| Abir
Mullick
State University of New York at Buffalo
Introduction
The fundamental purpose of bathing is to maintain health and physical
well being of the body. While most young, able-bodied people do not
think twice about taking bath, bathing is more difficult, more time
consuming, and more hazardous for older people with disabilities. The
Gallup organization in 1983 surveyed 1,500 non-institutionalized people
over the age of 55. "Using shower or tub" was one of the sixteen
problem areas identified for maintaining activities of daily living.
The National Center for Health Statistics in 1987 reported that about
10 percent of all people over the age of 65 have difficulty bathing,
and about 6 percent receive help (Lawton, 1990). The magnitude of problems
older people experience while bathing and the seriousness of the situation
raises many important questions. Why do they continue to bathe? How
difficult is it for older people to bathe? How safe is bathing for older
persons with disabilities? Why do older people bathe in unsafe conditions?
Physiologically, bathing allows cleansing of the skin and removal of
accumulated foreign matter. Bathing displaces dead skin, prevents irritations
and rashes that would otherwise transform into infections, and washes
away waste materials that can interfere with the normal functioning
of the skin. Bathing allows people to: 1) maintain acceptable social
standards of cleanliness, both appearance and olfactory, and 2) refresh,
revive, and relax through the washing process.
Bathing, like all forms of body cleansing activities, is habitual and
ritualistic. It is laden with social, psychological and philosophical
overtones. Philosophically, bathing is equated with cleanliness of body
and purity of soul, and it reflects aptly in the popular phrase, "Cleanliness
is indeed next to Godliness." People's obsession to maintain a
clean body is well known. Americans take at least seven baths a week.
The rising sale of deodorants, anti-perspirants, and mouth washes supports
the social emphasis for maintaining a clean body, and it reflects the
cultural and aesthetic spirit of the society (Kira, 1966).
This paper will first examine the safety aspects of bathing. It will
then present results of a study that investigated the safety and accessibility
needs related to bathing among older persons and their care-providers.
Finally, the conclusion will offer design directives to assist in design
of a safe and accessible bathing equipment.
The Magnitude of the Problem
Accidental Deaths
Advocates of bathroom safety are astounded by the high incidence of
bathing-related deaths. ABT Associates Inc.'s report to the Consumer
Product Safety Commission in 1975 indicated that many as 70 persons
over the age of 65 die of bathtub-related burn injuries every year.
According to the National Safety Council, one person dies everyday from
using bathtub/shower in the United States. Of the 24,000 accidental
deaths of people over the age of 65 every year, many are bathing related
(Burdman, 1986). The National Safety Council reported that 345 people
of all ages died in bathtubs in 1989, 364 in 1988, and 348 in 1987.
Bathtub related deaths during the three-year period exceeded those due
to handgun accidents, all forms of road vehicles accidents (excluding
motor vehicles), ladders and scaffolding falls, and ignition of clothing.
Because bathtub related deaths occur suddenly and in a supposedly protective
environment, these deaths tend to cause a greater degree of psychological
trauma for the families.
After the swimming pool, the bathtub is the second major site of drowning
in the home. Budnick and Ross (1985) studied bathtub-related drownings
between 1979-1981. They concluded that those with least control over
their environments - young and the elderly -have the greatest risk of
drowning. Children less than 5 years old accounted for 25 percent, and
those over the age of 75, 15.5 percent of the bathtub-related deaths.
Drowning deaths, for those over the age of 60, were primarily due to
having fallen in the tub. Among children less than 5 years old, about
16 percent of the deaths were due to being left unattended. Bathtub-related
drownings cut across age, sex and race barriers,. All people are prone
to deaths in the common household bathtub. Females accounted for 52
percent, Whites 80 percent, and Blacks 17.3 percent of the all bathtub
deaths. Seizure disorder was attributed as the most common cause of
bathtub drowning among persons aged 5-39.
Bathing Injuries
On an average, 370 persons of all ages sustain injuries from bathtub/shower
daily in the United States. The dangerous aspect of bathing is evident
from the injury data reported by the Consumer Product Safety Commission:
117,230 bathtub/shower injuries in 1989; 136,616 in 1990; and 139,434
in 1991.Those between the ages of 25-64 accounted for 37 percent of
all bathtub/shower injuries; the most vulnerable being those closer
to the upper age limit. The elderly accounted for 17 percent of bathtub/shower
injuries in 1989, 22 percent in 1990, and 20 percent in 1991. More elderly
people were injured from using bathtub/shower than from other potentially
dangerous equipment such as exercise equipment or cooking appliances
(ranges or ovens).
No room at home poses more threats to safety than
the bathroom (King, 1992; Koncelick 1982 ; Kira, 1966). The National
Safety Council reports that in 1990, "7.8 percent of all injury
episodes, or 4,547,000, involved persons of age 65 or older" (Accident
Facts, 1992, p23). The majority of the accidents took place in and around
the home. About 30 percent of all home accidents are due to falls, the
sixth leading cause of death. Falls result in 200,000 hip fractures,
and 25 percent of all hospital admissions for people over 65. The bathroom
is the primary location where many falls take place. Confined space
together with hard slippery surfaces create great risk for all people,
irrespective of their age or physical condition. The greatest danger
in the bathroom is slipping and falling when entering and exiting thebathtub
or shower. The hardness of the bathtub surface and sharp, protruding
fixtures are the chief agent of injury in slips and falls. The lack
of support surfaces for grasping in older bathtubs is the primary reason
why people slip and fall. This is particularly true for older homes,
a place where many of America's elderly reside.
Inconvenience
The results of a study published by the National Institute on Disability
and Rehabilitation Research indicates that in 1984 more people were
dependent in bathing than they were in dressing, transferring into and
out of bed/chair, meal preparation or performing light house work (NIDRR,
1992). Bathing related difficulties escalate sharply with age. They
vary greatly between the young-old(65-74), the old-old (75-84) and the
very-old old (85+). About 40,000 young old people reported difficulty
with bathing. There were twice as many old-olds and over five times
as many very-old olds who had problems with bathing. Not all people
experienced the same type of difficulties; some had more problems getting
in and out of the bathtub, while others had difficulty adjusting the
flow and temperature of water.
Bathing is a difficult task for a large number of the America's elderly.
Another study by the NIDRR indicated that in 1987, "a total of
3.6 million persons (12 percent in the community of over 65) had difficulty
with at least one Activity of Daily Living or mobility(walking) . .
. ADL and mobility difficulties affecting the greatest number of elderly
were bathing (2.5 million or 8.9 percent)" (NIDRR,1992, p66). Not
all individuals with bathing difficulties required help; about 252,000
people bathed unassisted; 1.4 million individuals required human assistance;
308,000 were dependent on the use of bathing aids and equipment; and
280,000 needed both.
Safety problems among the aged are generally due to the loss of physical
capabilities and poor design of bathing equipment. In order to compensate
for loss of capabilities, the elderly tend to over-exert themselves.
This seriously affects their security and personal well being. For example,
the elderly have difficulty bending over and kneeling down. They are
unable to access parts of their body when standing, and some even when
sitting. Many attempt to challenge their capabilities to access difficult
areas and injure themselves. The elderly are constrained by limited
reach and poor grip strength. They feel exerted by the poor design and
location of controls. They have problems reaching fixtures and grasping
them. Many receive injuries from applying excessive force. Poor balance
affects stabilization. This escalates their chances of slippage and
falling when entering and exiting the bathtub or shower.
Current Design
Review of available bathtubs and showers suggests
that safety was never the major issue in their design. Historically,
the development of bathing equipment has been more of chance than conscious
design. Institutional equipment has undergone a significant evolution
because assisted bathingis very difficult for care-providers. But, the
design of common household bathtub/showers has remained virtually unchanged.
The earliest known bathtub dates back to the Minoan dynasty in 1700
BC, and its form is almost identical to the bathtub forms that are in
use today. The present day bathtubs are much like the Minoan tub, the
only difference being they are made of manmade materials and have flowing
hot and cold water. Showers are relatively new. The earliest showers
were developed for medicinal purposes (e.g. water cure or rain bath)
in the early 1800s. Showers became common with the introduction of indoor
plumbing. Their design has remained virtually unchanged since the end
of the first World War.
There are many problems with the present designs of bathtubs and showers.
First, these products are outdated and they fail to meet the physical
needs of the aging population. Adaptive fixtures andequipment are "Band-Aid"
solution to complex problems not satisfied by conventional showers and
tubs. They highlight failures in conventional design and unresolved
problems. Grab bars make up for the absence of adequate support and
the need for greater physical security in the bath area. Bath mats overcome
the danger of the slippery floor surfaces. They reflect the need for
safer footing. Bath seats are a reminder of people's inability to stand
while bathing. They point the need for alternative ways of bathing.
Second, bathtubs and showers are ability-specific products. They conform
only to the functional capabilities and physical needs of young, able-bodied
individuals, and place considerable physical and mental demands on the
elderly, the children and those with disabilities. For example, the
positioning of controls and accessories often require standing and a
wide range of motion. Bathtubs and showers require good balance when
transferring in and out of them. Third, the design of bathtub/showers
do not reflect a lifespan perspective. Conceptually, children begin
to bathe on their own by the time they are 6 to 7 years old. They continue
to do so as grownups until they are about 50-60 years old. Beyond this
age, they begin to inherit equipment-related dependence, followed by
people-oriented dependence, and finally dependence on both. Bathtubs
and showers do not meet the changing needs of people. They are not responsive
to adaptation as people's functional capabilities and physical conditions
undergo age-related changes. For example, when unable to stand and bathe,
people sit down while bathing. The loss of reach from a person's restricted
movement makes controls and accessories inaccessible. Thus for much
of their lives, people either bathe in unsafe conditions or they are
dependent on assistance.
The Study
Purpose
The present study was conducted to assess the bathing needs and preferences
of older persons living at home, and their care-providers. It was designed
to generate qualitative data on bathing, and it was aimed at understanding
a variety of bathing issues. The results of the study are being used
to design a bathing facility capable of providing greater safety and
access to all.
Subjects
All together 40 participants (26 bathers and 14 care-providers) were
interviewed for the study. All bathers were over the age of 62, with
the exception of one 45 year old paraplegic male. The oldest person
was a 90-year old female. The interviewees consisted of: 20 independent
bathers (those who bathe on their own), 6 dependent bathers (those who
are bathed by another individual), 3 family care-providers (persons
who bathe their relatives/friends) and 11 homecare-providers (professionals
who bathe clients). Only three participants had mobility problems; two
depended upon the use of a walker, and one was a wheelchair user. With
the exception of the paraplegic male, who received assistance from his
wife once weekly, all independent bathers managed on their own. The
four dependent bathers were assisted by care-providers. All of the bathers
live in non-institutional settings, most of them in apartments, some
in their own homes, and a few in housing projects for senior citizens.
The family care-providers are members of a care-provider support group.
The homecare-providers are employed by three health care agencies, and
their involvement was suggested by their respective employers. All participants
(bathers and care-providers) were from theBuffalo area, and their participation
in the interviews was voluntary.
Methods
The field research was based solely on three categories of interviews:
focus group interviews consisting of four to seven participants, personal
interviews with bathers and joint interviews with dependent bathers
and their care-providers . The ambulatory bathers (independent) were
contacted through senior centers, and they were interviewed in focus
group settings in the senior centers. The non-ambulatory bathers (independent
and dependent ) were clients served by long-term care agencies. They
were interviewed in their homes (some with aides and others without).
The family care-providers were interviewed individually in their homes.
Professional aides were interviewed simultaneously, with or without
their clients, in focus group settings at their offices or in their
clients' homes. The focus group interviews lasted between one-and-one-half
to two hours, the personal interviews between three-quarters of an hour
to an hour, and the joint interviews between an hour and one-and-one-half
hours.
All interviews were audio-taped. The bathrooms of
those people interviewed in their homes were video-taped. Each of the
interviews was conducted in a discussion-like situation using a variety
of open-ended questions. Due to the uniqueness of each person's background
and the personal nature of the discussion topic, not all participants
were asked identical sets of questions. Instead, questions followed
the momentum of the discussion and responsiveness of the interviewee(s).
They revolved around a set of pre-determined bathing themes. The videos
were later reviewed to determine the environmental conditions of the
bathrooms. The content of the interviews were evaluated based on the
quality and frequency of responses received . The similarities, differences
and uniqueness of the information helped develop a pattern of bathing
needs andpreferences.
Findings
BathingDependence
Bathing dependence varies greatly between people and their physical
conditions. Ability to bathe independently did not depend on any one
factor. For example, a 63 year old female with left sided paralysis,
hip replacement and arthritis in the sacroiliac was dependent upon being
bathed, while an 85-year-old woman with arthritis, impaired vision and
shortness of breath bathed independently. Several persons, in spite
of as many as seven disabling conditions bathed independently. All three
mobility-impaired persons bathed independently. An 80-year-old who lived
independently in her own home was dependent on being bathed. While another
person who had difficulties living independently, bathed on her own.
Bathing dependence generally resulted from illness and/or injury. For
example, a 90-year-old mother's dependence was due to falls in the home,
and an 80-year-old woman's dependence resulted from a physical injury.
No individual was completely dependent on being bathed. They all offered
various levels of assistance. For example, one person who required help
with soaping, rinsing and drying, transferred on her own. Another person
who only needed help in transferring in and out, bathed mostly on her
own. Bathing dependence was both physiological and psychological. For
example, one person phoned her daughter before and after her bath. Another
person has her care-provider remain present in the bath area at all
time. A 90-year old mother made sure that her daughter stood outside
the closed bathroom door. People's ability to bathe on their own depended
on age, severity of disabling condition(s) and their willingness to
do so.
Mechanical and Physical Difficulties
Bathing difficulties vary significantly. The most common problem was
maintaining balance when bathing and making transfers. Those unable
to make safe transfers had abandoned tub-oriented bathing. Other problems
were largely due to inadequate reach, poor grasp and low level of thermal
sensitivity. Many individuals indicated that because of their inability
to "reach low," using controls from the outside of the tub
was impossible. Opening faucets and adjusting water temperature are
troublesome for many. Those who lack sensation in the hands frequently
misjudged the water temperature and got scalded. Low level of illumination
made it difficult for bathers to see controls and accessories. In the
absence of auxiliary heating, people felt cold while bathing. Inadequate
storage caused laying around of articles. This made it impossible to
keep the bath space organized. The size of the bathing space presented
diametrically opposite problems. Small size restricts movement of wheelchair
users and those providing care. Excessively large space makes controls
and accessories inaccessible, and wheelchair users become fatigued from
wheeling around in an attempt to reach for accessories.
Accessible showers, specially built to provide a greater degree of convenience,
are not free of problems. Several users of accessible showers indicated
that they have trouble using controls and bathing accessories while
sitting on built-in seats. Consequently, many of them were either forced
to stand up with water running to reach for accessories, or store them
on the seat. One individual had installed a transfer bench and a flexible
hose to combat the reaching difficulty. Another individual who has a
paralyzed right side, had no use of the grab-bar (since it was located
only on the right side). In the absence of a bar on the left side, getting
out of the shower safely was difficult. A third person, a lower limb
amputee, found it impossible to make transfers to and from the built-inseat.
She used a transfer seat to get in and out of the accessible shower,
and used the built-in seat to hold accessories.
A majority of persons have difficulty using integrated
level type controls.Even though they felt it was easier using such a
control, the difficulties were due to: 1) the problems of understanding
the color-coded signage for water temperature and flow, 2) the complex
operational demands of the faucets requiring two simultaneous actions,push
and turn, or pull and rotate, 3) the non-standard nature of these operations.
Those with tremor of the hand or arthritis in the hand were unable to
fine-tune the temperature and flow adjustments.
Practically all care-providers indicated that bathing people is the
hardest task for them, and getting people out of tub is the most difficult
part of the task. They reported that narrow passages and awkward layout
of bathrooms make it difficult to handle clients with side-by-side movements.
They also obstruct the movement of persons with mobility aids. Inadequate
space in the bathroom makes it difficult to roll-in wheelchairs. According
to homecare-providers, most clients have great difficulty accepting
bathing-oriented assistance from other people. They felt that gaining
clients' trust and cooperate in the bathing process are the most difficult
part of their job. They complained about sliding glass doors and how
they pose great difficulty in transferring people in and out of the
tub. Some of the other difficulties they mentioned included:
•lack of space between tub and adjoining fixtures,
•inadequate space around the tub,
•unavailability of a proper transferring device,
•slippery floor conditions,
•inadequate lighting,
•excessive postural stress resulting from bending
over,
•client's unwillingness to be bathed,
•client's ability to assist, and
•fatigue of bather. Care-providers find it difficult
to shower clients in a shower stall because they themselves become completely
drenched.
Unsafe Practice
Both individuals and care-providers frequently practiced unsafe methods
while bathing or assisting with the task. This was due to not understanding
the associated risk level. Standing while bathing in the absence of
adequate grab-bars was the most common of all unsafe practices. Some
people stood up to soap their underside knowing full well that they
had a balance problem. Others reached out to grasp objects fearing they
would fall. Some people had stored accessories on the bathseat, thereby
decreasing the seating area and increasing the chances of sliding off.
An individual who walks with the help of a walker adopted a series of
very dangerous methods to make transfers and regulate water temperature.
While transferring, he did several complex tasks simultaneously while
holding on to the walker with one hand and grasping the wall-mounted
grab-bar with the other. He then lifted, dragged and bumped his legs
up against the tub. While his hands tremble from the excessive force,
he transferred one leg at a time into the tub. The method he adopted
for adjusting the water temperature is equally dangerous. He operated
it by kneeling down on the narrow floor space between the tub and the
toilet, grasping the walker with one hand, extending himself over the
rim of the tub to reach the controls. The lighting level in the tub
was also very low.
Numerous individuals observed unsafe bathing practices
and jeopardized their safety and well being. For example, by placing
throw rugs outside the tub, many individuals encouraged tripping and
catching their walker/cane. Objects scattered around the bathroom constituted
hazards for everyone, especially those with visual impairments. One
individual admitted hanging on to the bathroom door and the sink to
make transfers. Another person who had difficulty reaching the controls
from outside the tub, regulated the water temperature from the inside
and often got scalded. A care-provider bathed her 90-year-old mother
in a tub that had no grab-bars. The tub was equipped with sliding glass
doors. When stepping in and out of the tub, the mother leaned on the
glass doors.
Common Accidents
Bathing-related accidents are due to the physical and mental stress
that both care-providers and clients experience. These problems are
compounded by medication and fatigue from heat. Several individuals
had either fallen or come close to falling in the bathroom. An individual
who has hip problems and arthritic knees, was unable to get up after
a tub bath. She sat on the tub floor for thirty minutes, rolled over
the tub edge to grab the sink, and dragged herself out of the tub. Many
people have reported falling into the tub while arising from the toilet
seat . One of these people used her emergency beeper for assistance
and was rescued by her family. Although none of the participants were
ever severely scalded, many have been and continue to be mildly scalded
because of poor sensation of the hands.
The risk of falling along with clients is a well known fear among care-providers.
Yet, only one among those interviewed admitted having done so. According
to the care-providers, if a bathing accident will usually occur under
the following conditions: 1) toward the end of the bathing procedure
since clients are both tired and relaxed at that time, 2) after a care-provider
as been on a case for some time, because a client's ability to assist
diminishes as his/her condition worsens, and 3) when transferring a
client out of the tub, because the client's body is damp, the tub inside
and the floor outside are wet and slippery, and the client and the provider
are fatigued.
Unsafe Bathing Conditions
Even though a concern for safety is on the rise, a large majority of
the elderly who live in older homes continue to bathe in unsafe conditions.
In spite of all their difficulties, they make no modifications to their
outdated bathroom, and expose themselves to unnecessary risk. There
are several reasons why they make no environmental changes. During their
early phase of functional decline, they simply make behavioral changes
in the way they bathe, hoping that this will compensate for the lack
of safety. Because a majority of them live on fixed incomes, retrofitting
the bathroom is an economic burden they are unable to bear. Even if
many individuals are willing to make modifications, the condition and
layout of the buildings they live in do not lend themselv es to make
bathroom modifications. Older residents are generally uninformed about
the type of technical assistance they need andwhere to look for it.
They see modifications as an acknowledgment of their own disabilities
and they are embarrassed by it. They think modifications will effect
the value of the property and/or burden the successor with undoing them.
Present Safety Measures
Both individuals and care-providers do take precautionary measures to
ensure safe bathing conditions. For example, most bathers and care-providers
place slip-resistant bath mats inside and outside the tub to prevent
skidding and falling. Those with grab-bars in the tub area hold on to
these bars when bathing. Many people make sure that hotel bathrooms
have grab-bars before reservations are made. Most people ensure safety
by being very careful about every activity. Care-providers ensure safety
by remaining vigilant and remaining with the person all the time. Home
care-providers wear sneakers in the bathroom and ensure good illumination
in the bath area.
Constant Stresses and Fears
Falling and colliding with hard, pointed fixtures was the most common
of all fears. People were afraid of falling while standing in the shower,
during transferring in and out of the tub, and while holding on to a
grab-bar. Some were afraid of getting scalded because of misjudging
the water temperature. One person had abandoned tub-oriented bathing
because of her fear about not being able to exit.
Both care-providers and clients experience physical and emotional stress
due to bathing. The most common stress is physical. People get tired
during and after showering, and they experience shortness of breath.
Non-ambulatory clients tire themselves easily from movement and from
the level of activity that is demanded by being bathed. Most home care-providers
get fatigued by bathing clients, assisting them during transfer, and
from bending over. Many experience serious emotional stress. This is
because they develop a family-like bonding with their clients. The emotional
stress results from the personal nature of the service they perform
and it is further heightened by the long hours of client contact and
proximity they maintain.
Many family care-providers experience very high levels of mental stress
from providing care to their relatives. Emotional stress is the most
difficult part of being a family care-provider, who sometimes are themselves
older and have other family responsibilities. In addition to looking
after other family members, many work outside their homes as well. Consequently,
they feel pressuredto meet their obligations. Most of them are exhausted
from providing constant attention and are burdened from having to contend
continually with family care. Often, lack of acknowledgment from the
one receiving care greatly escalates the level of emotional stress.
Client-related stress varies with:
•size, shape and physical condition of the client, and •the
level of nervousness, cooperation, and willingness the client may display
during bathing.
Environment-related stress is dependent on:
•the availability of transferring devices, and •physical features
of the bathroom such as the tub height, presence of sliding glass doors,
bathroom layout, narrow width of clearances, floor conditions and low
lighting level.
Care-provider related stress is a function of height, weight and physical
condition of the care-provider, and the time pressure resulting from
trying to complete all tasks quickly.
Conclusion
Safe and accessible bathing is not solely a concern of the elderly,
disabled and those caring for them. It is of utmost importance to all
people irrespective of their age, sex and cultural background. Eliminating
accidental deaths and injuries is of prime importance in creating a
safe bathing environment. To provide greater stimulation, control and
personal empowerment for bathers and care-providers, the following design
principles should be observed when making modifications to existing
bathrooms and the design of the future bathing equipment. It is important
that individuals consult their therapist and evaluate their needs before
making modifications or purchasing devices.
1. EnhanceSecurity
Bathing safely and with comfort is largely an environmental issue and
is guided by the quality and physical characteristics of the environment.
As we know, the incidence of falling while bathing threatens all persons
regardless of age but specially those with poor balance. In addition,
falling while providing care threatens the safety and well being of
care-providers.
Recommendations for Existing Bathrooms:
•Emergency Rescue Devices
Install emergency devices such as telephones or intercoms within effortless
reach of the users. These devices provide greater personal security.
They can alert monitoring individuals about accidents, advise accident
victims about how to get out of a crisis, and help individuals in the
rescue operation. •Better Illumination
Low illumination together with poor vision makes it difficult to detect
articles scattered around. Better illumination will direct attention
to potential threats fromprotruding objects and other hazardous conditions.
This can be achievedthrough:
•additional light source in the bath area, •natural daylight
via appropriate size window, •light colored walls in the bathroom,
and •using a transparent curtain.
•Storage
Accessories laying around create hazardous bathing conditions. Provide
greater storage space through wall mounted shelves. This will prevent
accidents from bumping objects into and skidding from articles scattered
around the floor.
Recommendations for New Bathing Equipment:
•incorporate easy to use rescue device and locate them in a strategic
position
•consider smart devices that will alert the central monitoring
system at the time of an emergency •build-in lighting fixtures
into the design of the equipment
•allow for adjusting the illumination level
•offer a choice of direct or diffused lighting
•build-in storage into the design of the equipment
•enable individuals to alter the location and size of storage
•round all edges and soften all corners to reduce the chances of
injury in a fall
•give a safe appearance to the surroundings through recessed fixtures
and rounded edges
•install anti-scalding device
2. Making Safe Transfers
Getting in and out of the tub is the most critical aspect of bathing
independently. It is also the most difficult aspect of providing care.
Poor balance and fear of falling greatly affects people's ability to
make safe transfers. Awkward tub shape, inadequate maneuvering space
and slippery floor conditions greatly adds to problem.
Recommendations for Existing Bathrooms:
•TransferBench
Install transfer bench for making easy transfers. These benches generally
remain partly inside and partly outside the tub. A persons would sit
on the part outside the tub and gradually slide his/her body inside
the tub. Transfer benches are available in various sizes and seat types.
Some are height adjustable and come with or without a backrest. Benches
with rubberized legs ensure safe positioning inside the tub.
•Grab Bars
Mount grab bars in the critical support areas. They can greatly assist
in easy and safe transferring in and out of the tub. Grab bars come
in various designs: horizontal, vertical, diagonal, hockey stick like,
combination, wrap-around, swing away or detachable. Grab bars can be
wall, floor, ceiling or tub mounted. Ridged, brushed, knurled or vinyl
coated grab bars provide better grasp. Because people's physical capabilities
and method of transfer vary significantly, their placement must accommodate
unique requirements of users. In addition to following codes, the positioning
of grab bars must be carefully tested under actual operating conditions.
Recommendations for New Bathing Equipment:
•eliminate the need for making transfers in and out of the tub
and the hazards caused by the activity •use mechanical devices
such as bathlifts before offering human assistance
•provide a build-in transfer device for those who need it
•explore alternative, non-threatening soaking possibilities that
are comfortable and less demanding •locate grab bars at strategic
points capable of facilitating transfers
•allow personalization of grab bars to meet unique needs of individuals
3. Prevent Slipping Inside and Outside theTub
Slipping inside the tub happens due to the smooth condition of the wet
tub surface. When getting out, slipping is caused by the smooth, wet
floor surface. Lack of hand rails further contributes to the problem.
Recommendations for Existing Bathrooms:
•Non-Slip Tub Floor
Non-slip tub floors can greatly add to the security of the bathers and
care-providers. Install bathmats, tub patches or non-skid surface in
the tub. Bathmats are rubberized floor coverings and they fit inside
the tub. They are placed temporarily and can be removed for cleaning
and/or repositioning. Unless they have suction cup-like backing, many
bathmats tend to get loose and slip. Bath patches are smallnon-skid
pieces. They are inexpensive and need to be permanently glued to the
tub surface. Non-skid tub surfaces are integral part of the tub floors
and they cover the entire floor surface. •Non-Skid Bathroom Floor
Carpet the bathroom floor or place a thick variety of throw rug outside
the tub. Even though carpeting is more effective than throw rugs, it
is generally harder to maintain. Thicker throw rugs are more slip resistant
than thinner ones. The floor underneath the rug must be dry and free
of unwanted objects. When stepping on the rug, individuals must not
rely solely rely their balance. They must use hand rails to support
and distribute their body weight.
•Grab Bars
Install grab bars inside and outside the tub. Because slip prevention
depends greatly on the quality of the support, it is important that
attention is paid to the selection of the grab bars and their placement
is carefully studiedunder actual conditions of use.
Recommendations for New Bathing Equipment:
•incorporate permanent, non-skid tub floor surfaces into the design
of bathtub
•extend same non-skid floor outside the tub
•install widespread distribution of grab bars in the form of handrails
•provide "invisible support" that offers assistance when
needed
•strengthen soap holders or towel rods so that they can act as
invisible supports
4. Prevent Over-exertion
Over extension can be attributed to poor design of the physical environment
and to an individual's psychological state of mind. First, it is caused
from labor of stretching for accessories and controls that are not within
easy reach. Second, over-extension is caused by difficulty in reaching
various parts of the body. Third, individuals concerned with poor reach
tend to challenge their reaching capabilities and over-extend.
•Articles Within Easy Grasp
Easy reach for bathers and care-providers is critical. To achieve this,
position all accessories and controls within comfortable reach. Appropriately
placed wall mounted storage greatly increase reach. Their placement
must be carefully examined and the final location thoroughlytested on
the basis of individual needs.
•Handheld Fixtures
Locate manual fixtures such as hand held showers to combat the difficulties
due to inflexible positioning of tub/shower controls. Such fixtures
will greatly increase access and prevent physical strain from over-extension.
•Bathing Devices
Devices such as wash mittens and bath brushes can greatly increase access
to parts of the body. The wash mittens are usually made out of terry
cloth, plastic mesh or soft sponge. Bath brushes are available in long,
short or curved handles. They come with cloth head, sponge tip or nylon
bristles. Wash mittens and bath brushes provide a person a great range
of access and bathing independence. •Plan Ahead and Take Time
It is essential that people pl an ahead for the type of accessories
they need before plunging into the bathtub. Make sure towels, soap and
shampoo arewithin easy reach. Bathing in a hurry can seriously jeopardize
safety. Allocate enough time to make transfers and when reaching for
articles. This will decrease psychological stress and increase bathing
pleasure.
Recommendations for New Bathing Equipment:
•locate accessories and controls within easy reach
•allow making easy adjustments to meet the changing needs of people
•built-in hand held fixtures into the design of the equipment
•remove all loose, add-on fixtures such as bathseat and bathmat,
and replace them with secure built-in products
Bathing independence for the elderly requires taking several considerations
into account. For example, personalization of the bathing environment
, on the one hand provides independence. But on the other hand, it is
unsuitable for people's general use. Custom design environments is particularly
beneficial for those with disabilities. They provide maximum utilization
of individual capabilities, enable a high degree of independence, and
offer a great deal of self-control. Adaptability of the bathing environment
will respond to the needs of a great variety of individuals, allow making
easy adjustments as people's needs and preferences change, and address
individual differences based on age, sex and physical conditions. It
will also provide a wider range of options, transform itself easily
to a variety of situations (i.e., for wheelchair use and those not confined
to use wheel chair use) and adjust to various space limitations (i.e.,
older bathrooms and newer construction).
Simple design of the bathing equipment is the key to safe and efficient
use of the product. In the case of the elderly, simplicity is synonymous
with age-sensitivity. It requires avoiding complicated gadgetry, removing
physical demands that contribute to emotional stress, and utilizing
easy-to-use mechanical means of assistance. Cultural compatibility of
bathing fixtures is essential to providing safety. Older people, by
the virtue of their social and technological beliefs represent a subculture
known as "traditional." Design for the elderly, therefore,
must respect their background and their cultural needs. The difficulties
people have with lever-type controls as explained in the finding is
typical of cultural issues designers must consider when developing a
product environment for them. Straight forward ergonomic solutions designed
for human convenience must to be examined against the backdrop of their
socio-cultural beliefs. Cultural compatibility will greatly influence
the usability and social acceptability of designed products. It can
be achieved through respecting the technological understanding of individuals,
paying attention to how people make decisions, and valuing their cultural
backgrounds
Accessible design should not be the exclusive domain of the majority
of the older and disabled population - it concerns everyone. Because
the elderly live with people of different ages, sexes and physical conditions,
and reside in homes where the bathroom is shared by others, a safe bathing
facility should not focus solely on their exclusive needs. It is vitally
important that the design of a the new bathing equipment adopt a lifespan
- all ages- approach to product development. Such an approach will eliminate
the need for "special design" situations that result in a
mismatch between the user's needs andthe confines of the environment
. It will also prevent making costly retrofits and rehabilitation of
obsolete structures. The life span approach will allow the product to
adapt to the continually changing needs of people and prevent millions
of individuals from bathing under unsafe conditions. In summation, a
universal design responsive to the lifetime needs of all people, will
ensure greater use, safety, privacy, independence and dignity. It will
meet both the physical and psychological needs of people of all ages
through their entire lifetime.
References
Burdman, G. Healthful Aging, Prentice-Hill, New Jersey, 1986.
Budnick, L., Ross, D.Bathtub-Related Drownings in the United States,
1979-81. American Journal of Public Health, 1985 Vol. 75, No. 6.
King, Vanessa.Safety Zone. Continuing Care, March 1992.
Kira, Alexander. The Bathroom: Criteria for Design, Cornell University,
Ithica, NY1966.
Koncelick, Joseph. Aging and the Product Environment, Hutchinson Ross,
Stroudsburg, PA,1982
Lawton, M. Aging and Performance of Home Tasks. Journal ofthe Human
Factors Society, 1990; Vol. 32, No. 5:527-536.
National Institute on Disability and Rehabilitation Research, Digest
of data on Persons with Disabilities, Washington D.C.,1992
National Safety Council, Accident Facts, 1992Edition
U.S.Consumer Product Safety Commission, National Injury Information
Clearinghouse, Washington D.C. Other
Articles Available for Free Automated
Doors: Towards Universal
Architectural Barriers to Normalization:
The Acoustic Environment of Group Homes
Hyperhomes:
A Technical information Manager for Home Modification Service to Older
People
Bathing For Older People with
Disabilities
Enabling
Home Environments: Strategies for Aging in Place
The
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