdominis can pull between the hip bones which
results in compression of the sacroiliac joints. This is called self-bracing [14]. In an in
vitro study it was demonstrated that pelvic floor muscles can have such a stabilizing
effect as well [15]. The model presents a deep muscle corset for pelvic stabilisation and
shows co-ordinated action of muscle groups with change of muscle stretch by change
of upper body posture. This model was supported by observations in the microgravity
environment [16].
During space flight it was reported by a cosmonaut that prolonged lumbar
kyphosis was related with low back pain as well as constipation. The latter can be
explained as follows: in space loss of lordosis occurs, which may cause strain in
ligamental structures as the iliolumbar ligaments inserting on the iliac crest (the site of
pain described by the cosmonaut). In order to stabilize the spine and pelvis the intra-
abdominal pressure can be increased and the pelvic floor muscles can have a higher
Figure 3. The relation between ventral rotation of L5 and backward rotation of the sacrum (counternutation).
Lumbar lordosis represents movement in opposite direction [11]. Waste of multifidus force or hyperactivity
may result in dysfunction of the pelvic floor muscles resulting in e.g. urine incontinence, frequency,
constipation or sexual complaints. Iliolumbar ligament (1), axis of rotation of sacroiliac joint (2), sacroiliac
joint surface (3), pelvic floor muscles (4), anus (5), vagina (6), urethra (7), pubic symphysis (8).
Figure 4. Deep muscle corset being subject to wasting and loss of co-ordination which relates low back pain
with pelvic floor problems. Biomechanical model on sacroiliac joint stability with transversely oriented
abdominal muscles (transversus abdominis), back muscles (sacral part of multifidus) and pelvic floor muscles
(a.o. coccygeus) [12,16].
level of activity. This higher level of activity can lead to constipation, as demonstrated
in a population of low back pain patients [13].
For the anthropometrics popliteal height is chosen. It was shown that this is a
better measure than a percentage of body height for the choice of optimal, individual
seat height [17]. For different countries different values of P50 have to be chosen. For
an adjustable toilet height the range could be chosen between the P5 female adults in
Spain and Portugal (34 cm) [18] and the P95 male adults in the Netherlands (53 cm)
[9].
4. Discussion
This study questions the suitability of higher toilets for the elderly. Arguments against
elevation of the toilet are the chance of constipation and loss of postural control. The
assumption that elevating the toilet will facilitate seating oneself and raising to ones
feet lacks any evidence in scientific literature. One may find it a given to solve the
problem of transfer by offering the elderly a firm support for the feet. In addition, hand
grips can be offered which may be positioned perfectly in front of the individuals
trunk.
Absence of foot support may cause loss of postural control, sinking in the toilet
seat, and risk of fall during standing up. An example is stumbling over slippers fallen
from the dangling feet. Answers to the questionnaire revealed that the opening of a
toilet raiser is insufficient, which causes the elderly to shift forward for cleaning after
defecation and shift backwards for urination. Shifting forward to achieve foot contact
can dirty the seat.
The ignored advance of a standard toilet is that it facilitates the changing of body
posture. A biomechanical model describes the so-called click-clack movement which
entails backward tilt of the pelvis combined with forward flexion of the spine towards
lumbar kyphosis. This results in backward tilt of the sacrum with respect to the ilium.
The opposite movement (the clack-click movement) towards a forward position of the
trunk and hollow back may elongate pelvic floor muscles which could facilitate
defecation by means of stretch induced sphincter response while pelvic floor relaxation
may ease puborectalis tension. These speculations suggest that postural change with
alternating click-clack movement as well as small lateral shifts may facilitate
defecation. Such shifts are limited or even impossible when sitting unstable on an
elevated toilet seat.
Medical indications for toilet elevation may play a role in specific cases. For
example, restricted flexion in hip and knee joints which possibly may be related to
contraction of the rectus femoris muscles. The question is whether adequate
physiotherapy can solve this problem. Another question remaining is whether physical
aids induce the retardation of physical functioning. This is in accordance with the
paradigms invalidating invalidity and use it or lose it. No research is known to us
to how elderly make a transfer to standing, coming from being seated with dangling
feet.
A plausible solution to the previously mentioned problems may be a toilet which
can be adjusted in height. Examples exist of sophisticated designs which can lift the
elderly by means of a raising and forward tilting seat. For temporarily use the
instalment is firm and simple. The range of sitting height for Europe could be 34-
53 cm.
Elderly do not choose elevated toilets themselves, these are prescribed [19]. Here
it can be noted that after use of a toilet seat much higher than the usual 43 cm (e.g.
53 cm) elderly return to their easy chairs (40-43 cm) or the dinner table (43-45 cm).
An essential question which needs research to be answered is: which diseases and
impairments require a special aid in toilet use. The present study leads to the
conclusion that the use of a toilet raiser has only disadvantages for the users and
should not be recommended as a solution for facilitating sitting down and standing up.
Instead, hand grips at proper height in front of the impaired may offer a solution
without the accompanied disadvantages of toilet elevation.
The results of present study lead to the consideration that a toilet raiser should not
be installed at random as a solution for facilitating sitting down and standing up.
Instead, hand grips at proper height in front of the impaired may offer a solution
without the accompanied disadvantages of toilet elevation. Thus, advocating against
permanent instalment of toilets higher than normal is certainly justified.
References
[1] Sikirov D. Comparison of straining during defecation in three positions; results and implications for
human health. Dig Dis Sci. 2003;48(7):1201-1205.
[2] Sikirov BA. Primary constipation: an underlying mechanism. Med Hypotheses. 1989;28(2): 71-73.
[3] Kira A. The Bathroom. Penguin Books 1966; 1976.
[4] Altomare DF, Rinaldi M, Veglia A, Guglielmi A, Sallustio PL, Tripoli G. Contribution of posture to the
maintenance of anal continence. Int J Colorectal Dis. 2001;16(1):51-54.
[5] Jorge JM, Ger GC, Gonzalez L, Wexner SD. Patient position during cinedefecography; influence on
perineal descent and other measurements. Dis Colon Rectum. 1994;37(9):927-931.
[6] Piloni V, Montesi A, Amadio L, Giammarchi C. The coronal anatomy of the pelvis at rest and under
straining. Radiol Med. 1994;88(5):612-619.
[7] Dubrovsky B, Filipini D. Neurobiological aspects of the pelvic floor muscles involved defecation.
Neurosci Biobehav Rev. 1990;14(2):157-168.
[8] Holschneider AM. The problem of anorectal continence. Prog Pediatr Surg. 1976;9:85-97.
[9] Steenbekkers LPA, Beijsterveldt CEM. Design-relevant characteristics of ageing users; backgrounds
and guidelines for product innovation. Delft: Delft University Press; 1998.
[10] Snijders CJ. The form of the spine related to the human posture. Agressologie. 1972;13B:5-14.
[11] Snijders CJ, Hermans PFG, Niesing R, Spoor CW, Stoeckart R. The influence of slouching and lumbar
support on iliolumbar ligaments, intervertebral discs and sacroiliac joints. Clinical Biomechanics.
2004;19(4):323-329.
[12] Snijders CJ, Vleeming A, Stoeckart R Transfer of lumbosacral load to iliac bones and legs. Part II -
Loading of the sacroiliac joints when lifting in stooped posture. Clinical Biomechanics. 1993;8:295-301
[13] Pool-Goudzwaard AL, Slieker ten Hove MCPH, Vierhout ME, Mulder PGH, Pool JJM, Snijders CJ,
Stoeckart R. Relations between pregnancy related low back pain, pelvic floor activity and pelvic floor
dysfunction. International Urogynaecology Journal. 2005;16(6):468-474.
[14] Snijders CJ, Ribbers MTLM, Bakker JV de, Stoeckart R, Stam HJ. EMG recordingsof abdominal and
back muscles in various standing postures: validation of a biomechanical model on sacroiliac joint
stability. Journal of Electromyography and Kinesiology. 1998;8:205-214.
[15] Pool-Goudzwaard AL, Hoek van Dijke GA, Gurp M van, Mulder P, Snijders CJ, Stoeckart R.
Contribution of pelvic floor muscles to stiffness of the pelvic ring. Clinical Biomechanics.
2004;19:564-571.
[16] Snijders CJ, Richardson CA, Pool-Goudzwaard AL, Hides JA. Low back pain in microgravity;
causality and countermeasures. 15th IAA Humans in Space Symposium. 2005 May 22-26; Graz,
Austria.
[17] Molenbroek JFM, Kroon-Ramaekers YMT, Snijders CJ. Revision of the design of a standard for
the dimension of school furniture. Ergonomics. 2003;46(7):681-694.
[18] Jrgens HW, Aune IW, Pieper U. International Anthropometric Data FB587. International Labour
Organisation; 1990.
[19] Plante R. Inquiry among elderly on problems with toilet use. Intern report (in Dutch). Delft University
of Technology, department ID of the Faculty of Industrial Design Engineering; 2002.
Section 5
Design for Improved Toilet Environments
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-217
Designing for Older Peoples Experience of

Bathing
Stella U. BOESS1
Abstract. Design work was done for the interior of an assisted bathroom in a
sheltered housing complex for older people in England. The study included initial
research with potential users, the design work and an evaluation of the design
outcomes with actual users. An analysis is presented of the extent to which the
outcomes of the design work contributed to the enhancement of well-being of
users. Conclusions are drawn on a useful approach to the design of assistive
environments. Firstly, an integrative perspective should be adopted that considers
various stakeholder needs and integrates them in a desirable overall impression.
Secondly, designers should regard assistive technology from the users perspective,
including a critical view on it. And thirdly, designers should take what can be
observed from users as a point of departure, and then project their own ideas of
what is desirable over that situation, towards proposals that go beyond what
already exists.
Keywords. Design Process, Assistive Environments, Well-Being, Design

Evaluation
1. Introduction
This chapter analyses to what extent the outcomes of a design project contributed to the
enhancement of well-being of users.
Design work was done for the interior of an assisted bathroom in a sheltered
housing complex for older people in England. The design process included initial
research with potential users, the design work and an evaluation of the design outcomes
with actual users. Some insights from an evaluation of this design project are presented
here. Three aspects of the design process were identified that influenced the success of
design outcomes for users. It is suggested that these three aspects, Integration,
Proximity and Projection, should be taken into account in a design project that aims to
enhance the well-being of users.
There are parallels between the design case featured in this chapter and the design
of accessible toilet environments that is the focus of this book. Both are situated in a
semi-public area, involve personal cleansing functionality and are frequented by people
who benefit from its assistive functionalities. The reflections on the design process
might therefore be transferable. The analysis provides points of departure for further
research into design approaches that seek to enhance users well-being.
1
Contact Information: Stella Boess, Faculty of Industrial Design Engineering, Delft University of
Technology; Address: Landbergstraat 15, 2628 CE Delft, The Netherlands; Email: s.u.boess@tudelft.nl
218 S.U. Boess / Designing for Older Peoples Experience of Bathing
2. Issues in Users Experience of Assistive Functionalities
Connell and Sanford [1], in discussing disability generally, raised the issue that
specialised provision was a potential instrument of the stigma and stereotyping
experienced by people with disabilities. Mullick [2] set up experimental test situations
of bathrooms and demonstrated empirically that people felt more disabled in an
environment adapted specifically for disability, than in a conventional one.
Sociological studies (e.g. [3]) highlighted the fact that assistive devices are often
disliked and underused by older people in their daily lives. The devices are mostly
provided through the mediation of medical professionals. Outlets are discreetly tucked
away, because ownership and use of such products is perceived to be stigmatising their
user. These sources point to issues of stigmatisation and disablement that can arise
from assistive technology.
2.1. Theoretical Aspects of Experience Issues
An important influence on how successfully people interact with their environment is

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

their environment.
Research on existing and potential assistive environments, investigating their
symbolic meanings.
Besides these theoretical notions, there are precedent approaches to the design of
assistive functionalities. A design project can profit from insights in them. Some
precedents are looked at in the following section.
S.U. Boess / Designing for Older Peoples Experience of Bathing 219
3. Design Approach Precedents
3.1. Public and General Provision
Since the 1960s, architects and planners have addressed the problems of disability and
access by establishing criteria for supportive housing, and especially for bathrooms [9,
10], and designing in accordance with them. Goldsmith [11] tells the story of the
disability movements struggle in the UK and the US for access to public amenities,
seeking to overcome their marginalisation in society. The movement succeeded in
getting equal access legislation introduced (e.g. ADAAG [12]). By now, many types of
equipment have been developed in industry in accordance with such guidelines, to
assist disabled and/or older people in their daily lives.
Recommendations and guidelines are being developed for the purpose of
guaranteeing equal access, and their (ever-evolving) contents are ideally something of a
bottom line for consumer products as well as public access provisions.
3.2. Changes in Consumption Culture
The demographic change of recent years has also resulted in the emergence of
initiatives that focus on access for and cultural integration of older people. These
initiatives tend to focus on a change in consumption culture.
Initiatives like DesignAge (founded in 1991) at the Royal College of Art in London
raised the issue that older people are a target market waiting to be discovered, and
stimulated designers interest in designing products for older people [13]. Such a
change towards a more positive view is now becoming noticeable in Western societies.
Manufacturers are discovering the Third Agers [14], and this has created a shift in
design and marketing towards more inclusivity, as well as increased demand for
research into their lifestyles and preferences.
Recent research on the topic of bathrooms therefore differs from traditional
research on disability provisions by focusing on the preferences (e.g. [15]) and
experiences of older consumers (e.g. [16,17]), rather than mainly on technical
adaptations to compensate disabilities.
Some findings and conclusions from a study by Boess et al [17] are reported next.
The study reflects on those aspects of a design process that contributed to the
enhancement of well-being for users.
4. The Design Project
A design project was carried out at Staffordshire University, UK, by the author and
another designer researcher, and in collaboration with a sheltered housing provider.
The sheltered housing provider sought design recommendations for the individual
bathrooms of their residents and design proposals for an assisted bathroom. This type
of room exists in most older peoples residences in the UK. The main purpose of an
assisted bathroom is for carers to assist people in bathing who cannot do so in their
own flats. Before any design work was started, the prospective users needs were
researched:
Figure 1. Focus group session with Figure 2. An interactively usable scale model
moodboard making
Figure 3. Three of the moodboards made by participants
Figure 4. The bathrooms of some of the interview participants
An initial qualitative study to research user needs and wishes comprised focus
group interviews (Figure 1) which included participants making moodboards of
their ideal bathroom (Figure 3), individual interviews and photographic
documentation of participants homes, with in total 24 participants between 60
and 90 years of age (Figure 4). They were residents of various sheltered
residences in England.
The staffs needs were researched through visiting existing assisted bathrooms,
interviewing staff, and through interactive use of a scale model of the proposed
design in discussions with the management of the older peoples residence
(Figure 2).
Research methods and activities have been reported elsewhere [18,19]. The
analysis of the initial research resulted in a model describing participants efforts to
realise their needs and wishes by negotiating their well-being through physical,
perceptual or projective interactions with their environment. The conclusions of the
initial research were that the design of bathroom facilities for older sheltered housing
residents should:
Answer cultural needs (Im not into putting on the style, not at my age, but I
would like a nice peach bathroom and peach curtains [] and [] a few flowers
in the window)
Realise usability: adaptability in use and low physical demands on the user;
unobtrusive safety (Grab bars [are for] them, the disabled.) But also:
(Getting in and out, its difficult, you know.)
Provide for an overall relaxing atmosphere (I love a good soak. Get the Radox
going ...)
The research outcomes were applied in design work on the assisted bathroom of a
newly built sheltered residence. In this sheltered housing residence, the assisted
bathroom was situated in a semi-public central area of the building complex, and
integrated with the sports facilities.
The design interventions that were based on the research, and which were
implemented in addition to the standard elements of an assisted bathroom (bathtub with
seat, toilet with grab bars, wash basin), are shown in Figure 5. The author carried out a
qualitative evaluation of the design work after the assisted bathroom had been in use
for a year. Traces of use of the assisted bathroom were noted. For example, it was
observed how objects in the room had been changed or not changed, how storage and
decoration ledges were being used, and what objects had been placed in the room.
Furthermore, short interviews with five residents, two carers and a longer
interview with the manager of the residence were conducted. Methodological aspects of
the evaluation have been explained elsewhere [20].
The evaluation resulted in an assessment of the successes and failures of the design
intervention, on the basis of observations and emerging narratives. These were also
used to look again critically at the initial study findings and design approach. This
assessment led to the identification of three themes that influence to what extent a
design process produces outcomes that enhance the well-being of users, by supporting
them in their physical and physiological interactions with their environment, and by
contributing to their ability to establish or re-establish an intact identity as individuals.
The three themes are described in the following.
Figure 5. Schematic of the design interventions
5. Outcomes of Reflection on the Project: the Three Themes of Integration,

Proximity and Projection
5.1. Integration
Integration means that a design approach needs to arrive at a central theme that
corresponds to users experience of their environments, under which various disparate
elements must be integrated.
Users of the assisted bathroom liked the overall design. But they also pinpointed
some shortcomings. For example, grab bars had been selected which were the standard
choice to comply with the functional requirements for an assistive room of this kind.
Users of the room found that the combination of design aspects which carried
contrasting associations for them, disability versus homely bathing, detracted from the
overall quality of their experience of using the room. The grab bars should have been
integrated better with an overall impression suggesting homely bathing (Figure 6).
Furthermore, a design process needs to investigate a design problem from the
perspective of all stakeholders involved, even if the needs of one particular group are
the focus of the design. The research had focused primarily on one group of users: the
Figure 6. Standard grab bars and cleaning equipment versus a homely bathroom feel.
senior residents who would bath in the room. The staffs needs had been researched
through interviewing and interactive use of a scale model as mentioned above, but not
to a sufficient extent, as it turned out. It would have been necessary to also observe and
follow actual activities. There was not enough space for the storage of cleaning
equipment in the room (Figure 6). It ended up being left out in the open, which was
perceived as a problem by users. The staffs needs would have had to be researched
better to also serve the senior users better. The needs of various kinds of user have to
be integrated.
Summarizing, a design process should deliver an integration of sometimes
disparate elements towards one desired overall impression. It should involve an
encompassing assessment of the stakeholder issues involved by looking at the design
problem from several perspectives, and then integrating them towards one main goal.
5.2. Proximity
Proximity means that a design approach needs to be sympathetic to users experience

of their environment. For example, a bench had been custom-designed for the assisted
bathroom so that users could sit on it to undress (Figure 7). A custom-designed grab
bar that had been planned to go next to it, had been dropped from the planning process.
That meant it was not easy to get up from the bench. An extra chair of a kind that had
been popular with participants of the initial research (it was represented in an image as
part of the visual tool), was brought in later (Figure 7). The relatively cheap rattan chair
had integrated arm rests which were found to be conveniently usable as supports.
In the research, it had been found that participants were very resilient,
compensating reduced physical fitness in coping with environmental demands. They
asserted their individual preferences and sometimes rejected institutional or
technological solutions, instead preferring informal and ad-hoc solutions.
Designers should develop a sympathetic proximity to users experience of their
environment. Through user research, designers can learn to view technology from the
users perspective and examine its benefits critically. Technology can alleviate
environmental press but it can also, and this should not be overlooked by an overly
optimistic designers view, cause people to get stuck in situations beyond their own
ability to cope.
Figure 7. Custom-designed bench with rattan chair in front of it
5.3. Projection
Projection means that a design approach needs to realise that an observed status quo
may bear little resemblance to a situation that would be desirable to users. Designers
should take as a point of departure their observations and users statements on what
enhances well-being. Then, designers should connect that to their own specially
developed expertise of desirable aesthetics of environments. That way, ideas can be
taken much further than the status quo.
For example, while some participants of our initial study had said Im happy
[with my disabled shower], some also said things like this isnt home, Im ashamed
of my bathroom, So were stuck again. Some of the very environments which,
presumably, had been specially geared towards answering residents needs and wishes,
were apparently perceived by them as oppressive or limiting. Participants did not want
design for old. How could a designer distinguish between being the problem and
being subjected to a problem? How or how much are the things that surround users
intrinsic to their lives, and how much are they just being attributed to them while
looking on from an outsider perspective?
In the case of this research, participants felt that a desirable bathroom environment
would have a feel of fresh air and homeliness, would allow for them to realise personal
care privately and possibly with informal help (friend or relative rather than carer),
would provide them with readily available low-tech tools, and would be flexibly
adaptable to the flow of their varying (rather than invariably declining) physical fitness.
From wishes such as these, the following idea themes were generated for a better, even
more user-oriented design of an assistive bathroom environment:
Home/Wellness. Aesthetic home- or wellness associations and functionalities.

Such associations should be aesthetic guiding motives for design, with assistive
functionality integrated into these notions.
Soft tools. Functions in the room could be seen in terms of tools that can easily be
manipulated and moved around, that are pleasing to the hand and that have an
easy-access place where they live. Items might be grouped as toolboxes.
Nature. The ability to stay connected with the time of day, with the weather, and
the season of the year is desirable.
Fold-up. Physical objects as well as forms of organization should be geared
towards adaptability to use at a particular time, in a particular place, by a
particular person, but not present an obstacle, e. g. through physical volume and
weight, in carrying out other tasks.
Walk-in. An open space that can be furnished with appropriate functionality.
Possibly also seating functionality set into a wall with water drain in the floor, to
provide for walk-in semi-bathing.
6. Conclusions
This chapter has presented a set of guidelines for a design approach. These are based on
the evaluation of a design project that was concerned with an assisted bathroom for
older people in a sheltered housing residence in England. A design approach that seeks
to produce outcomes that can enhance well-being of users, should;
adopt an integrative perspective of various stakeholder needs and activities
towards a specific chosen desirable overall impression,
establish a sympathetic proximity to the ways people interact with their
environments, learn to view technology from the users perspective and examine
its benefits critically,
take what can be observed and heard from users as a point of departure, and then
project the designers own ideas of what is desirable over that situation, towards
proposals that go beyond what already exists.
Recent reflections on design approaches posed challenges to the ways design is often
carried out in practice. One of those challenges is that the distance between designers
and users should be reduced, in order to prevent designers from considering their own
experience sufficiently representative of users experience [21]. New approaches
should be more collaborative [22]. Another challenge addresses the notion that a
designer is a neutral entity, quasi-mysteriously producing designs that benefit others.

Schn argued that to serve a user well, a design had to satisfy a designer and user alike
[23].
This study sought to identify three characteristics of a design approach that can
address these challenges. Further research needs to be done on design situations and
how the three themes affect them positively. It should focus on how outcomes are
produced that enhance users well-being.
Acknowledgements
Thanks to David Durling, Cherie Lebbon and Christopher Maggs for their much valued support and guidance
as supervisors of my PhD study. They have been instrumental in helping me shape the ideas presented in this
chapter. Thanks also to the DAAD (Deutscher Akademischer Austauschdienst), Germany, and to
Staffordshire University, UK for each funding part of my PhD work on which the chapter is based.
References
[1] Connell B, Sanford JA. Research Implications of Universal Design [page 36]. In: Steinfeld E, Danford
G Scott, editors. Enabling Environments: Measuring the Impact of Environment on Disability and
Rehabilitation. New York: Kluwer; 1999. Chapter 2; p.35-55.
[2] Mullick A. 1999. Bathing For Older People With Disabilities. The Idea Center at State University of
New York at Buffalo [Internet]. 1999 [cited 2002 Mar 17]. Available from:
http://www.ap.buffalo.edu/~idea/publications/free_pubs/pubs_bathing.html.
[3] Mollenkopf H. Technical aids in old age. In: Report of the Arbeitsgruppe Sozialberichterstattung.
Berlin, Germany: Wissenschaftszentrum Berlin fr Sozialforschung; 1993, p. 96-103.
[4] Lawton MP. Competence, environmental press, and the adaption of older people. In: Lawton MP,
Windley PG, Byerts TO, editors. Gerontological Monograph No. 7 of the Gerontological Society.
Aging and the Environment: Theoretical Approaches. New York: Springer; 1982.
[5] Steinfeld E, Danford G Scott, editors. Enabling Environments: Measuring the Impact of Environment
on Disability and Rehabilitation. New York: Kluwer; 1999.
[6] Verbeek P, Kockelkoren P. The Things That Matter. Design Issues. 1998;14(3):28-42.
[7] Mayer KU, Baltes PB, editors. Die Berliner Altersstudie (The Berlin Study of Ageing) [pages 518 and
540]. Berlin: Akademie Verlag; 1996.
[8] Goffman E. Stigma: Notes on the Management of Spoiled Identity. Prentice-Hall; 1963.
[9] Goldsmith S. Designing for the disabled. 3rd ed. London: RIBA; 1976.
[10] Kira A. The bathroom. New York: Viking Press; 1976.
[11] Goldsmith S. Designing for the Disabled, The New Paradigm. Oxford: Butterworth-Heinemann; 1997.
[12] U.S. Architectural and Transportation Barriers Compliance Board. ADAAG. Americans With
Disabilities Act Accessibility Guidelines , Checklist for Buildings and Facilities. Washington, D.C.:
U.S. Architectural and Transportation Barriers Compliance Board; 1991.
[13] Coleman R, editor. Working Together: A New Approach to Design. London: Royal College of Art;
1997.
[14] Laslett P. A fresh map of life: The emergence of the Third Age. London: Weidenfeld; 1989.
[15] Berlo A van. Ontwerp van veilige en comfortabele badkamerprodukten voor alle leeftijden. (Designing
safe and comfortable bathing products for all ages). Eindhoven: Centrum Techniek Ouderen; 1996.
[16] Mullick A. 1999 (ibid.)
[17] Boess S, Lebbon C. Wellbathing, a study for design. In: Placencia Porrero I, Ballabio E, editors.
Improving the Quality of Life for the European Citizen. Proceedings of TIDE (Technology for
Inclusive Design and Equality). 1998 Jun 23-25; Helsinki, Finland. Amsterdam: IOS Press; 1998.
[18] Boess S. An Indian who doesnt know how to grow the maize. Reflecting on a designers experience of
user-centred designing [Unpublished Doctoral Thesis]. UK: Staffordshire University; 2002.
[19] Boess S, Durling D, Lebbon C, Maggs C. Participative Image-based Research as a Basis for New
Product Development. In: Green WS, Jordan PW, editors. Pleasure with Products: Beyond Usability.
London: Taylor and Francis; 2000. Chapter 17; p.231-246.
[20] Boess S. An Indian who doesnt know how to grow the maize. In: Durling D, Shackleton J, editors.
Common Ground. Proceedings of the International Design Research Society conference. 2002 Sep 5-7;
Brunel University, UK. Stoke on Trent, UK: Staffordshire University Press; 2002.
[21] Margolin V. The Product Milieu and Social Action. In: Buchanan R, Margolin V, editors. Discovering
Design: Explorations in Design Studies. Chicago and London: The University of Chicago Press; 1995.
p. 121-145.
[22] Scrivener S, Ball L, Woodcock A, editors. Collaborative Design. Proceedings of the Co-Designing
conference. 2000 Sep 11-13; Coventry, UK. London: Springer; 2000
[23] Bennett J. Reflective Conversation with Materials, an interview with Donald Schn. In: Winograd T.
Bringing Design to Software [Internet]. Addison-Wesley; 1996 [cited 2002 Feb 21]. Available from:
http://hci.stanford.edu/bds/9-schon.html
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-228
Anthropometrical Aspects of a Friendly

Rest Room
Johan F.M. MOLENBROEKa,1 and Renate DE BRUINa,b
a
Section Applied Ergonomics and Design Faculty of Industrial Design Engineering
Delft University of Technology, Delft, The Netherlands
b
Abstract. To give an impression of the aspects involved in the study of body

spaces in toilet environment. There are only a few anthropometrical sources about
elderly and disabled people. For the purpose of toilet environment this is even
rarer. First a new measurement study was prepared within the consortium to fill
the gap. But after reconsideration of the time, budget and available human
resources the plan was changed in using existing resources in close relation with
observational studies. The data from the Geron-project (1993-1998) in Delft have
mainly been used as a basic source of raw data. This seemed very relevant for this
project and as a next step this knowledge was completed with the quantified usage
studies done within the FRR-project in the laboratory at TU Delft but also at a
selection of sheltered homes in the Netherlands. To set up an anthropometric study
within a consortium of partners in different countries seems only possible if the
main goal of the budget is to study anthropometry like in the Caesar-project. If as
in this FRR-project anthropometry is only one of the aspects -though an important
aspect-within the product development project, then it is better to integrate existing
raw data with the results of observational research continuously during the
development process.
Keywords. Anthropometry, Toilet Environment, Elderly, Disabled
1. Introduction
Product developers are becoming more and more aware of the importance of applying
knowledge about the human body dimensions so called anthropometrics in the early
stages of design, in order to make their products better fit to the sizes of their
customers. In some products the differences between people, with regards to their body
dimensions as well as the behaviour that results from it, have unavoidably been
recognized from the beginnings on. For instance in bicycle design; you can buy
different sizes for every age, length and even the differences between the sexes are
incorporated. In the period 1920-1950 when the popularity of bicycles as a means of
personal transport was at its height, women in general wore dresses or skirts [1,2,3].
The bridge in between the saddle and the steering therefore was very hinder some and
another construction was made to provide stability without obstructing any dresses and
1
Corresponding Author: Johan Molenbroek, Faculty of Industrial Design Engineering, Delft University
of Technology; Address: Landbergstraat 15, 2628 CE Delft; Email: j.f.m.molenbroek@tudelft.nl
J.F.M. Molenbroek and R. de Bruin / Anthropometrical Aspects of a Friendly Rest Room 229
skirt-clothing (however this not being the optimal solution; anyone who has ever tried
knows about the many other problems with skirt-driving, like getting the fabric stuck in
between the pedals or chain, blowing skirts and crawling skirts that go beyond the area
one wants to expose in public). Even now one refers to the bike without bridge to as a
female-bicycle even though trousers are worn by women just as commonly now.
In other products there seems to be hardly any developments with regards to
applying anthropometrical knowledge, ever since the first designs were brought on the
market. A typical example - and topic of this paper - is our modern water closet. It has
stayed with its purely functional design up until now, without taking into account the
variations between people. It seems rather strange that a product that is used several
times a day and clearly will benefit from fitting to the customers body dimensions and
behaviour is not available in more variations on the market (see Figure 1). In this
particular case the reason probably can be found in the nature of the product; it is
attached to the sewer system, which makes a quick change rather cumbersome. The
subject of toileting also being a taboo to talk about in public might not help the
developments either.
Figure 1. Available variations of toilet bowls in the local D-I-Y store
A first start to change something in toilet design was made though in the EU-
funded Friendly Rest Room project. The goal of the project was to come up with a
design for the toilet environment and the components in it (toilet bowl, water basin,
support bars) that would better fit to the needs of physically more challenged
individuals, like elderly and disabled, through taking into account the anthropometrics
and behaviour variations in this user group and to combine this knowledge with a
smart content using the possibilities of building automation.
A part of the FRR project consequently entailed finding and applying the right
anthropometric data. In general there can be several reasons why anthropometric data
are not being used or used properly in the development of the consumer products:
230 J.F.M. Molenbroek and R. de Bruin / Anthropometrical Aspects of a Friendly Rest Room
Lack of data on the specific type of users or specific dimension (e.g. nationality
of the data sample or specific body dimensions of which there are no records)
Representation of the data is incomplete or leads to reading errors (e.g. tables that
only show the P5 and P95 values, while the P1 and P99 values are needed)
Invalid data (e.g. errors made when measuring, using incorrect or
unrepresentative data or when using a small sample size)
Lack of knowledge to apply the data correctly e.g. in design-teams (e.g. when
knowledge level with regards to the human anatomy and/or statistics is not
sufficient)
The importance of implementing anthropometrics in product design and the

product development process is recognized since long in the curriculum of Industrial
Design Engineering at the Delft University of Technology and students are early on
taught about it (see also www.dined.nl). Still in practice not all product developers are
trained that well in applying anthropometrics2. In this paper the Friendly Rest Room
project will be used as an example of how anthropometrics were implemented in a
practical design problem and the limitations that were faced.
2. Anthropometric Data Resources
In order to design a better fitting toilet for elderly and disabled designers need to know
in detail about the specific body dimensions of this group, their dynamic behaviour and
preferences that are originating from their capabilities and incapabilities. Thus
extensive anthropometric and ergonomic data is needed. In the last 40 years several
studies have been carried out and published with regards to the anthropometry of
elderly and disabled.
Only some of these studies present real databases on empirical measurements, for
example Damon and Stoudt [4], Hobson [5], Wright et al. [6], DIN 33402 [7],
Molenbroek [8] and Steenbekkers [9]. Others present overviews, discuss or make
estimations for other unmeasured- variables like Diffrient [10], Kelly and Kroemer
[11] and Pheasant [12].
Recently the World Engineering Anthropometry Resource (WEAR) group
launched a web-portal to foresee product designers and developers in an overview of
anthropometric data sources and an indication of their quality and application domain
[13a].
Brown e.a. [13b] and Rogers e.a. [14] conclude that there is a serious lack of data
for elderly and disabled that is appropriate for use by designers, particularly dynamic
data. Referring to the objectives of the FRR project and the earlier mentioned obstacles
in using anthropometric data in the consumer product development, we can conclude
that typically lack of data on the specific type of users and specific dimensions is at
stake. In general there are not many anthropometric data resources with regards to the
population of elderly and disabled. The data resources that are available do not contain
2
The research program Dynamic Anthropometrics of the section Applied Ergonomics and Design at
Faculty Industrial Design Engineering, Delft University of Technology is in the process to develop an
ergonomics information system (called EIS) for designers and investigators, which compensates their
knowledge in the field of anatomy and statistics, but also compensates their knowledge in the anthropometric
design process [15, 16, 17, 18].
much data on dynamic anthropometry measures (like dynamic patterns for support
during sitting/rising), let alone specific data on user behaviour around the very sensitive
topic of toileting e.g. with regards to cleansing and backward reach.
3. Methods
To solve the lack of appropriate anthropometrical data several methods have been used
in the FRR project. We will discuss these methods following the flowchart of the
anthropometrical design process in Figure 2.
3.1. Design Process
The flowchart of the anthropometric design process starts with the need for a new
design that solves a certain design problem. In the FRR project the objectives were to
carry out the necessary research and design, the engineering and evaluation of
prototypes for a more user friendly rest room for elderly and persons with disabilities.
The general design problem was consequently defined as: The elements of the FRR
should be able to adjust to the individual needs of older persons with functional
limitations or disabilities, allowing them to gain greater autonomy, independence, self-
esteem, dignity, safety, improved self-care and therefore enable them to enjoy a better
quality of life.
Research activities and design and development activities took place simultaneously in
the project. The research results were translated into a set of design specifications
gradually building up during the course of the project. Product ideas and design
concepts were developed based on these growing design specifications. Several
successive FRR prototype generations were tested at 5 European test sites, the so called
User Research Bases (URBs). In these URBs the FRR prototypes or parts of the
prototypes were tested by in total more than 230 test persons from the target group
elderly and disabled.
It was set at the beginning of the project that it would not be feasible to come up with a
fully market ready prototype of a Friendly Rest Room within the projects boundaries
of time and budget. The final design therefore is equivalent to the last generation test
prototypes. Findings of the user tests would serve as a basis for further developments of
user friendly rest room products and disseminated as such.
3.2. Static Anthropometry: Defining the Target Group
The target group of the FRR consists of elderly and people with disabilities.
Though differences in behaviour and preferences are without doubt to be expected, no
specific differentiation was made in gender; men and women were equally subject of
study. With regards to ethnicity and type of disability initially no distinction was made
either.
Figure 2. Flowchart of the anthropometric design process

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

Male Female
1 Limitation of walking n=5 n=5
2 Limitation of sitting / rising (dynamic) n=5 n=5
3 Limitation of sitting / standing (static) n=5 n=5
4 Limitation in use of arms or hands n=5 n=5
5 Limitation in movement resulting from a n=5 n=5
disorder in balance
6 Limitation in the senses (vision, hearing, n=5 n=5
smell, touch)
7 Limitation in movement of the torso n=5 n=5
8 Limitation in the mind / memory n=5 n=5
Total n = 40 n = 40
In practice the successive prototypes were eventually tested by 230 test persons in total.
The test person selection however had not been done following the structure from table
1, but was done according to the availability of test persons at the different test
locations (URBs). Each URB focused on the typological sample groups they were in
practice most close to, e.g. through former studies, experience or contacts. URB Lund
therefore mainly tested limitation in vision and limitation of walking. URB Vienna
gathered their test persons through the MS Society, and therefore tested limitations of
walking, sitting/rising and use of arms or hands. URB Athens tested with both elderly
and disabled and therefore did not focus specifically on certain limitations, but more or
less covered them all.
Cultural coverage and differences in ethnicity were covered as well, because every
URB gathered their test persons geographically not far from their test location, which
consequently resulted in a Swedish, Austrian and Greek sample.
3.3. Dynamic Anthropometry: Defining User Behaviour in order to Find the Relevant
Variables
The next step in the anthropometric design process is to analyse the context of use.
Goal of this analysis is to determine which anthropometric variables are relevant to the
design. The analysis entails studying posture, movements and the sequence of
movements. In toilet design one wants to know for instance about toilet rituals and the
manual handling that has to be done. Especially in elderly individuals who have
balance problems it turned out that the turning movements near the toilet,
undressing/dressing and sitting/standing are experienced as cumbersome[21,22].
In order to find out more about the context of use in elderly and disabled around
this very sensitive topic of toileting several explorative studies were performed. In
these studies also the influences of socio-cultural differences, the use and handling of
artefacts in the toilet area (clothing, tools, equipment) and the influence of the physical
environment on the context of use were studied.
First a visit to a home for elderly was made to explore the settings of the toilet
facilities offered here and the common problems that were experiences, both by staff as
elderly habitants themselves (see Figure 3). Addressing the problem elderly people
have with the fixed height of standard Dutch toilets, next an explorative study into
toilet heights and toilet raisers was performed [21]. In this study 15 elderly were
interviewed about their toilet facility and a video was made of how they moved from
their living area to their toilet area and sat/rose from their toilet (clothing on, see Figure
4). The results from these explorative studies showed that as one gets older more
problems are experienced with sitting/rising from the toilet, with cleansing of body
parts and the lack of proper (non-stigmatising) support for these activities.
In order to find more about the exact needs for support during sitting/rising from
the toilet and cleansing, a more controlled laboratory study was performed with 9
healthy elderly women and 6 healthy elderly man (see Figure 5) [23, 24]. Additionally
a master thesis study [25] was performed on reducing the fall risks for elderly in the
restroom and an innovative design for non-stigmatising toilet support bars was made
[26, 27]. The results of both studies are described more elaborately in this volume as
well [28, 29].
Figure 3. Visiting a sheltered home for elderly (Ede, NL)
Figure 4. Visiting elderly in their homes (Delft, NL)

Figure 5. Laboratory test environment to determine the location for support around the toilet (Delft, NL)
3.4. Anthropometric Measurements and Anthropometric Resources
After defining the target group and having analysed the context of use now a list of
anthropometric variables relevant to the design of a toilet for elderly and disabled was
available. Next step was to decide how to translate this list in a set of exact design
specifications. These design specifications should enable all intended users of the toilet
to use it effectively and efficiently, and not be limited by their size.
The question was whether to perform the necessary anthropometrical
measurements ourselves, or to look for appropriate anthropometrical data resources? In
the FRR project it was decided to use an already available and fairly recent large
anthropometrical data set on Dutch elderly (GDVV, measured in 1982 and Delft
GERON-project, measured in 1993-1998) [8,9,30] and retrieve any other unknown data
by measuring small user groups. In this way -amongst others- the difference between
elderly from Greece and Sweden in comparison to Dutch elderly was retrieved, which
resulted in a lowering of the minimum of the height adjustability.
For measuring the small groups of elderly and disabled in the URBs, an
anthropometrical measurement protocol was written and measurement chairs were built
(see Figure 6 and 7).
Figure 6. Detail of the anthropometrical measurement protocol used in the FRR project
Figure 7. Two anthropometrics measurement chairs
Table 2. Six relevant anthropometric dimensions for using a toilet (data from Molenbroek [8])
P1 P99 User variables Additional variables Product variables

(mm) (mm)
429 583 Buttock-popliteal depth - Ca.50 mm (for rising from Toilet seat depth
toilet seat)
344 516 Popliteal height + Heel height (for public Toilet seat height (adjustability
use) range)
- Thickness toilet seat
316 454 Hip breadth Toilet seat width
Distance between horizontal
support bars (adjustability
range)
177 299 Elbow height bended Height horizontal support bars
while seated (adjustability range)
690 1010 Reach depth envelope Forward reach distance vertical
measured from back to support
grip Location handles vertical
support
40kg 120kg Body weight in kg Strength of toilet and support
construction
Thickness toilet seat
3.5. Anthropometric Estimations
The anthropometric data set on Dutch elderly that was used in the FRR project was
used to determine the needed dimensions of the new toilet design. A transformation
table was used to estimate the design specifications from the sitting measurements
presented in this dataset (see table 2). A similar table was used in a former study of
Molenbroek to determine the right dimensions of a wheelchair design [31].
3.6. Allowances
In any other product normally it is necessary to add allowances for clothing and shoes.
In toilet design the influence of clothing is obviously not direct, since one uses the
toilet bare skinned, but there is an indirect influence though. Particularly in the (semi-)
public toilet environment one does not want the undressed clothing to fall onto (filthy)
floors, which results in all kinds of strategic cloth handling positions, while performing
the normal sitting/cleansing/rising activities. One can imagine that having to hold on to
clothing limits the amount of comfortable body positions and can seriously lead to fall-
risky situations. This problem is less serious in the clean home environment, but still
it is true that handling of cloths effects the way people act in the toilet area (see also
Figure 8).
Since in a home environment people use the toilet without their shoes on, but in
(semi-)public environment they will definitely wear shoes, it was decided to design for
both situations and adjust the range of height adjustability accordingly (see also table
2).
Figure 8. Balancing and handling of cloths during toilet use
3.7. Critical Values
Last but not least in the design process a decision has to be taken about the way the
anthropometrics of the target group is dealt with. In other words, the choice for a
certain type of anthropometric accommodation will result in critical values of product
dimensioning. The following list will explain each type of accommodation and gives an
example with regards to (current) toilet design solutions:
Select users who fit the design; The standard height of a toilet bowl fixed to the
floor- is 40 cm. This height is based on the assumption that the general popliteal
height is about this height. However there are many people for whom this height
is too low, and others for whom it is too high. Even though most of these people
can use the toilet nevertheless, it can be rather uncomfortable with folded legs, or
even risk full when your feet are not touching the ground. In current toilet design
you can conclude that nothing special is done to fit the product to its user; the
user will simply have to fit or otherwise has to search for salvation elsewhere.
Custom fit each individual; A so called freely hanging toilet bowl can be
positioned and installed according to your own personal needs. When in a family
for instance, more than one individual is to use the toilet and his family members
differ much in length for example, the problem is not solved unfortunately.
Have several fixed sizes; In the market there are several types of toilet seat
raisers. These extra high toilet seats can solve the problem that one family
member needs a higher than standard toilet and the other family members do not.
Toilet seat raisers are not an optimal solution though, because they often show
problems with stability (or perception of stability) and hygienic issues (difficult to
remove easily and clean). In addition to this they do not offer a solution to the
individuals who are in need of a lower than standard toilet bowl.
Make it adjustable; In the FRR project this solution was chosen for the final toilet
design. The freely hanging toilet bowl was adjustable in height and operated
with a handheld control. Also a solution for the sitting/rising problems elderly
face was offered, through the extra option of tilting the bowl.
Design for the extreme individual: In the FRR project this solution was in fact
chosen as well because the range of height adjustability of the toilet bowl was
determined by the anthropometric of the smallest Greek test person and the tallest
Dutch test person.
3.8. Design Guideline
The outcome of all the different phases in the anthropometric design process can finally
be put into an anthropometric design guideline. In the FRR project this design
guideline gradually was built up while going through the successive stages of prototype
testing and user behaviour studies.
4. Results
The anthropometric design guideline was used on several moments within the design
process. It was crucial to have short and frequent communication between the designers
and the anthropometric specialist and the anthropometric knowledge transfer was
especially important in the development of the following parts of the FRR:
The height and sizes of a patented door handle: it should be comfortable to be

reached and gripped by elderly persons as well as wheelchair users.
The shape, size and height of a wall mounted grab bar.
The range of the height and angle of the toilet bowl in- and excluding seat; it was
discussed that the highest position, when sloped at maximum, also could be used
as a urinal for men while standing.
The size and the shape of the seat in close relation with the transfer-seat
The range of the width and height of the horizontal and vertical grab bars. This
described in more detail in the chapters from Dekker and Buzink [29].
The range in vertical and horizontal position of the wash basin. Also more
elaborately described in Dekker and Buzink [29].
5. Conclusions
In the FRR project anthropometry has been tightly woven trough the design process
and apart from a good communication between designers and researchers, it also
requires the availability of a lot of data and -if not available- the ability to perform user
studies with a small sample to find out which measurements are relevant. When no data
exists on the relevant body dimensions, these will have to be measured in short time in
an effective and efficient way.
To set up an anthropometric study within a consortium of partners in different
countries seems only possible if the main goal of the budget is to study anthropometry
like for instance this is the case in the Caesar-project [32]. If as in this FRR-project
anthropometry is only one of the many important aspects within a product development
project, then it is often better to integrate existing raw data with the results of
observational research continuously during the development process.
References
[1] IIAV, Internationaal Informatiecentrum en Archief voor de Vrouwenbeweging, 2007. Damesfietsers &
emancipatie [online]. Damesfietsblog, The Netherlands. Available from:
http://www.damesfietsblog.nl/damesfietsers-emancipatie <Dutch weblog about women and bicycles>
[2] Mooncycle, Vrouwen met een passie voor fietsen, 2008. Techniek, Kies je type fiets, De juiste fiets
[online]. Mooncycle, Belgium. Available from: http://home.versateladsl.be/vt6100788/fiets.html
<Belgian website about women and bicycles>
[3] Lesisz, R., 2004. Honderd jaar fietsen in Nederland 1850-1950. Over het begin van de fietscultuur.
Thesis (PhD). University of Wrocaw and Erasmus Leerstoel voor Nederlandse Filologie.
[4] Damon, A and Stoudt, H.W., 1963. The functional anthropometry of old men. Human Factors, 5(10),
485-491.
[5] Hobson, D.A. and Molenbroek, J.F.M., 1990. Anthropometry and design for the disabled-experiences
with seating design for the cerebral-palsy population. Applied Ergonomics, 21(1), 43-54.
[6] Wright, U., Govindaraju M. and Mital, A., 1997. Reach Profiles of Men and Women 65 to 89 years of
age. Experimental Aging Research, 23 (4), 369-395.
[7] Deutsches Institut fr Normung, 1981. DIN 33402, Krpemasse des Menschen Beuth Verlag, Berlin.
[8] Molenbroek, J.F.M., 1987. Anthropometry of elderly people in the Netherlands; research and
applications. Applied Ergonomics, 18 (3), 187-199.
[9] Steenbekkers, L.P.A. and Van Beijsterveldt, C.E.M., Eds., 1998. Design-relevant characteristics of
ageing users; backgrounds and guidelines for product innovation, Series ageing and Ergonomics, Vol.1.
Delft: Delft University Press.
[10] Diffrient, N., Tilley, A.R., & Bardagjy, J.C., 1974). Humanscale 1/2/3. Part 3, Requirements for the
handicapped and elderly. Cambridge, MA: The MIT Press.
[11] Kelly, P.L. and Kroemer, K.H.E., 1990. Anthropometry of the elderly: status and recommendations.
Human Factors, 32(5), 571-595.
[12] Pheasant, S., 1996. Bodyspace: Anthropometry, Ergonomics and the Design of Work. London: Taylor
& Francis Press.
[13a] WEAR, World Anthropometry Engineering Resource [Internet] 2009 [cited 2010 Jul 1]. Available
from: http://www.wearanthro.org
[13b] Brown, R., Rogers, N., Ward, J., Wright, D. and Jeffries, G., 1995. The application of an
anthropometric database of elderly and disabled people. Biomedical Sciences Instrumentation, 31, 235-
239.
[14] Rogers N, Ward J, Brown R, Wright D. , 1996. Ergonomic data of elderly people and their application
in rehabilitation design. Disability and Rehabilitation, 18(10), 487-496.
[15] Huijboom, J.M., 1998. AIS, A tool to apply anthropometry to design. Thesis (MSc). Industrial Design
Engineering, Delft University of Technology.
[16] Molenbroek, J., Visser, R., 1997. Anthropometric Information System (AIS). Proceedings of the IEA
1997, P. Seppala, Finn.Inst.of Occup. Health, Helsinki, Finland, Volume 2, p. 76-78.
[17] Visser, R., 1996. Anthropometric Information System (in Dutch). Thesis (MSc). Industrial Design
[18] Stap, E.van der, 1995. Anthropometric Information System (in Dutch). Thesis (MSc). Industrial Design
[19] Kanis, H. and Arisz, H.J., 2000. How many participants: a simple means for concurrent monitoring. In
Proceedings of the XIVth triennial congress of the International Ergonomics Association and 44th
annual meeting of the Human Factors and Ergonomics Society. Santa Monica CA (USA): Human
Factors and Ergonomics Society, pp. 6-637-6-640.
[20] Arisz, H.J., Kanis, H., and Rooden, M.J., 2000. How many participants: a simple statistic with some
limitations. In: P.T. Mccabe, M.A. Hanson, & S.A. Robertson, Eds., Contemporary ergonomics 2000
London (UK): Taylor & Francis, 229-233.
[21] Plante R., 2002. Inquiry among elderly on problems with toilet use. Intern report (in Dutch). Delft
University of Technology, Faculty of Industrial Design Engineering.
[22] Buzink, S.N., Molenbroek, J.F.M., Haagsman, E.M., & Bruin, R. de., 2005. Falls in the toilet
environment: a study on influential factors. Gerontechnology, 4(1), 15-26.
[23] Dekker, D., Buzink, S.N., Molenbroek, J.F.M. and Bruin, R. de, 2007. Hand supports to assist toilet use
among the elderly. Applied Ergonomics, 38 (1), 109-118
[24] Buzink, S.N.,Dekker, D.,Bruin, R. de, and Molenbroek, J.F.M., 2006. Methods of personal hygiene
utilized during perineal cleansing: acceptance, postures and preferences in elderly Dutch citizens.
Tijdschrift voor Ergonomie, 31(3), 36-44.
[25] Buzink, S.N., 2004. De ontwikkeling van een product ter preventie van valongevallen in toiletruimten
(in Dutch). Thesis (MSc). Industrial Design Engineering, Delft University of Technology.
[26] Buzink, S.N.,Molenbroek, J.F.M., Bruin, R. de, Haagsman, E.M., and Groothuizen, T., 2006.
Prevention of falls in the toilet environment. In: R.N. Pikaar, E.A.P. Koningsveld, and P.J.M. Settels,
eds., Proceedings IEA2006, Meeting Diversity in Ergonomics. Amsterdam: Elsevier, 4585-4591.
[27] Buzink, S.N., Molenbroek, J.F.M., Haagsman, E.M., Bruin, R. de, and Groothuizen, T., 2004. S'wing;
een valpreventie product voor de toiletruimte. Tijdschrift voor Ergonomie, 29(5), 4-11.
[28] Buzink, S.N. Fall prevention in the toilet environment. This volume.
[29] Dekker, D. and Buzink, S.N. User preferences regarding body support and personal hygiene in the toilet
environment. This volume.
[30] Molenbroek, J.F.M., Houtkamp J.J., and Burger, A.K.C., 1983. Anthropometry of elderly. Report
Special Subjects Part 6 (in Dutch ) Faculty of Industrial Design Engineering, Delft University of
Technology, Delft.
[31] Molenbroek, J.F.M. and Zhang, B., 2000. Anthropometry of the elderly and the disabled with special
attention to (wheel)chair design. In Proceedings of the XIVth triennial congress of the International
Ergonomics Association and 44th annual meeting of the Human Factors Ergonomics Society. Santa
Monica CA (USA): Human Factors and Ergonomics Society, pp. 4-704-4-707.
[32] SAE International, 2008. Civilian American and European Surface Anthropometry Resource Project
CAESAR [online]. Available from: http://store.sae.org/caesar/
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-242
Involvement of Users and Practitioners

in Anticipating Future Usage
with Design Models
Theo ROODEN1
and
The Hague University of Applied Sciences School of Human Technology, The Hague,
The Netherlands
Abstract. User involved usability assessments during design processes improve

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

future users with a proposed product. The development of usable products can give
competitive advantage and it may also be considered a designer's professional
responsibility.
A central difficulty in usage-centred design is that a product needs to be designed
for a variety of users who will use it in a variety of ways in a variety of contexts.
Another difficulty with usage-centred design approaches is the limited help derived
from empirical data currently in ergonomics handbooks and ergonomics guidelines.
These considerations explain why it is necessary to combine the creative design
process with various usability evaluations, see Figure 1. Figure 1 presents the design
process as a series of phases, with deliverables of the design phases available for
usability assessment. Preferably design and research should run parallel, with ongoing
feed of research information into the creative process.
1
Contact information: Theo Rooden; Tel: +31 (0)70 4458920; Email: m.j.rooden@hhs.nl
T. Rooden / Involvement of Users and Practitioners in Anticipating Future Usage 243
The earlier usability assessments can be made in the design process the better, as
the opportunity for improvement by design is greater in the early phases. Various
methods exist to assist designers with usability assessments. A distinction can be made
between methods with, and those without user involvement. Methods without user
involvement, also called usability inspection methods (see [1] for an overview), include
heuristic evaluation, and cognitive walkthrough. At the core of user-involved usability
assessments are observational studies, such as user trialling. During design processes
users can be observed interacting with design models, such as drawings, foam models,
and computer simulations.
Figure 1. Usage-centred design process, characterised by consecutive and iterative phases of creative design
and usage research (derived from [3,4]).
This chapter deals with issues related to usability assessments with design models.
The first topic is the design models themselves. The second topic is the methods of user
trialling with design models. The third and final topic is the role of practitioners in
usability assessments with design models. With each topic, recommendations for
244 T. Rooden / Involvement of Users and Practitioners in Anticipating Future Usage
design practice are included. These recommendations are derived from PhD research
by the author [2]. This PhD research contained empirical studies comparing user
activities with various design models and actual products, and interpretation by
practitioners.
2. Design Models
A design model (e.g. a set of drawings, a computer simulation, or working prototype)

represents a design in some phase of development. Budget (both time and money)
prevents some characteristics from being represented in the design model. And the
design may not be detailed enough yet to have a full range of characteristics
represented in material form. In observational studies, differences between the design
itself and the design model may introduce 'artificial' ways of usage, and may prevent
relevant ways of usage from being noticed. When building design models for usability
assessment, it would be helpful to know which characteristics can be left out without
penalty, and which characteristics should necessarily be represented in the design
model. Although research has been aimed at developing guidelines for constructing
design models for usability assessment, the studies were limited in scope and did not
yield groundbreaking recommendations [5,6,7,8]. One claim is that aesthetic
refinement of the design model does not matter [7]. Even this claim is disputable
because only quantitative comparisons were made: Although various design models,
differing only in the degree of aesthetic refinement, did not differ in the number of
'errors', nothing was said about possible differences in the nature of the errors in the
various conditions. In depth qualitative research comparing user trials with various
design models in our own research showed that basing conclusions on summative
quantitative measures is misleading [2]. Although there may not be a set of general
guidelines for constructing design models, our research has yielded some
recommendations.
2.1. Represent Innovative Aspects of the Design
It is known that user activities are very much guided by previous experience with
similar products and interactions. An implication is that characteristics of a design
which are not represented in the design model may be filled in by participants in a user
trial based on their previous experiences with similar products. This goes well as long
as design solutions match expectations from previous experience. In building a design
model, one should represent those characteristics which cannot easily be filled in by
experience, or which will be filled in incorrectly. This is complicated by the fact that a
variety of users may draw from a large variety of experiences. New, innovative or rare
design solutions should at least be tested by having them represented in the design
model. When the designed interaction does not follow from the products functioning
and is without a logical rationale, it should also be represented in the design model.
2.2. Research Questions Are Guiding
It is obvious that research questions are guiding in decisions when building a design
model. What is it that the design team want to know from usage research? When
physical aspects are of relevance, a real size 3D-model seems essential. Usage of a
product may be guided by certain features of the design. These (combinations of)
characteristics may be identified by the term 'cues' or 'usecues' [11]. Some cues are
explicitly designed into a product, like graphics and auditory signals. Other cues are
designed into a product more intuitively, like the size of a button or the shape of an
LCD, which have become implicit. When doubts exist about the quality of certain
designed use cues, these specific cues should be represented and tested in user trials. A
difficulty with this is that use cues through experience and familiarity with cultural
conventions, both for designers and users. When doubts exist about the quality of
certain designed usecues, these specific cues should be represented and tested in user
trials. A difficulty with this is that usecues often do not work in isolation and that their
quality can only be assessed in combination with other characteristics of the design.
2.3. Show All Sides of the Design
Particularly when making design models in the form of drawings, one should be aware
that a necessarily chosen viewpoint hides a part of the design from the users in the
trials. Recommendations include the preparation of additional drawings showing all
sides of the design or making a 3D-model or a dynamic computer rendering. This
shortcoming of drawings can also be compensated for by methodological precautions:
In user trialling, users can be told about invisible information by the test leader. It
requires a skillful test leader to decide at what moment to give away the information. It
is probably best to intervene at the moment when users have made wrong assumptions
about hidden information. A test leader is only able to do so when participants are
thinking aloud, revealing some of their thoughts during usage. Having users think
aloud is recommended anyway, as information about users thoughts and perceptions
during usage is often helpful in linking usability problems to characteristics of the
design. This is exactly the kind of information designers need to further improve the
design.
2.4. Show Changes in Appearance during the Interaction
This is another recommendation mainly relevant for usability assessments with

drawings. The interaction becomes more lifelike when changes are made visible and
users and evaluators do not need to remember the status of the product. This can be
achieved by preparing a series of drawings that are shown at the relevant moment,
Figure 2. One requirement is that use actions need to be predictable to some extent in
order to be able to prepare such drawings. Flexibility is required because of the known
limitations to predicting user activities. Interaction on LCD-drawings can be simulated
with little overlays or with computer simulations.
Figure 2. Video captures from a user trial with a series of drawings of a coffee-maker design. In the first
picture, the participant indicates by gesturing and talking that she would remove the jug. She is then
presented with a separate drawing of the jug and a drawing of the body of the machine without the jug. After
having indicated that she would remove the top of the machine, she is presented (in the third picture) with a
view of the interior.
2.5. Create Manipulable Models
When users interact with real products and 3D-models, actions can be observed and
recorded for analysis, in particular on video-tape. When a design proposal is
represented by drawings, a limitation for user trialling is that use actions cannot
actually be performed. Information about actions will be meagre, unless actions are
simulated by gesturing or by talking about intended actions. The information revealed
about these actions in user trials may be limited. Some people may be more inclined to
talk with their hands than others, and talking about manipulations has known
limitations. Manipulations consist of skilled behaviour and most participants do not
have an adequate vocabulary at hand. Manipulation can be encouraged when the
drawings are real-size cut-out shapes, Figure 3. When manipulation is an important
ingredient of the interaction, full scale 3D-models should be considered.
Figure 3. Cut-out drawings

3. User Trialling with Design Models
User trials with design models differ from user trials with actual products. Design
models bring along some degree of artificiality and cannot actually be used in a natural
environment. Limitations of these user trials in capturing user activities should be
understood. At the same time, some of the shortcomings and deficiencies of design
models as such can be compensated by explaining their status and supplying additional
information to participants in user trials.
3.1. Let Users Focus on Results
A difficulty with user trialling with non-functioning models is that users cannot
actually focus on task performance, which may trigger activities not expected with real
products. When using everyday products, such as an iron, the user's attention is
probably directed at the task at hand or the performance, for instance removing
wrinkles from a shirt. Having participants use a non-functioning design model in user
trialling presents them with an unnatural situation. The product can no longer have this
mediating role. In the case of the iron, the aim of user activities can not be to get rid of
wrinkles in a shirt. Participants' approaches may become more consciously focused on
the interaction itself, possibly leading to different, unrealistic activities. Some
participants adopt a kind of expert role, in which they undertake to demonstrate and
explain, instead of just operate the design model. With this explaining behaviour, the
order of actions when operating design models may be less well-considered and trivial
actions may be omitted when describing and demonstrating what one would do if it
were a real product. This yields an incomplete picture.
It is advised to make the interaction as real as possible, for instance by supplying
participants with a realistic task, and by simulating results. In case of the iron, supply a
setting with a real ironing board, and add a basket with a variety of garments.
Additional information can be collected by user trialling with working prototypes
or by observing usage of existing products with similar functionality.
3.2. Encourage Pointing and Gesturing
The problems of verbalising manipulations in user trialling with drawings may be

solved by making drawings manipulable (see last recommendation in previous section),
but also by encouraging participants to point at parts of the drawings and to show their
intended manipulations by gesturing.
3.3. Collect Information Concurrently, Probe Actively
This recommendation is strongly related to user trialling as a design tool. Information

about why users do what they do is crucial in informing designers. Formal methods of
thinking aloud [9] do not accommodate for the elicitation of such information. Asking
questions during a trial probably evokes more valuable information than retrospective
interviews. It should be realised that active concurrent probing compromises
possibilities of observing natural usage. In retrospective interviews, a video recording
of the trial can be reviewed together with the participant to refresh his or her memory.
3.4. User Perspective
In our approach to the topic of design models, we regard the design model as the
representation of a design proposal. It should be realised that users do not have this
frame of reference, and they will build their own product based on the design model. In
a user trial it is important to know how users fill in gaps of the design model, because
only then it is possible to conclude whether the demonstrated ways of usage would
occur when the participants are confronted with the finished design.
3.5. Complement User Trialling with Other Usability Assessment Methods
User trialling with design models captures only a part of possible user activities. It
generally focuses on first time usage, and it often takes place in a neutral environment
like a usability laboratory. Other methods may help to anticipate usability problems in
a larger variety of use contexts, a variety of users, and a variety of tasks. Other methods
include heuristic evaluation [10], and observation of usage of similar products.
4. Involving Expertise in Usability Assessments
In the previous section, the role of practitioners during user trials was already
mentioned. His or her position can help improve the quality of the collected
information. However, the role of practitioners is crucial in the analysis of the
observations as well. The general approach in an analysis will be a systematic scrutiny
of the data to extract usability problems and causes, preferably with guidance of a
previously set definition of what constitutes a usability problem. With this approach it
is still possible to include 'artificial' usability problems (i.e. problems which cannot
occur with the real product), and relevant ways of usage and usability problems may
not be noticed. Practitioners will be able to filter out usability problems that are
artificially created by design models, and will at the same time anticipate usability
problems which do not readily come to light in user trials with design models (see last
recommendation in previous section).
We had practitioners view recordings of user trials and had them extract usability
problems [2]. Large inter-individual differences in the number of anticipated usability
problems were shown. Knowing why certain practitioners outperformed others may
inform the selection of practitioners for usability assessment and may reveal effective
approaches for usability assessment. Our study suggests that the approaches adopted by
practitioners (e.g. systematic approach, time investment) are more important than
actual expertise, although the ability to empathise with a variety of users seems
essential. It is advisable not to rely on a single analyst, but to combine findings from
several analysts, preferably with various backgrounds.
5. Conclusions
This chapter presented a general overview of issues related to the application of design
models in usage-centred design, together with recommendations for design practice.
One might get the impression that user trialling with design models comes with too
many difficulties to be carried out with confidence. This is not the case, our
experiences are positive: in general participants bridge the gap between design model
and intended product very well, supplying invaluable information in the user trials to
be used as input in usage-centred design. Practitioners are encouraged to integrate
usage observation with design models into their design processes, to reflect on the
findings, to improve methods, and to tune these to their specific contexts. The
recommendations presented in this chapter can be helpful in this process.
References
[1] Nielsen J, Mack RL. Usability inspection methods. New York: Wiley; 1994.
[2] Rooden MJ. Design models for anticipating usage [PhD thesis]. Delft: Faculty of Industrial Design
Engineering, Delft University of Technology; 2001.
[3] Den Buurman R. Designing smart products; a user-centred approach. In: Seppala P, Luopajarvi T,
Nygard CH, Mattila M, editors. Proceedings of the 13th Triennial Congress of the International
Ergonomics Association; 1997; Tampere, Finland. Helsinki: Finnish Institute of Occupational Health;
1997, p2-3 2-5.
[4] Marinissen AH. Ergonomic aspects in designing automotive displays with route guidance information.
In: Grieco A, Molteni G, Piccoli B, Occhipinti E, editors. Selected papers of the Fourth International
Scientific Conference Work with Display Units 94. Milan, Italy; 1995, p271-176.
[5] Fay D, Hurwitz J, Teare S. The use of low-fidelity prototypes in user interface design. In: Proceedings
of the 13th International Symposium Human Factors in Telecommunication; 1990 Sep 10-14; Torino,
Italy. 1990, p23-31.
[6] Prmper J, Heinbokel T, Kuting HJ. Virtuelle Prototypen als Werkzuege zur Benutzerzentrierten
Productentwicklung. Zeitschrift fr Arbeitswissenschaft. 1993; 3(47); 160-167. [In German].
[7] Wiklund ME, Thurrot C, Dumas JS. Does the fidelity of software prototypes affect the perception of
usability? In: Proceedings of the Human Factors Society 36 th Annual Meeting; 1992 Oct 12-16; Atlanta,
Georgia/Innovations for Interactions. 1992, p399-403.
[8] Virzi RA, Sokolov JL, Karis D. Usability problem identification using both low- and high-fidelity
prototypes. In: CHI Conference Proceedings Human Factors in Computing Systems, 1996 April 13-18;
Vancouver, British Columbia, Canada. 1996, p236-243
[9] Ericsson KA, Simon HA. Protocol Analysis: verbal reports as data. Cambridge: MIT Press; 1993.
[10] Nielsen J. Usability Engineering. Boston: Academic Press; 1993.
[11] Kanis H, Rooden MJ, Green WS. Usecues in the Delft design course. In: McCabe PT, Hanson MA,
Robertson SA, editors. Contemporary Ergonomics. London: Taylor and Francis; 2000. p365-369.
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-250
Key Dimensions of Client Satisfaction with

Assistive Technology: A Cross-validation 1
of a Canadian Measure in The Netherlands

Louise DEMERSa , Roelof WESSELS b, Rhoda WEISS-LAMBROUc, Bernadette
SKAd and Luc P. DE WITTEb
a
Centre for Clinical Epidemiology and Community Studies Sir Mortimer B. Davis
Jewish General Hospital, Montreal, Canada
b
Institute for Rehabilitation Research, Hoensbroek, The Netherlands
c
cole de radaptation Universit de Montral, Montreal, Canada
d
Centre de recherche de l'Institut universitaire de griatrie de Montral, Montreal,
Canada
Abstract. The purpose of this study was to conduct a cross-validation of the

bidimensional structure of a satisfaction measure with assistive technology. Data
were drawn from a follow-up study of 243 subjects who had been administered the
Dutch version of the Quebec User Evaluation of Satisfaction with assistive
Technology (QUEST). Ratings related to 12 satisfaction items were analysed.
Factor analysis results showed that the underlying structure of satisfaction with
assistive technology consists of two dimensions related to assistive technology,
Device (eight items) and Services (four items), accounting for 40% of the common
variance. This finding was consistent with a previous Canadian study and was
interpreted as supporting the adequacy and stability of the QUEST measure of
satisfaction. Although the structure is delineated, further studies are recommended
to support its use in European countries.
Keywords. Assistive Technology, User Satisfaction, Validation, Factor Analysis,

Outcome Assessment, Quest
1. Introduction
In this new era of evidence-based practice, satisfaction information is conferred

considerable importance as a patient outcome and, as a result, measurement of the
concept is gaining status [1,2,3]. It is common belief that satisfaction data can help
clinicians, researchers, managers, and payers improve what they do, for example, by
enabling services monitoring and creating positive attitudes among patients or clients
[4]. According to Keith [2], satisfaction can be defined as an attitude about a service, a
product, a service provider or a person's health status. This definition emphasises the
diversity of purposes satisfaction outcomes may address.
1
This chapter has been published before as part of the doctoral thesis of Roelof Wessels Ask the user :
user perspective in the assessment of assistive technology and in the Journal of Rehabilitation Medicine
2001, 33: 187-191 and is reprinted here with his permission.
L. Demers et al. / Key Dimensions of Client Satisfaction with Assistive Technology 251
Figure 1. Satisfaction with assistive technology model, inspired from Simon & Patrick [6]
In the field of assistive technology, user satisfaction is identified as one of five

main outcomes categories, together with clinical results, functional status, quality of
life, and costs [5]. Although the use of these outcomes is strongly advocated,
satisfaction assessment tools are scarce, due in part, to a vacuum in the theoretical
knowledge concerning the phenomenon under study. Indeed, satisfaction determinants
are vague and indefinite and this situation is prejudicial for the measurement of the
concept, frequently making it totally arbitrary.
Despite important conceptual limitations, it is useful in the context of this study to
represent the relations between the variables involved in the experience of assistive
technology within a general frame of reference. The linear satisfaction theoretical
model depicted in Figure 1 was inspired by Simon & Patrick`s work [6] in
rehabilitation. Expressed satisfaction, which appears in the corner box, may be
conceived as a reaction to assistive technology provision and, therefore, as a dependent
variable. Satisfaction can also trigger a subsequent action or behaviour, whereby it is
approached as an independent variable. According to this model, the core concept
under study can be broken down into several dimensions, all of which contribute to the
user perception.
This multidimensional approach is strongly supported by empirical work in the
field of rehabilitation [7,8] as well as in other health domains [9,10]. To date however,
there is little agreement about the conceptual structure of satisfaction measures with
assistive technology.
A first step in the definition of key satisfaction dimensions with assistive
technology was recently taken in the context of the development of the Quebec User
Evaluation of Satisfaction with assistive Technology (QUEST) tool [11]. This outcome
measurement instrument was designed to measure satisfaction with assistive
technology devices in a structured and standardised way. Although its experimental
version consisted of 24 variables, an item analysis subsequently reduced this number
252 L. Demers et al. / Key Dimensions of Client Satisfaction with Assistive Technology
by half [12]. As part of the same methodological study, the 12 selected items were
submitted to factor analysis. Results suggested that the underlying structure of
satisfaction consists of two key dimensions respectively related to assistive technology
Device and Services. As shown in Figure 2, the Device dimension embraced eight
items related to salient characteristics of the assistive technology whereas the Services
dimension encompassed four intercorrelated items. The fit of the proposed
measurement model was judged as reasonably good, with an acceptable amount of
explained total item variance totalling 48.4% [12]. Several studies [13,14,15] have been
published which support the bidimensional approach of assistive technology, thus
strengthening its validity.
From a methodological perspective however, there are two issues that challenge
the stability of this conceptual structure. Both stem from the fact that the data used
were obtained from a single sample of subjects. The first criticism is that all
satisfaction ratings were drawn from seating and mobility aids as well as lower limb
prostheses [12]. Logically, it can be argued that different patterns of inter-correlated
items might have emerged with other types of devices. The second criticism concerns
the cross-cultural application of the satisfaction structure proposed, since it was based
on a single North American setting, that of Montreal. Provision of assistive technology
is likely to vary substantially across countries, not to mention continents.
Both limitations need to be addressed in order to give credibility to the proposed
structure and support its adequacy
The goal of the present study was to conduct a cross-validation of the bidimensional
structure of satisfaction with assistive technology, using a sample of subjects that
differed from the original research with respect to cultural setting and types of devices.
Figure 2. Key dimensions of satisfaction with assistive technology

2. Methods
2.1. Subjects
Data were obtained from a previous Dutch follow-up study involving 375 subjects [16].
The devices used by these people included toilet adaptations, shower seats and chairs,
wheelchairs, adapted beds, stairlifts, home adaptations and adapted beds. A large
proportion of this sample (82%) was recruited from the TNO-PG, a Dutch organisation
for applied scientific research located in Leiden. These subjects had been provided with
an assistive technology device in the past and were taking part in a larger questionnaire
survey. The remaining 18% of the sample were selected from the Institute for
Rehabilitation Research (iRv) in Hoensbroek, which houses an assistive technology
service delivery centre. A follow-up evaluation was implemented three months after the
clients had received a new device. In both of these regions, subjects were visited in
their home. No formal training of the evaluators was provided and a large number of
them (total of n=31) were involved in the data collection. Prior to conducting the
analysis, the dataset was inspected to ensure it was suitable for the intended purpose.
Data were screened with regards to age of subjects (children were excluded from
sample), aberrant data (zero variability), missing data and non-applicable responses
(individuals who responded to less than 50% of the questions were excluded).
2.2. Items
All subjects were administered the Dutch version of the experimental QUEST, the D-
QUEST [17]. The translation was based on a set of standardised procedures as
discussed in two articles [16, 18]. The consistency of viewpoints between the authors
of the tool, the researchers from the iRv and several Dutch occupational therapists was
a strong contributing factor for obtaining conceptual equivalence between the English
and Dutch versions. It also permitted the adaptation of the instrument to the specific
context of assistive technology provision and use in the Netherlands.
The D-QUEST was administered in full. However in this study, satisfaction ratings
with 12 items selected from the previous item analysis of the QUEST [12] were
included in the analysis. These target items are listed in Table 1, together with their
definition. Each item was scored with a 5-point satisfaction scale, with a score of 1
denoting not satisfied at all, 2 not very satisfied, 3 more or less satisfied, 4 quite
satisfied, and 5 indicating very satisfied. In terms of psychometric properties, they
were found to be reliable with respect to test retest stability and interrater
reproducibility, with weighted kappa values respectively ranging from 0.51 to 0.74, and
from 0.35 to 0.72 [19]. With respect to content validity, all 12 items were considered of
primary importance for assessing satisfaction according to 50% and more assistive
technology experts (n=12) recruited in the United States, the Netherlands and Canada
[18]. Moreover, these items were rated as highly important (mean scores of 4.00 to
4.85 on a 5-point importance scale) by 158 Canadian users of assistive technology [12].
2.3. Procedures
Factor analysis is an analytical technique that permits the reduction of a certain number
of interrelated variables to a smaller number of latent hidden dimensions [20]. In test
development and cross-validation, it reveals the pattern of shared variation within a set
of items. Principal Axis Factoring (PAF) is the most widely used method of factor
extraction for explaining common variance [20] and it was used in this study. Principal
Components Analysis (PCA) which is designed to extract total (not common) variance,
is automatically produced as a preliminary step to PAF. The statistic pertaining to total
variance was examined.
Because the QUEST provided subjects with the option of scoring items as non-
applicable, there was a large proportion of missing data (24%). The percentage of
missing responses per item is given in Table 1. Therefore, in order to avoid a
significant reduction of the sample size, a pairwise strategy was used to compute the
matrix of inter-item correlation coefficients. Accordingly, all valid responses were
analysed. To obtain a simple structure, items loading (correlating) high on one factor
and low on the remaining factors were needed. Loading values may vary from 0.000 to
1.000. Meaningful item loadings for each factor were examined after both orthogonal
(varimax) and oblique (oblimin) rotations. In one case, the factors are independent,
whereas in the second case, they are allowed to correlate. The results were similar, but
orthogonal rotation was retained because it was easier to interpret.
Table 1. QUEST items, definitions and percentage of missing data (ATD = Assistive Technology Device).
% of missing
No Item Definition
data
1. Comfort Physical and psychological well-being associated with use 5.8
of ATD.
2. Dimensions Convenience of the device's size (height, width, length). 6.2
3. Professional services Quality of information on ATD provided, accessibility and 18.1
competence of professionals.
4. Follow-up services Ongoing support services for ATD. 42.0
5. Simplicity of use Ease in using the ATD. 2.5
6. Effectiveness Goal achievement with the ATD. 7.4
7. Repairs and servicing Ease in having the ATD repaired and serviced. 48.6
8. Durability Robustness and sturdiness of the ATD. 9.9
9. Adjustments Simplicity in setting/fixing the components of ATD. 42.4
10. Safety Degree to which the ATD is safe, secure and harmless. 6.6
11. Service delivery Ease in acquiring the ATD including length of time. 14.8
12. Weight Ease in lifting and/or moving the ATD. 62.1
3. Results
Factor analysis was performed on a matrix of correlations between item scores obtained
from 243 subjects (67.5% of the original sample). This sample size exceeded the
recommendation of having at least 10 times as many subjects as variables [21]. Both
the Bartlett Test of Sphericity (p<0.000) and the Kaiser-Meyer-Olkin Measure of

Sampling Adequacy (KMO) (0.76) demonstrated that the data were appropriate for the
planned analysis. The results yielded two factors accounting for 40% of the total
common variance among the 12 items. Based on PCA, the total item variance
explained by this solution attained 49%. Consistent with common practice, each factor
Table 2. Dutch and Canadian results of factor analysis (after orthogonal rotation) of 12 QUEST satisfaction
items.
Factor 1 Factor 2
Item Communalities
Device Services
Dutch (n=253)
1. Comfort 0.764 0.611
2. Dimensions 0.611 0.399
5. Simplicity of use 0.766 0.609
6. Effectiveness 0.585 0.377 0.484
8. Durability 0.339 0.395 0.271
9. Adjustments 0.629 0.402
10. Safety 0.467 0.305
12. Weight 0.474 0.316 0.325
3. Professional service 0.503 0.333
4. Follow-up services 0.651 0.434
7. Repairs/servicing 0.685 0.475
11. Service delivery 0.312 0.108
Canadian (n=150)
1. Comfort 0.420 0.193
2. Dimensions 0.608 0.381
5. Simplicity of use 0.661 0.485
6. Effectiveness 0.589 0.346 0.466
8. Durability 0.361 0.419 0.306
9. Adjustments 0.658 0.449
10. Safety 0.396 0.224
12. Weight 0.577 0.338
3. Professional service 0.689 0.509
4. Follow-up services 0.823 0.696
7. Repairs/servicing 0.689 0.487
11. Service delivery 0.394 0.180
was interpreted according to the variables (QUEST items) that 'loaded' or were mostly
highly correlated.
The factor structure matrix shown in Table 2 represents the loadings of the 12
items with the factors. The communalities, or the proportion of variance that is
accounted for by this solution, are reported in the right-hand column. Small portions of
durability (#8), and service delivery (#11) variances were explained (0.271 and 0.108
respectively). For this analysis, a conservative threshold for meaningful loadings at
0.30 was employed [20].
Results revealed that most items are high on one factor and low on the other, thus
contributing positively to a simple resulting structure. Three items, however, performed
slightly differently. Items effectiveness (#6) and weight (#12) loaded on both factors but
more substantially with Factor 1. Item durability (#8) loaded moderately on the two
factors, however, somewhat more with Factor 2.
The largest factor was consistent with a Device dimension and accounted for 24.6% of
the explained common item variance. It was characterised by high loadings of all
technical and 'user-interface' features of the assistive technology. Indeed, comfort (#1),
dimensions (#2), simplicity of use (#5), effectiveness (#6), adjustments (#9), safety
(#10), and weight (#12) all loaded high on this factor. Despite its dual allegiance, it was
reasonable to also assign durability (#8) to Factor 1 because it is usually considered as
a technical characteristic of a device.
The second factor, Services, accounted for 15.1% of the explained common
variance. It was defined by high loadings of consumer service aspects of assistive
technology. The items involved included professional services (#3), follow-up services
(#4), repairs/servicing (#7) and service delivery (#11). As noted previously, items
effectiveness (#6), durability (#8), and weight (#12) also moderately correlated with
Factor 2, despite their stronger affiliation with Factor 1. Table 2 also reproduces the
Canadian factor analysis in order to make comparison of results.
4. Discussion and Conclusions
To gain confidence in outcome assessments and increase knowledge of user perception

and satisfaction, it is essential to build theoretical backgrounds that support the
proposed approaches. Based on a previous study of the QUEST tool, it was
hypothesised that satisfaction with assistive technology should be considered as a
bidimensional construct, encompassing satisfaction with the Device and Services. To
test the validity of this proposition, a different sample of subjects from that on which
the items were originally selected. By conducting the same analyses as in the original
study, we are quite confident that the results of this replication study were not due to
some methodological scheme.
The existence of the Device and Services components for the assessment of
satisfaction with assistive technology was confirmed by the fact that the same factorial
structure emerged from this study data. Indeed, the first factor embraced 8 items:
comfort, dimensions, simplicity of use, effectiveness, durability, adjustments, safety,
and weight. On the basis of content validity, it is reasonable to include durability in the
device dimension. However, because of its allegiance to both factors, the position of
this item is rather weak and should be considered in future studies. It is important to
note that, despite some minor differences in loadings and communalities values, the
same pooling of items had been obtained in the previous study from Demers et al. [12].
From a theoretical perspective, this finding is consistent with those who view
technology quality as a top priority in device selection [13], use [22], and evaluation
[14,15,23]. Similarly, the second factor regrouped the four items most closely
associated with Services aspects of assistive technology provision: professional
services, follow-up services, repairs/servicing, and service delivery, with loadings and
communality values very close to those published originally [12].
Based on the literature reviewed, defining these two key dimensions of satisfaction
with assistive technology appears sound. Although it is the first time that such a
conceptual structure is empirically supported for satisfaction, theoretical reflections of
authors concerned with use, delivery and evaluation of assistive technology distinguish
the same dimensions and view the concept in a similar way. This has been highlighted
by Bain [15] who, in her systematic evaluative approach, suggested that assistive
technology is comprised of devices and service delivery. Similarly, Kohn et al. [14]
explicitly referred to two areas of practice: the provision of services, and the devices
themselves. Vanderheiden [13] also emphasized that the proper choice of advanced
technology and effective delivery were the essential conditions for successful assistive
technology provision.
The data set used for this study was diametrically different from the original study.
Indeed, subjects were assessed in the context of a clinical follow-up, with few
standardised procedures. Compared with the strict management of a research protocol,
it is not surprising to see more interviewers involved, varying degrees of training and a
variety in the types of devices. In addition, although Canada and the Netherlands'
health and social services systems may, due to common western values, resemble each
other in some ways, delivery of assistive technology in the two countries is clearly
distinct. Examples of differences include private/public funding, training, follow-up,
and availability of devices, all of which may influence the users' perception. By
revealing an identical factorial solution, this study provides a strong support for the
adequacy and stability of the measure of satisfaction.
One benefit of this study is to confirm that measurement of satisfaction with
assistive technology should be divided in two components, related to the device and the
services characteristics of assistive technology. In conclusion, future studies will need
to be conducted to support the applicability of the QUEST tool in the European
countries.
Acknowledgements
This paper is based on the doctoral thesis of Louise Demers. The authors gratefully acknowledge the
financial support provided by the Foundation of Quality and Usability Research of Technical Aids in the
Netherlands and the Fonds pour la recherche en sant du Qubec in Canada. Special thanks are extended to
the assistive technology users and to the personnel of TNO-PG for sharing with us their data.
Obituary
Dr.Roelof Wessels studied industrial design engineering in Delft and thereafter worked as scientific
researcher at the Institute for Rehabilitation Research in Hoensbroeck. Although suffering from Multiple
Sclerosis that gave him some limitations, he was always optimistic and energetic. Unfortunately he passed
away at 16 November 2007 at the age of 39 years old. He is survived by his wife and his children.
References
[1] Robertson SC, Colborn AP. Outcomes research for rehabilitation issues and solutions. Journal of
Rehabilitation Outcomes Measurement 1997; 1:15-23.
[2] Keith RA. Patient satisfaction and rehabilitation services. Archives of Physical Medicine and
Rehabilitation 1998; 79:1122-1128.
[3] Osborn CE. Developing instruments for assessment of patient outcomes. Journal of Rehabilitation
Outcomes Measurement 1998; 2:18-25.
[4] Scherer MJ, Vitaliti LT. A functional approach to technological factors and their assessment in
rehabilitation. In: Dittmar SS, Gresham GE, editors. Functional assessment and outcome measures for
the rehabilitation health professional. Gaithersburg: Aspen, 1997: 69-88.
[5] DeRuyter F. Evaluating outcomes in assistive technology: Do we understand the commitment?
Assistive Technology 1995; 7:3-16.
[6] Simon SE, Patrick A. Understanding and assessing consumer satisfaction in rehabilitation. Journal of
Rehabilitation Outcomes Measurement 1997; 1(5):1-14.
[7] McComas J, Kosseim M, Macintosh D. Client-centred approach to develop a seating clinic satisfaction
questionnaire: a qualitative study. The American Journal of Occupational Therapy 1995; 49:980-985.
[8] Wilson KG, Crupi CD, Greene G, Dehoux E, Korol KT. Consumer satisfaction with a rehabilitation
mobile outreach program. Archives of Physical Medicine and Rehabilitation 1995; 76:899-904.
[9] Fitzpatrick R. Surveys of patient satisfaction: I - Important general considerations. British Medical
Journal 1991; 302:887-889.
[10] Steiber SR, Krowinski WJ. Measuring and managing patient satisfaction. Chigago: American Hospital
Publications, 1990.
[11] Demers L, Weiss-Lambrou R, Ska B. Development of the Quebec User Evaluation of Satisfaction with
assistive Technology (QUEST). Assistive Technology 1996; 8:3-13.
[12] Demers L, Weiss-Lambrou R, Ska B. Item analysis of the Quebec User Evaluation of Satisfaction with
assistive Technology (QUEST). Assistive Technology 2001; 12(2).
[13] Vanderheiden GC. Service delivery mechanisms in rehabilitation technology. The American Journal of
Occupational Therapy 1987; 41:703-710.
[14] Kohn J, Mortola P, LeBlanc M. Clinical trials and quality control: Checkpoints in the provision of
assistive technology. Assistive Technology 1991; 3:67-74.
[15] Bain BK. Assistive technology in occupational therapy. In: Neistadt ME, Crepeau EB, eds. Williard and
Spackman's occupational therapy. Philadelphia: Lippincott, 1997: 498-513.
[16] Wessels RD, De Witte LP, Weiss-Lambrou R, Demers L, Wijlhuizen G. A Dutch version of QUEST
(D-QUEST) applied as a routine follow-up within the service delivery process. In: Placiencia Porrero I,
Ballabio E, editors. Improving the quality of life for the European Citizen. Amsterdam: IOS Press,
1998: 420-424.
[17] Wessels R, De Witte L, Knopps HThP. D-QUEST. Hoesbroek: Institute for Rehabilitation Research
(iRv), PO 192, 6430 AD Hoesbroek, the Netherlands, 2000.
[18] Demers L, Wessels R, Weiss-Lambrou R, Ska R, De Witte L. An international content validation of the
Quebec User Evaluation of Satisfaction with assistive Technology. Occupational Therapy International
1999; 6:159-175.
[19] Demers L, Ska B, Giroux F, Weiss-Lambrou R. Stability and reproducibility of the Quebec User
Evaluation of Satisfaction with assistive Technology (QUEST). Journal of Rehabilitation Outcomes
Measurement 1999; 3(4):42-52.
[20] Pedhazur EJ, Schmelkin LP. Measurement, design, and analysis: An integrated approach. Hillsdale:
Lawrence Erlbaum Associates, 1991.
[21] Nunally JC. Psychometric theory. 2 ed. NewYork: McGraw-Hill, 1978.
[22] Galvin JC, Scherer MJ. Evaluating, selecting, and using appropriate assistive technology. Gaitherburg:
Aspen, 1996.
[23] Eblen C. Issues involved in the evaluation of assistive devices. Topics in Geriatric Rehabilitation 1992;
8(2):6-11.
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-259
Plea for Use of Lowered Toilet for All

Pamela MUSCH1, Maarten DEN HARTOG
Studio DenHartogMusch, Arnhem, The Netherlands
Abstract. The posture of squatting is biomechanically considered a healthier

posture than the western toilet posture. For the western population, squatting
proves to be a difficult and uncomfortable experience. By lowering the seat and
combining it with point and foot support, a more comfortable squatting posture is
created. In this article the lower point support posture is analysed and visualised in
anatomical and ergonomic sense. Furthermore, the expectation is expressed that
the lower point- supported toilet concept will prevent problems with constipation,
safety and hygiene. It is probable that after experienced use the (more flexible)
elderly user will be able to use the toilet longer and more independently, albeit
with some special adaptations. A plea for further research on and investigation into
the preventive function of a lower point-supported toilet concept is expressed.
Some solutions for further development are discussed in order to improve this
toilet concept for the elderly user. The lower point-supported toilet concept
presented in this article should be tested and developed further and should be
regarded as a first step towards a preventive and healthy toilet for every adult, the
elderly included.
Keywords. Squatting, Elderly, Toilet, Pelvic Floor Muscle, Constipation, Support
1. Introduction
The increasing population of elderly people and the risks of dizziness and falling that
come with age demand a safe and responsible design of toilets. For the elderly toilet
user preventive measures are advertised widely: toilet seats with increased height and
bathrooms with impressive adjustment functions. One cannot deny the fact of the actual
seating thus being made more comfortable, but considering almost any other aspect of
toilet use (hygiene, increased problems of constipation, balance problems), these
solutions overshoot the mark. They merely lead to an increased probability of
constipation, to unhygienic situations and unnecessary tumbling risks. Tumbling risk
occurs because of the loss of foot contact with the floor or because of the often
inadequately placed support, most likely in the situation of toilet users with shorter
arms and legs.
Snijders, Molenbroek and Plante already described the disadvantages of elevated
toilet seats [3] and argued for rethinking the almost automatic installation of such
toilets for elderly people. This article shows that a lower point-supported posture for
toilet use may even be a better solution to solve the above mentioned problems.
In literature [2] the squatting posture appears to be the most natural one in which
unobstructed and hygienic toilet use is possible. The deeper the squatting, the less
1
Contact Information: Studio DenHartogMusch; Address: Wichard van Pontlaan 201, 6824 GJ Arnhem,
The Netherlands; Tel: +31 (0)26 3882637; Fax: +31 (0)26 3882639; E-mail: mail@denhartogmusch.nl
260 P. Musch and M. den Hartog / Plea for Use of Lowered Toilet for All
obstruction of the bowels. Because the feet are in good contact with the floor, the risk
of tumbling is decreased, which makes the squatting posture a safe option.
Of course, for the elderly toilet user, the squatting posture is unquestionably more
difficult to realize than sitting down on an elevated toilet seat. This is also true for the
younger toilet user: squatting definitely takes more effort and causes more strain than
regular sitting on a toilet. This, of course, raises the necessary questions concerning the
idea of a lower point-supported toilet, especially in relation to the elderly.
Besides this, the use of conventional squatting toilets meets with many
psychological barriers in the western society. Objections are of a both physical and
psychological nature [2]:
Squatting is regarded as unhygienic, clothes get dirty easily

Squatting is not at all easy and directing is difficult
Keeping balance is difficult
Large strains occur on leg muscles and knee joints, especially when squatting
longer
In this applied research the central question was how to find a proper way to create
a (kind of) squatting toilet posture that provides a more comfortable experience than
the native squatting posture. This resulted in a lower point-supported toilet concept.
Secondly, possibilities to improve hygiene and user comfort (clothes, cleaning
buttocks) in comparison to the conventional squatting toilet were examined. In
conclusion, adaptations to the lower point-supported toilet concept for the elderly user
were looked into.
The argumentation in this article leads to the conviction that the (preventive) use of
a lower point-supported toilet offers a healthy, hygienic and safe solution for users up
to old age.
2. Methods
The described explorative study contains a literature study of the squatting posture and
a physical (interactive) study of the lower point-supported sitting (with a mock-up and
a questionnaire). These formed the basis for a design study in which a lower point-
supported toilet concept was created.
2.1. Study of the Squatting Posture
The posture of the conventional squatting toilet (with a hole in the ground) is very
similar to the native squatting posture in some Asian countries, for example Indonesia.
In literature, this posture is considered to be a better posture than the posture of the
western toilet with its seat at an average height of 42 cm [1].
P. Musch and M. den Hartog / Plea for Use of Lowered Toilet for All 261
Figure 1. Various squatting postures, lower point-supported seating and regular seating
Native unstrained squatting posture (A), western or inexperienced squatting (B), squatting with foot support
(C), squatting with foot support and point support (D), regular sitting (E)
When squatting, the bowels are stimulated, the muscles around the pelvic floor are
not strained, and the buttocks are spread which is far more hygienic (reduction of the
need for cleaning).
The native squatting posture (with feet flat on the ground, see Figure 1A) is a
comfortable posture, but it requires flexible ankles, hips and knees. Whether because of
lack of flexibility in these joints or because of insufficient length of ligaments, it is not
known, but certain is that most of the western population can hardly attain this posture.
The differences between Asian and western populations can be attributed to a
combination of inexperience and a different structure of joints and muscles.
The (inexperienced) western squatting posture looks like Figure 1B. This posture
leads to a lot of strain on the calves, and the knees are relatively heavily loaded. Many
people find it difficult to get up out of this posture, particularly because of balancing
problems. For going into and getting up from the squatting position, the whole body
has to cooperate. By far the largest contribution to the total effort is delivered by the
legs.
2.2. Squatting Less Deep, a Logical Solution
The dexterity with which people can go into a squatting position depends on the length,
size and flexibility of their joints, and also on practice, therefore it can vary
considerably per person. If we examine the native squatting posture (Figure 1A), by
measuring diverse people in this posture, and by using Boschmallen (P5 woman/P95
man), the distance of the buttocks to the ground varies from 150 205 mm.
A wedge support at an angle of 15 o under the heels makes squatting more comfortable
(Figure 1C). In this particular squatting posture, the buttocks are a little higher, and the
distance of the buttocks to the ground varies between 230 and 280 mm [4]. Squatting
with the use of a foot support makes both getting up from and going down into the
squatting posture easier and also enables better balance. Even more comfortable than
squatting with a foot support is the lower point-supported posture (Figure 1D), in
which a large part of the body weight is transferred to the point supports (see also
Figure 2). Their height is 25.5 mm, which is an average height and 16.5 mm lower than
the average toilet height of 42 cm. For illustration, the regular sitting posture is shown
(Figure 1E).
2.3. Lowered Sitting Posture Ideal for Toilet
If we examine the various squatting postures (Figure 1A, 1B and 1C) and compare
them to the regular sitting posture (Figure 1E), it appears that the sitting posture in
respect to the stool has a disadvantage: the anteflexion of the hip joint will not be large
enough to tilt the pelvis when spreading the legs, thus more or less obstructing the
transit of the faeces [3]. The sitting posture compared to the native squatting posture
(Figure 1A), however, does have the advantage that leg muscles and knee joints are
strained less as the swells carry the major part of the body weight (60/70% is carried by
the seat, see also Figure 2). This advantage is quite similar in the situation of the lower
point-supported posture (point support, see Figure 2B), where the support takes
between 40 and 50% of the body weight off of the legs. Considering this aspect, the
lower point-supported posture offers almost the same advantages as a regular toilet
seat, on top of its other advantages in comparison to elevated toilets (low risk of
tumbling, better transit of faeces, lower risk of constipation).
2.4. Further Studies
The forces in the lower point-supported sitting posture (Figure 2 middle) are carried by
the ligaments and the muscles. The actual distribution of these forces and torques on
every component (bone, tissue, muscles) theoretically has been determined, however
has not been confirmed yet by measurements in practice. With these measurement data
a more accurate validation of the profits of the lower point-supported sitting posture
can be made.
Buttock support 60-70% Point support 40-50%
Figure 2. Forces in different toilet sitting postures

3. Lowered Sitting As a Training for the Stool?
It has not been proven, but it seems logical to suppose that regular use of a point-
supported lower toilet starting at young age will develop better muscle condition and
flexibility for the user. Together with better posture (of the pelvis) this could help
decrease potential constipation problems or maybe even prevent them in old age.
As the elderly population is not trained in this respect, it is expected that
inexperienced use of a lower point-supported toilet will most certainly cause problems.
Solutions can be found in aids that help to start and support the movement at a higher
level, and those that support the user during the downward movement into the lower
supported position, including adequate aids to help the user get up again. A sit-stand
support will function in a similar way as current solutions for sit-stand aids, only
differing at the end position which is significantly lower than usual. By the way, every
centimeter lower is already an improvement compared to the current toilet elevators.
It is known [5] that a passive stimulation of muscles indirectly causes a training
effect on those muscles working in the opposite direction. This also works for the use
of the squatting muscles during a supported movement, both for the movement of the
actual squatting and for the movement of getting up from out of the lower point-
supported posture. We therefore may postulate the assumption that the lower point-
supported toilet posture can be regarded as training for these muscles, with a matching
expectation of positive side effects on potential constipation.
3.1. More Stability When Sitting Lower
The gravity centre of an upright sitting person on a regular toilet is about 20 cm behind
the feet. (see Figure 3C). The exact distance depends on the body size of the user and
on the actual posture of the user. Sitting down on a toilet seat requires a backward
horizontal gravity centre displacement of about 20 cm, some 2/3 of the seat depth. To
get up without using the arms, the user has to throw the upper body forwards, which
creates a momentum that brings the gravity centre above the feet again. Frequently,
elderly toilet users are either not able to or do not dare to deliver this momentum. In
that case the elderly toilet user will either choose to slide to the front of the seat, or will
reach out for a support. Both choices create a risk of tumbling.
In the Figure 3, a P50 woman is shown in four postures: lower point-supported
sitting, squatting on a platform with a slope of 15 o, sitting on an average toilet seat (42
cm height) and finally standing upright. The gravity centres in all postures are marked
indicatively with a black dot.
When sitting on a lower point-supported construction, the distance between the
gravity centre and the feet is about 8 cm. Standing up from this lower point-supported
posture is safer as it requires only leaning forward, thus bringing the gravity centre
above the feet. Additionally, the fact that the legs are in good contact with the floor
creates a very stable situation. To get up again there is no need to slide or reach
forward, the user just has to stretch his legs. Only in situations where a toilet user (who
is able to go into this lowered position) lacks muscle strength or stability, extra support
will be necessary.
Figure 3. P50 woman on point-supported seat, squatting on a sloping platform 15 o, sitting on toilet (42 cm)
and standing upright. The black dot indicates the gravity centre.
3.2. Lower Point Support More Hygienic
In regular every day female toilet use the cleaning is practically realized by sliding
forward and backward on the toilet seat. Men will probably prefer to stand up in order
to clean, thus avoiding undesirable skin-seat contact. The situation with increased
toilet seat height creates difficulties for the elderly lady in this respect, since the
opening quite often is significantly smaller. For small women with shorter legs situated
at increased height, not being able to reach the floor, an unhygienic smearing of the
seat can be the result.
On a regular toilet seat, skin contact with the seat is normal. The lower point-
supported toilet concept reduces this skin contact to the point-support. In theory, the
lower point-supported toilet concept shows an advantage with respect to hygiene. Since
the faeces pass at close distance to the point support, the design of this support will
have to be determined very precisely to enable the user to take place in exactly the right
position and to create the conditions for hygienic use.
Similar to the squatting posture, the lower point-supported posture causes the
buttocks to be more spread open, thus reducing the need for cleaning. For this reason
the lower point-supported posture can more easily be combined with integrated
hydration/dry systems because these systems will work more effectively. Hydration/dry
systems also match the cultures in which the use of toilet paper is considered
unhygienic. Without a hydration system, it is necessary to clean buttocks at the lower
position, because when cleaning after getting up, the buttocks automatically join, with
increased need for cleaning as a result. For the elderly user this raises the question
whether it is possible to comfortably clean in the lower point-supported position. At the
same time one should question the stability of elderly persons sitting on a seat far too
high for the legs to reach the floor, wanting to clean and not being able to do so without
holding oneself with one hand or having to stand on the floor first, which causes a dirty
toilet seat. A slightly more uncomfortable lower point-supported posture with both feet
firmly on the ground might be preferred purely from a safety and hygiene point of
view.
3.3. Pressing Easier in Squatting Posture
In literature [2] it is indicated that the squatting posture shows a relaxation of the
muscles of the pelvic floor, so that the bowels are not obstructed during discharge. It is
also mentioned that squatting enables a better possibility to press with the abdominal
muscles [4]. The posture of the lower seat with point support seems to provide almost
the same stimulating conditions for the pelvis to rotate and for the legs to spread, thus
creating a situation for the upper legs to push back. This will result in a preventive
advantage with respect to constipation problems.
4. Ergonomics of the Lower Sitting Posture
With a regular toilet seat the users weight is spread over the whole surface of the toilet
seat. In the situation of the lower point-supported posture, more body weight is
concentrated on a significantly smaller surface. This requires specific dimensions for
the shape and comfort of the design of the point support. It also means that the legs will
be actively used for balance. On average, adult buttock bones are some 25 mm wide
and some 40-50 mm long, and the distance in between varies from 120 to160 mm [2].
With female buttocks, this in between distance is on average some 20 mm wider than
with male buttocks. For optimal comfort the buttock bones will have to be supported
fully yet allowing for hygienic toilet use. The ideal point support opening therefore
should lie somewhere between 75 and 90 mm. This demands a clever design, especially
with respect to the space needed for cleaning both at the front and at the back side of
the point support. Broad openings at the front and back side of the toilet seem a logical
solution, since the user of the lower point-supported toilet will not be able to slide on
the seat as usual. Finally it is important that the toilet offers enough space to place the
feet as close to the gravity centre of the body as possible.
Figure 4. ADAPS study: Use of mockup by P5 woman and P95 man

4.1. Ergonomic Demands for Lowered Sitting with Point Support
The above-mentioned translation of the squatting posture anthropometry into a lower

point-supported posture was first put into a geometric substructure. The research was at
first focused on the able-bodied adult user up to an age of 55 years. The goal of the
study was the development of a preventive toilet concept with an integrated point
support to be used by everybody. Later it was decided to examine the concept for use
by the elderly user as well. The geometric substructure was qualitatively examined by
making use of the ADAPS programme (see Figure 4), after which a foam mock-up (see
Figure 5) was built that was tested by 20 people (wearing clothes).
In the foam mock-up the point support is integrated at an average (free squatting)
height (Figure 1C) of 25.5 cm, combined with a foot support in the form of a wedge
with an angle of 15o. The ADAPS study above did not make use of this foot support.
The support of 15o under the feet provides the user with some extra comfort and makes
it more easy to go into the lower sitting posture [4].
4.2. Testing the Lower Sitting Concept
A group of twenty test subjects with an average age of 27 years examined the lower
point-supported sitting posture of the mock-up. On a questionnaire comments were
given on the mock-up, on the movement necessary to go into lower supported sitting,
on the comfort of the height itself, on the overall dimensions (space for cleaning), and
on the appeal of the concept in general. The responses were used to improve the mock-
up and to translate the mock-up geometry into a dimensioned and materialised global
product design.
In Figure 6 a translation is shown of the geometric substructure into a
contemporary looking lower point-supported toilet concept.
5. Increasing Elderly Population
This study was concluded in 1996, a period in which it seemed far too early to publish
the innovative toilet concept. But today in 2008, the time seems right for the insight
that elderly people are (preventively) helped by a lower point-supported toilet. The
main advantages of this concept are lower risk of falling, less constipation problems,
and increased hygiene. All of this leads, in the long run, to a prolonged independent use
of the toilet in old age. This vision, however, does require some adaptations of the
concept shown in Figure 6.
5.1. Solutions for Adapting the Concept to the Elderly User
Though the pictures of squatting elderly people in Figure 7 do justify some optimism,
elderly users in general will have trouble to go into a lower sitting posture, if they ever
reach that posture at all. (In this respect we focus on the elderly that are still flexible.)
To support the elderly user during the movement of going down and getting up from
the lower point-supported sitting posture, the toilet can be provided with a seat lifter
and a support bar, preferably in front of the toilet [3].
Figure 8 indicatively shows a possible position for such a support bar for a P95
Figure 5. Dimensions of the mock-up

Figure 6. Materialized concept for lower point-supported toilet (front, side and scaled top view) Studio
DenHartogMusch, Arnhem 1996.
Figure 7. Squatting of a healthy elderly person (male, 75 years, 1.78 m, no support, feet flat with shoes,
distance buttock to floor 25 cm; and female, 72 years, support, shoes, distance buttock to floor 23 cm, heels
up).
male and a P5 female. Adaptations like the ones indicated here will probably be
appropriate to adapt the concept of lower point-supported toilet to the elderly user, but
the only way to examine this is by doing more research.
6. Conclusions
In the situation of lower point-supported sitting the gravity centre is closer to the feet,
so the forces necessary to stand up can more easily be delivered by the legs. In
comparison to the situation on a regular toilet seat, this leads to a significant reduction
of the arm force needed in the case of a small person, since both feet already touch the
ground. From this viewpoint, the lower point-supported toilet offers a more stable
situation and therefore justifies the expectation that it will offer a safer condition than
the current elevated toilet seats. Further investigation is needed to provide proof for this
statement.
Though still a lot of research has to be done to determine the definitive dimensions
of the lower point-supported toilet and its additional supporting devices for the elderly
user, there are strong indications that -despite the challenging movement of squatting
for the elderly person- the concept of the lower point-supported toilet has serious user
comfort to offer and may prevent many problems of hygiene, constipation and unsafety
with conventional toilet seats.
Figure 8. (Above) indicatively supported lower sitting with sit-stand-up aid and support bar in front of P95
male, (below) indicatively supported lower sitting with sit-stand-up aid and support bar in front of P5 female
References
[1] Sikirov D. Comparison of straining during defecation in three positions; results and implications for
human health. Digestive Diseases and Sciences 2003; 48(8); 1201-1205.
[2] Hoekstra G. Toegepast onderzoek naar houding en antropometrie bij hurkend toiletteren. [Intern report,
in Dutch]; Studio DenHartogMusch. Delft: Delft University of Technology, Faculty of Industrial
Design Engineering;1995.
[3] Snijders CJ, Molenbroek JFM, Plante RA. Biomechanical Aspects of Defecation with Implications for
the Height of the Toilet. This volume.
[4] Sonneveld M. Baarsteun voor verticaal baren [Master thesis, in Dutch] Delft University of Technology,
Faculty of Industrial Design Engineering; 1989.
[5] Hill AV. The heat of shortening and the dynamic constants of muscle. Proceedings of the Royal Society
of Medicine 1938; B126: 136-95.
IOS Press, 2011
doi:10.3233/978-1-60750-752-9-271
Alla Turca: Squatting for Health and

Hygiene
Oya DEMIRBILEK1
University of New South Wales, Sydney, Australia
Abstract. This paper describes the traditional alla turca Turkish toilet, or squat
toilet, as well as its more modern sitting version, and the hygiene etiquette in using
the toilet, including the pros and cons of the squatting posture and the squat toilet.
This is complemented with modern design solutions for these two types of toilets.
Keywords. Defecation, Constipation, Toilet, Height, Elderly, Pelvic Floor Muscle,

Low Back Pain
1. Introduction
In most Muslim countries, squat toilets are the norm. These toilets, used by almost two
thirds of the world population, may seem archaic and undignified to most
Westerners, but they have been proven as being much healthier and more hygienic than
the sitting ones [1]. There are several types of squat toilets (also known as Eastern, alla
turca, Turkish, or Natural-Position toilet). These all consist essentially of a hole in the
ground and places for the feet, with one exception, the "pedestal" squat toilet, which is
as high as a standard sitting toilet. Old Turkish squat toilets, as well as the ones found
in remote areas in the countryside, have a water tap and/or a container of water for
washing the intimate parts with the left hand, and if available, toilet papers (see Figure
1).
During the Ottoman period, squat toilets were in private rooms generally located
outside of homes for hygienic reasons. This changed with the development and
improvement of drainage and sewage systems and these toilets took their place inside
the home, in a section called eyvan [2]. Figure 2 shows the basic types of Turkish squat
toilets from the Ottoman period.
In urban Turkish homes, many toilets have evolved to the sitting types (also
known as alla franca, Flush Toilets or Western Toilets) for most buildings. This was
considered as modernisation and many families have opted to the sitting posture,
finding it more comfortable and aesthetic, and more Western looking. The hygiene and
health aspects of the squat toilet have slowly been ignored. Even after the introduction
of toilet paper, water still remained as a cleansing agent, and has also been incorporated
to sitting toilets (see Figure 7), in the form of a nozzle that comes out from underneath
the toilet seat, from the back and squirts a jet of water. This is now a common feature
in most households.
1
Contact Information: Oya Demirbilek; Email: o.demirbilek@unsw.edu.au
272 O. Demirbilek / Alla Turca: Squatting for Health and Hygiene
One could possibly also squat over standard Western sitting toilets, after raising
the toilet lid, but this requires extra care, as they are not specifically designed for this
purpose. Some retrofitting apparatus and designs are available to facilitate this task.
Please see Figures 10 and 11 for such examples.
2. Hygiene Etiquette in Using a Turkish Toilet
In relation to the grooming activities following the use of a toilet, Gallagher [3]
separates the users in two categories the wipers and the washers. The Turkish culture
belongs mainly to the washers category. Muslims, Japanese and continental Europeans
are all washers, mostly using a bidet after passing motion. For the Muslims, this is
also a religious requirement, while for the others; washing gives them a greater sense of
hygiene. In the Muslim faith, this washing is concerned with cleanliness and purity of
body and soul, and can be applied to both sitting and squatting toilet postures. This
comes from the fact that the Islamic culture gives an important role to water in praying,
to purify the body and the soul. In the Islamic garden, the water is the mirror of the
Heavens and the symbol of life [4] says Aye Birsel, designer of Zo, the Toto washlet
(see Figure 7).
Figure 1. A typical Turkish squat toilet with a water tap on the right, a toilet paper roll holder and a wall
mounted flush button.
O. Demirbilek / Alla Turca: Squatting for Health and Hygiene 273
Figure 2. Ottoman squat toilets [2]
The Islamic faith has a long list of prescriptive rules regarding personal hygiene
when it comes to the use of the toilet. This set of rules is known as Qadaahul Haajah.
It is important to understand that these rules have been established well before the
invention of toilet seats and toilet paper. Leaving the religious concerns aside, some of
the rules for the hygienic etiquette of using a squat Turkish toilet are as follows [5]:
x One should squat keeping thighs wide apart applying the stress on the left foot.
x After relieving oneself it is essential to perform Istinja (washing with water) of the
intimate parts with the left hand and water. This has been updated by religious
leaders as: "At the beginning of Istinja, it is preferable to use toilet paper three
times.
x After this process the hands should also be washed thoroughly.
Figure 3. Puborectalis muscle in the sitting and squatting posture [15,16]
3. Advantages of the Squat Toilet
The use of a squat toilet is said to have many health advantages from a physiological
point of view [6,7,8,9,10,11,12,13]. First of all, it is considered hygienic, as it does not
involve any contact between the user and a potentially unsanitary surface. There is also
no potential splashing as there is no water in the bowl. Ergonomically, the squatting
posture provides a natural body posture and is healthier than the sitting one, as it
provides for the alignment of the rectum and the anus in a near vertical position. This is
facilitating the complete evacuation of bodily waste. Furthermore, elimination of waste
in this posture protects the nerves controlling the prostate, bladder and uterus from
being stretched and damaged.
Squatting also relaxes the puborectalis muscle and straightens the bend to allow
waste to be evacuated easily (see Figure 3). It is also said that squatting helps in
reducing the occurrence of diseases of the digestive system, such as constipation and
hemorrhoids [14,15] and other colorectal disorders (such as colitis, diverticulosis and
appendicitis). For pregnant women, the squatting posture is also said to be better as it
does not apply pressure on the uterus, and daily squatting is reported to help prepare for
a more natural delivery [12].
One other big advantage of squat toilets is that they are very easy to clean. They
also consume less water per flush than western toilets and hence are more
environmentally friendly.
4. Disadvantages of the Squat Toilet
From an ergonomic point of view, squat toilets are more difficult to use, requiring
careful balancing skills. This is particularly important for people with knee joint
problems, limited mobility or recovering from leg injuries. Elderly people may find it
very hard to squat and rise back, if they are not used to it. For the large majority of the
Muslim population, especially those practicing the religion with a regime of five
prayers a day (involving a lot of kneeling down and rising up), squatting would not be a
problem.
Another big disadvantage is that squat toilets may often smell bad, as their traps
design does not allow for a complete flush. The sitting toilet, due to its bowl design that
traps most of the odor under water and to the fact that it is completely flushed after
each use, does not retain any odor.
Yet another disadvantage related to hygiene pointed out by Gen [2] is that the
footrest may get dirty and cause the transfer of microbes around. This may not be such
a big problem for domestic toilets as most people in Eastern and Asian countries take
their shoes off inside their home, and some also have special slippers for using the
squat toilet. On the other hand, this is a problem in public restrooms [2].
Finally, squat toilets may also allow splatter to occur on one's own legs and feet,
not to mention the potential to lose back pocket belongings into the hole.
5. Modern Toilet Designs
Modern versions of Turkish toilet designs have been created during the years and the
following section will discuss examples of these.
5.1. Squat Toilets
Although it is difficult to find examples of modern squat toilets, there are few designers
reinterpreting the squat toilet. Two re-designs of the traditional Turkish squat toilet can
be seen in Figures 4 and 5, both designed by Inci Mutlu and Gamze Akay for VitrA. In
Sun (Figure 5), the foot grid, usually in the shape of two elephant feet has been
extended all around the recess and the hole.
The Water Room (Figure 6) was designed by Aye Birsel. This design is inspired
by the beauty of water in nature, and incorporates a minimalist squat toilet which
consists of a recess and a hole, with a bar to hold while rising up and a soft rock to lean
Figure 4. Squat Toilet by Gamze Turkolu Akay and Figure 5. Sun Turkish squat toilet [18]
nci Mutlu for Eczacba VitrA [17]
Figure 6. The Water Room incorporating a squat toilet
against (encircled on the left of the image). The water room was awarded first prize at
the Design the Future competition in Japan, in 1989, and an ID Magazine Award for
Concepts in 1990.
5.2. Sitting Toilet with Imbedded Washing Pipe
As mentioned earlier, most seated type Turkish toilets have a washing copper pipe
incorporated. A modern version is Zo (Figure 7) designed by Aye Birsel for the
Japanese company Toto.
Figure 7. Zo Washlet
Figure 8. Flo Figure 9. Pinz Ideation 2-in-1 [19]
5.3. Hybrid Toilets, Squatting/Sitting Versions
Flo (Figure 8) was designed by a team of staff and graduate students at Arizona State
University, with the aim to design a sustainable, transgenerational toilet that would be
usable by toddlers as well as by their grandparents [13]. Figure 9 shows Pinz,
incorporating dual use of sit and squat toilet [19]. The benefits of Pinz are cited as
follows: 1) Non-splashing, as the water level is close to he body; 2) Water saving with
a pressurized cistern located next to the siphon jet; 3) No blockage with a large trap
way (8 cm internal diameter); 4) Safe, as unlike Turkish toilets, this one is above the
floor level with a rim around, avoiding slipping into the pan; 5) Hoods on both ends to
contain urine spray, like Japanese squat toilets; 6) Easy installation, simply bolted onto
the floor, like a normal toilet; and finally, 7) Choice of wet or dry landing.
5.4. Retrofit Squatting Devices for Sitting Toilets
Figure 10 and 11 below show two different temporary retrofit squatting devices easy to
install. The first one, NaturesPlatform, provides a platform over an existing seated
toilet, enabling the user to squat. This device is manufactured in the UK. The second
one, Lillipad also allows for a semi-squat position for those with limited flexibility, by
raising the feet onto the front step while sitting on the toilet and leaning forwards. A
more permanent example, the Toilet Transformer, Westernises and converts old-style
Japanese squat toilets into the 21st century (see Figure 12).
Figure 10. NaturesPlatform, Nature's Platform toilet converter (http://www.naturesplatform.com/)
Figure 11. Lillipad: retrofit squatting device for seated toilets [20]
6. Conclusion
Squat toilets have been designed and used in India, the Far East, Asia and Anatolia
since ancient times. The instinctive squatting posture may well have inspired the design
of the first squat toilets [2]. This posture has advantages and disadvantages. The main
advantages can be summarized as follows: considered hygienic, this posture provides a
natural body posture that allows better relaxation during body waste evacuation, which
prevents diseases in the small intestines. Furthermore, it is eco-friendly as it uses less
water.
The disadvantages can be summarised as follows: this posture may not be
comfortable for all, especially for the disabled and for elderly people with arthritis in
the knee. Another disadvantage is that, in heavily used public restrooms, the footrests
may hold dirt and bacteria that could be spread around by users [2].
Despite health and hygiene advantages, the Turkish squat toilet is getting less
popular as days go by. The comfort of the sitting posture and the wide range of
beautiful sitting toilet designs seem to shadow the advantages of the squat posture. The
squat toilet is in desperate need of reinterpretation and innovation by talented designers
to return into peoples daily life. Finally, increased concerns about the environment and
irresponsible use of natural resources may well bring squat toilets back as a healthy and
sustainable alternative to flushed sitting toilets.
Figure 12. Toilet transformer [21]
References
[1] Nature's Platform. Health Benefits of the Natural Squatting Position. [Internet]. 2006 [cited 2009
October 6]. Available from: http://www.naturesplatform.com/health_benefits.html
[2] Gen M. The Evolution of Toilets and its Current State [Master Thesis]. Ankara: Middle East Technical
University; 2009.
[3] Gallagher W. Bath and Body Works. The Wilson Quarterly. 2008 Winter; 32(1):89
[4] Birsel A. On My Way to Water [Internet]. 2002 [cited 2002 May 5]. Available from:
http://www.core77.com/Reactor/ayse/bio.html
[5] QuantumFoam. Islamic Toilet Etiquette, QuantumFoam's Diary [Internet]. 2009 [cited 2009 October
10]. Available from: http://www.kuro5hin.org/ story/2009/2/20/15517/5559
[6] Aaron H. Our Common Ailment. New York: Dodge; 1938.
[7] Bokus HL. Gastroenterology. Philadelphia: Saunders; 1944.
[8] Hornibrook F. The Case for the Health Closet. The Architects Journal. 1963(July 31): p.221-232.
[9] Davenport HW. Handbook of physiology, 4 (2nd ed.). Chicago: Appleton-Century-Crofts; 1966.
[10] Kira A. The Bathroom. New York: Penguin; 1976

[11] Heller J, Henkin W. Body Wise. New York: J.P Tarcher Inc/St Martin's Press; 1986.
[12] Balaskas J. New Active Birth. London: Thorsons; 1991.
[13] Christensen T, Takamura J, Shin D, Bacalzo D. Go With The Flo: A report on a collaborative toilet
design project that utilized a transdisciplinary approach. International Conference in Lisbon. IADE
Design Research Society; 2006.
[14] Dimmer C, Martin B, Reeves N, Sullivan F. Squatting for the Prevention of Hemorrhoids? Townsend
Letter for Doctors & Patients. 1996;159:6670. Available from:
http://www.uow.edu.au/arts/sts/bmartin/pubs/96tldp.html.
[15] Natures Platform. A Clinical Study of Sitting vs. Squatting. 2002 [cited 2009 October 12]. Available
from: http://www.naturesplatform.co.uk/site/clinical_study_of_sitting_squatting.php
[16] Toilet related ailments .com. Colon Cancer - Why Is It So Common In the West, But Not In Other
Places? [Internet] 2009 [cited October 8]. Available from: http://www.toilet-related-
ailments.com/colon-cancer.html
[17] zcan CA. H20 Not Water Everywhere Cultures Evolutionary Design Practices. The 6 th International
Conference of the European Academy of Design. Bremen; 2006.
[18] VitrA Bathroom Culture. 2008 [cited 2009 Dec 3]. Available from: http://enexp.vitra.com.tr/
design_culture/overview.aspx
[19] Pinz Ideation. 2009 [cited 2009 Oct 7]. Available from: http://www.pinz.com.sg
[20] Lillipad. 2009 [cited 2009 October 8]. Available from: http://lillipad.co.nz/
[21] Toilet Transformer: zaps old-style Japanese squatters into the 21st century. 2007 [cited 2009 Dec 5].
Available from: http://www.digitalworldtokyo.com/index.php/digital_tokyo/articles/toilet_
transformer_zaps_old_style_japanese_squatters_into_the_21st_century/
IOS Press, 2011
Subject Index
ADL 127, 166 knowledge base 94
ageing 3 knowledge management 94
ambient intelligence 151 laboratory testing 141
anthropometry 228 low back pain 207, 271
applied ergonomics 35 multiple sclerosis 166
assisted transfer 151 observational study 127, 141
assistive devices 183 older persons 151, 166
assistive environments 217 outcome assessment 250
assistive technology 35, 49, 60, 69, peer review 49
101, 112, 250 pelvic floor muscle 207, 259, 271
autonomy 166 personal hygiene 194
body support 194 potentially vulnerable users 49
care 19 quantitative research 69
co-operative work 94 quest 250
comfort 19 RFID 151, 166
computer based interviews 80 research ethics 60
computer security 27 rest room 35, 101
confidentiality 27 safety 19
constipation 207, 259, 271 security 19
cultural differences 35 seniors 194
day care 166 slips 183
defecation 207, 271 smart home 112
demography 3 smart toilet 112
design 112 squatting 259
design evaluation 217 support 183, 259
design for all 7 toilet 35, 60, 69, 80, 101, 127, 141,
design process 217 151, 166, 183, 194, 207, 259, 271
disabilities 127 toilet environment 228
disabled 35, 228 triangulation 60
elderly 35, 101, 127, 141, 207, trips and falls 183
228, 259, 271 universal design 7
ethical guidance 49 usability 242
ethics 35, 49 user centred design 242
experiences 19 user involvement 49, 60
factor analysis 250 user needs 60, 69
health data 27 user preferences 194
height 207, 271 user satisfaction 250
home automation 19 user test 194
human computer interface 101 user trialling 242
inclusive design 7, 35, 183 user-driven research 3, 60, 69
information gathering 80 validation 250
information systems 27 virtual reality 80
international survey 69 well-being 217
IOS Press, 2011
Author Index
Alm, N. 80, 101 Liaskos, J. 27, 94, 141
Ambrose, I. v Magnusson, C. 101
Boess, S.U. 217 Mantas, J. vii, ix, 27, 94
Buzink, S.N. 183, 194 Mayer, P. 101, 151, 166
Charalampidou, M. 94 Menezello, T. 127
Day, G. 3 Molenbroek, J.F.M. vii, ix, 7, 35,
Day, C. 60, 69, 166 112, 183, 194, 207, 228
de Bruin, R. vii, ix, 7, 35, 112, 183, Morrison, K. 80
228 Musch, P. 259
de Witte, L.P. 250 Panek, P. 101, 151, 166
Dekker, D. 112, 194 Plante, R.A. 207
Demers, L. 250 Rauhala, M. 49
Demirbilek, O. 271 Rist, A. 112
den Hartog, M. 259 Rooden, T. 242
Edelmayer, G. 101, 151, 166 Schlathau, R. 166
Egger de Campo, M. 60, 166 Ska, B. 250
Gentile, N. 166 Snijders, C.J. 207
Gregor, P. 80 Sourtzi, P. 127, 141
Groothuizen, T.J.J. 7, 112, 183 van Berlo, A. 19
Haagsman, E.M. 183 van Weeren, M.H. 80, 112
Hands, K. 80 Weiss-Lambrou, R. 250
Hine, N. 80 Wessels, R. 250
Joel, S. 80 Zagler, W.L. 151
Knall, G. 141

A Friendly Rest Room: Developing Toilets of The Future For Disabled and Elderly People

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

A Friendly Rest Room: Developing Toilets of The Future For Disabled and Elderly People

Uploaded by

Copyright:

Available Formats

A FRIENDLY REST ROOM:

DEVELOPING TOILETS OF THE FUTURE

ISSN 1383-813X (print)

Amsterdam Berlin Tokyo Washington, DC

ISBN 978-1-60750-751-2 (print)

Distributor in the USA and Canada

PRINTED IN THE NETHERLANDS

As part of its Fifth Framework Programme of Research and Technological Develop-

Dr. Johan F.M. MOLENBROEK

Dr. John MANTAS

Renate DE BRUIN MSc

Section 1. General, Organizational and Developmental Issues

Meeting the Challenges of Demographic Change 3

Section 2. The Friendly Rest Room Project

Overview of the FRR Project; Designing the Toilet of the Future 35

The Final FRR Components 112

Section 3. FRR Case Studies and User Tests

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

Fall Prevention in the Toilet Environment 183

Section 5. Design for Improved Toilet Environments

Designing for Older Peoples Experience of Bathing 217

Plea for Use of Lowered Toilet for All 259

Subject Index 281

Meeting the Challenges of Demographic

Keywords. Demography, User-Driven Research, Ageing

in 1999 gave an important impetus to this process. It resulted in a heightened awareness

2. The Importance of User Involvement Strategies

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

x The FRR actually contributes to older persons independence, thus increasing

To summarize: User Driven Research reflects key values of socio-political relevance

1. Democracy: user involvement is active democracy, as it enables persons

Thus, EURAG European Federation of Older Persons welcomes the approach of

[1] Pohlmann S. Liaison Office Ageing, Deutsches Zentrum fr Altersfragen; 2001

Design for All: Not Excluded by Design

Keywords: Inclusive Design, Design for All, Universal Design

1.1. The Need to Design for All

1.2. History of Design for All

Design for All is a process whereby designers, manufacturers and service

The Design for All philosophy developed in Scandinavia, as a logical continuation

x EIDD - Design for All Europe.

x EDeAN - The European Design for All eAccessibility Network.

1.3. Diversity of Terminology

2. Design for All in Practice

2.1. How Inclusive is Your Design Process?

2.2. Is the Investment Worth It?

During the month of September 1996 I recorded in my diary every instance I

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

2.3. How to Start Designing for All?

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

2.4. DfA in the Toilet Environment: an Example

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

3. Design for All: Still Some Roadblocks

3.1. Designers Interpretation

Good design requires consideration of all aspects of human beings: the

3.2. Tools for Designers

In the curriculum of leading educations for engineering, architecture, software

wellbeing is the core of their curriculum. Hopefully, educations for business

Experiences with Smart Homes for Older

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

2. Home Automation for Older People

x Safety & Security

3.1. Safety & Security

3.1.1. Access Control