Journal of Integrated Care

Age-Related Disability and Bathroom Use

Maria Burton Heath Reed Paul Chamberlain

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To cite this document:
Maria Burton Heath Reed Paul Chamberlain, (2011),"Age-Related Disability and Bathroom Use", Journal of Integrated Care,
Vol. 19 Iss 1 pp. 37 - 43
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Environment, Design and Rehabilitation (EDR) Series

Age-Related Disability
and Bathroom Use
Maria Burton
Senior Research Fellow

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Heath Reed
Principal Designer
Paul Chamberlain
Design Director
Lab 4 Living, Sheffield Hallam University, UK
Contact details: M.Burton@shu.ac.uk

ABSTRACT
Age-related disability in bathroom use is already a significant problem, and is destined to become even
greater. Previous research has focused on how the person can be enabled to cope with the bathroom
environment by functional training or introduction of assistive technologies. More recently attention
has been drawn to the design of bathroom furniture. This article outlines the work undertaken to
establish the views of the bathroom of older people and carers, and how involvement of older people
as researchers has given strong direction, support and confidence in identification of issues in need of
attention and in product development.
KEY WORDS
bathroom disability; bathroom design; lay researchers; older people

Introduction
Between five and seven per cent of people over
the age of 65 who are living in the community
experience problems when using the bathroom
(Weiner et al, 1990; Murphy et al, 2007) and for
the purposes of this paper will be referred to
as having bathroom disability. They range from
those who experience such severe difficulties
that they require personal assistance with
bathroom use to those who experience day-to-

day challenges but still manage independently

(Ahluwalia et al, 2010; Steel & Gray, 2009; Naik &
Gill, 2005).
One solution commonly employed to
promote continued independence is to use
assistive technologies to modify the environment
to promote function and safety (Gitlin et al,
1993; Tinetti et al, 1994). Assistive technologies
for the bathroom such as toilet seat raises, long-

10.5042/jic.2011.0034
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Age-Related Disability and Bathroom Use

People over the age of 50 were invited to take

part in the project. A variety of community groups
of older people were contacted, and individuals
were invited to participate. There were 73
expressions of interest received (51 women and 22
men). Relevant black and ethnic minority groups
were contacted, but only three people from ethnic
minorities participated.

Faculty of Health and Wellbeing Research Ethics

Committee.
The first stage of consultation with the
volunteer older people involved focus groups.
The aim of the first round of focus groups was to
explore concerns about bathroom use from their
personal experience, or as someone involved
in caring for another person. To achieve this,
potential participants who were also carers were
asked to identify themselves. Several people were
carers and were with their agreement assigned to
one or the other group.
The groups were held at the University and
facilitated by two members of the project team.
Following consent they were video-recorded.
Beforehand, participants were asked to identify
something about their bathroom that they loved
and something they hated which they would
be prepared to share with the rest of the group.
Each group lasted for approximately two and
a half hours (with breaks). Each person was
invited to speak in turn about their loves and
hates and other participants were encouraged
to comment.
At the end of each group all the participants
were asked if they would like to remain involved
with the project. They were offered two forms
of involvement. The first entailed participating
in a short lay-researcher training programme
which would be followed by their visiting other
participants individually at home to collect data
from them about their bathroom and bathroom
use. The second way of being involved was to
be interviewed by the lay researchers. There was
considerable interest expressed, and 20 people
volunteered for the researcher role and 28 were
willing to be interviewed at home. The remaining
participants were willing to be contacted to give
feedback on the product developments.

Methods used for problem identification

Older people as researchers

Ethical approval to undertake the research

was obtained from Sheffield Hallam University

Given the sensitivities of discussing personal

details and habits, it was recognised that there

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handled sponges and grab rails can bridge the

gap between the functional limitations of the
individual and bathroom activity. However, there
are a number of well-documented problems with
existing assistive technologies (Steel & Gray,
2009; Naik & Gill, 2005; Aminzadeh et al, 2000).
The consequences of bathroom disability tend
to be accepted by those who experience it, but
at best it can erode quality of life, for example
by denial of the pleasure that can be derived
from bathing, and at worst lead to incidents
that have a significant impact on physical and/
or psychological health, such as falling or getting
stuck in the bath. Those who have bathroom
disability are more likely to experience accidents
and serious injury requiring hospitalisation
(Ostbye et al, 2004) and skilled nursing care
(Brody et al, 1997).
It can be argued that assistive technologies fill
the gap created in part by poor design of bathroom
furniture, and attention is now being given to
how inclusive bathroom design can maintain the
independence and quality of life of older people
(Mullick, 1993; Naik & Gill, 2005; KT-Equal, 2009).
This paper describes how information was
obtained from a sample of older people to inform
design of future bathroom furniture for a project
called the Future Bathroom.

The study
Engagement of older people

38

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Age-Related Disability and Bathroom Use

could be barriers to obtaining detailed information

about bathroom use. The reason for involving
older people as data collectors was to overcome
this challenge. It was considered that those
of a similar age and with local understanding
would have more empathy with those who had
volunteered to be interviewed, and encourage
more open discussion about bathroom use. Eleven
of the 20 who had originally volunteered were
subsequently available to take part in two days
of bespoke training. They were all retired women
aged between 56 and 80 and from a variety of
personal and professional backgrounds.

Lay researcher training

As previously described, the main task for those
who had volunteered to be lay researchers was
to interview participants in their home about their
bathrooms, enlarging upon loves and hates
identified in the focus groups. They were also
asked to contribute ideas on other issues that
should be addressed. All those who volunteered
successfully completed both training days, and
feedback was very positive.
The training was undertaken in two oneday sessions at the University. The first day
was spent considering the generic research
skills and knowledge required for the role,
such as interviewing and listening skills, ethical
considerations and the need for consent,
confidentiality and lone working practices.
The content of day two focused on the aims
of the project and how they were to be taken
forward. It involved introducing the volunteers to
the design research methods which they would
have to engage with. Probe packs are often used
by designers to enhance the quality and breadth
of data collected, and tailored to meet the
requirements of the particular project (Lucero et
al, 2007). For this project a pack was assembled
for the lay researchers use which included a
checklist, pro-forma data collection sheets,
measuring, sketching and recording materials,

a camera for photographing the bathroom, a

dictaphone for recording the interview and a
mobile phone. A pack was assembled for use
by the interviewee which included a disposable
camera, a bathroom use diary, a notebook and
a stamped addressed envelope for return of data
to the University. The pack was provided to
interviewees so that more information, possibly
of a more personal nature, could be recorded
by the participant over the ensuing week. The
inclusion of the mobile phone for each lay
researcher was in response to potential security
issues identified in the Universitys good practice
guidelines for lone workers and to comply with
ethical requirements. As part of the training,
and to gather some preliminary data, each lay
researcher was asked to visit another at home,
to run through procedures, practise interview
techniques and learn from one another. This
data was also used in the analysis, and therefore
all those who adopted the researcher role
also became the researched through their
participation as interviewees.

The home visits

Over a three-month period the lay researchers
conducted 24 home visits (including those
between themselves). Once signed consent
had been obtained, each interview involved
the researcher asking the participant a series of
questions about their bathroom, prompted by a
topic guide. Photographs and measurements were
recorded, usually jointly between interviewer and
interviewee, to create a rich description of the
positives and negatives of the bathroom.

Data analysis
Interview tapes were transcribed and the scripts
read and identified by all the project team which
they then discussed together in combination
with the photographs, bathroom plans and any
other data that had been collected. The emergent
themes from the interviews were then shared with

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Age-Related Disability and Bathroom Use

the lay researchers and nine of the interviewees

who had offered to join a group discussion at the
University. The aim of the sharing was to explore
the level of consensus and potential differences
in interpretation of the data between the project
team and older people.

Results

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The main themes were to be:

differing views of the bathroom
concerns about safety in the bathroom
bathroom furniture of the wrong shape, and/
or size and in the wrong place, causing access
problems
lack of space
anticipation of future needs and subsequent
economic considerations
seeking solutions to bathroom problems.

Differing views of the bathroom

People viewed the bathroom as a place of either
function or luxury. Words such as luxurious
and pampering were used in association with
using the bath, whereas the shower elicited
words such as quick and economical. There
was also a view of the overall bathroom space
as a chore, with much reference to the need for
cleaning and maintenance.

Safety in the bathroom

Much of the discussion of safety was related
to the fear of an event happening rather than
accidents that had occurred. There was a fear
of falling, getting stuck in the bath or slipping,
and anxiety about loss of balance. In this study
no-one reported having had an accident, but some
reported near misses such as taking a long time
to get out of the bath or having to grab furniture
to prevent a fall, and most were mindful of the
possibility of an accident. Even people who had
had no personal experience of being stuck in the
bath but had heard of others to whom this had
happened said that they had altered their routine

40

to guard against such an event, for example by

having a shower instead, or only taking a bath
when a member of the family was in the house.
Controlling hot water was frequently cited as a
worry. Difficulty with reaching the taps and being
able to turn them off if the water became too hot
was a source of concern.
There were also some examples of risky
routines. For one woman, getting out of the
shower was difficult because the step was high
and she wasnt able to position a grab rail in a
suitable place to help her. Her solution was an
arrangement of a walking frame, a freestanding
towel rail which was placed on top of a bath
mat to anchor it in place, and towels placed on
the floor to prevent slipping. This was the only
way she able to continue using her shower, but
as she comments:
it isnt a thing you want to be doing
forever. (78-year-old female who lives alone)

Bathroom furniture and lack of space

All those interviewed made observations
about the lack of space and the height and/
or position of their bathroom furniture. It was
reported that the height of the toilet, sink, bath
and shower frequently caused problems for
at least one member of the household. Where
there were existing major or minor adaptations
to accommodate someone with a disability, the
problems were greater. Some of those who had
assistive technologies in their bathrooms agreed
that they alleviated one problem but could
create others, for example a toilet raise made it
difficult for others to use the toilet (particularly
grandchildren).
Sinks were commonly too low for men,
particularly when shaving, with the result
that they had to bend over the sink, causing
discomfort particularly for those who suffered
from back pain. Baths were often too high or
deep for those who are smaller or have reduced

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Age-Related Disability and Bathroom Use

joint movement or poor strength. Similarly,

showers with a high step caused access problems
with entry, but more especially when getting out.
The position of the furniture was said either
to hinder or to help usage. Toilets positioned
close to the bath were considered an obstacle to
easy access. However, some interviewees found
it beneficial to use a seat for dressing or a way of
providing support when transferring to and from
the bath. For carers assisting in the bathroom,
lack of space was often highlighted as making
bathroom use more difficult or even impossible.
Nevertheless, while small bathrooms were
frequently reported in a negative way, a small
number of interviewees preferred them. The close
proximity of the furniture gave a sense of security
to some, as they felt they could use the furniture
to give support and assist with standing. One
woman commented:
now that Im getting a bit awkward on
my feet its quite useful having things near,
because sometimes you sort of stagger a little,
and if I were in a big room I might fall over
but its quite handy. Also, with the loo being
near the bath, if I were in trouble I could
always use the bath to heave myself up.
(80-year-old female who lives alone)

Anticipation of future need

Anticipating future needs can be difficult, but
this study found evidence of it. Several of those
interviewed described how they felt that future
decline in bathroom ability was inevitable.
at the moment Im absolutely fine, I can
step over the side of the bath, but I can see
that that perhaps in future years might be a
difficulty...
When replacement bathrooms were being
contemplated, potential decline in ability
and associated safety concerns were taken

into consideration. All the interviewees said

that at present they were capable of using
their bathroom independently, but some
acknowledged a slight reduction in abilities,
such as reduced knee or hip bend or diminished
strength, so greater effort was required to conduct
the necessary functional tasks.
Of the 24 people interviewed, 18 said that
they normally showered. Even for those who
were capable of getting into and out of a bath,
showering was more usual because it was
deemed more practical and more economical
both financially and ecologically. When
bathrooms were refurbished, showers frequently
replaced baths and in some cases wet rooms
were chosen.

Seeking solutions
During the course of the interviews there were
many examples of people seeking information
about the best way to tackle their bathroom
problems. Conversations between the lay
researcher and the interviewee frequently
included exchanges of information and
experiences. Information was swapped about
products and practices which had and had not
been of benefit. Wet rooms were a common
topic of conversation, some expressing the desire
to have one installed while others highlighted
the problems that they can create. A worrying
issue that emerged was that, even though people
researched the bathroom products and furniture
before installation, they were subsequently
not always appropriate to meet their needs.
One interviewee gave the example of a newly
installed shower.
Im not 100% sure that Ive got the right
one when I saw it in the showroom its fine,
when I use it at the moment its no problem,
but it has got quite a high step The high
step is fine walking into it, but coming out of
it

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Age-Related Disability and Bathroom Use

Similarly, the positions of taps, shower rails

and heads, and drains were all reported to create
new problems.

Using the results to inform the

Future Bathroom project

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The data from the focus groups and interviews

were further analysed by the project team and a
number of commonalities were identified across
the data sets leading to three main themes,
including the problems of bathroom furniture
that is the wrong shape, size and/or place, the
changing abilities and needs of the older person
and visitors to the house, accessibility for cleaning
and the desire for a larger space. All these issues
appear to signal the need for bathroom furniture
to be more flexible or adaptable, rather than for
extra or different assistive technology. So the first
theme to be taken forward by the project into
prototype development was the creation of an
adaptable bathroom.
The second significant theme was bathroom
safety. There were many references in both
the focus groups and the interviews to either
current or potential safety fears when using
the bathroom. The concerns raised were
predominantly fear of falling or being stuck in the
bath tub, and often related to decline in vision,
hearing, balance and strength.
The desire and need to recycle and produce
sustainable products and practices were alluded
to in many of the interviews. Being ecologically
and financially sound in the use of water and
energy and in replacement of bathroom furniture
was a thread which ran through the interviews
and was a third over-arching theme.
Validation of the three themes was explored
in group discussion with the lay researchers and
nine of those who were interviewed. Following
overall agreement, artefacts (prototype products
and visuals) were created to stimulate on-going
feedback between the project team and the
community researchers and interviewees.

42

Taking the work forward

Following theme validation, artefacts were created
to stimulate ongoing discussion between the
project team, participants, industrial partners and
other stakeholders.
Ideas have been presented in two rounds of
feedback workshops. All those who took part in
the original focus groups were invited; the results
are reported elsewhere.
Following completion of this EPSRC-funded
study it is hoped that some, if not all, of the ideas
will be developed into products which will be
available to purchase from mainstream bathroom
outlets. During this study we have concentrated
on the more overt issues, but there are other areas
which are in need of attention. The problems of
declining sight and hearing and their impact on
bathroom use, the need for appropriate storage
to decrease clutter in older peoples bathrooms,
and further investigation into the operation and
location of taps are three such areas.
Whatever the direction of our future studies,
the inclusion of older people in the design
and conduct of the study is assured. We have
also learned a lot about the need for good
communication, attention to detail in the training
course, and management of older people within
the university system. Throughout this study
we have gained a great deal of knowledge
from older people about what is important in
bathroom design, which has given the project
team confidence in the themes developed and
the direction of the research.

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Utilization of bathroom safety devices, patterns of bathing
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Journal of Integrated Care Volume 19 Issue 1 February 2011 Pier Professional Ltd

Age-Related Disability and Bathroom Use

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Journal of Assistive Technologies

Enabling technologies for inclusion in health, support, care and education
Aims and scope
Journal of Assistive Technologies debates definitions and concepts within assistive
technologies, and addresses ethics, policy, legislation and issues for day-to-day practice.
Articles focus on how people use assistive and enabling technologies, rather than solely
on the technology itself, and raise awareness of available technologies for a wide and
varied readership.

... helpful in keeping

abreast of recent
research on assistive
technology especially
on local initiatives.

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Mullick A (1993) Bathing for older people with disabilities.

Technology 2 (4)1929.

Naik AD & Gill TM (2005) Underutilization of

environmental adaptations for bathing in community-living
older persons. Journal of American Geriatrics Society 53 (9)
1497503.

Professor Anthea Tinker

Institute of Gerontology,
Kings College London, UK

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This article has been cited by:

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1. Gail Mountain. 2011. Moving from Specialism to Mainstream. Journal of Integrated Care 19:1, 44-47. [Abstract] [PDF]