To use an evidence-based design process, you have to know what the best available evidence is. But research is published faster than anyone can read it. In this blog series, The Center for Health Design’s research team will provide insight into a few healthcare design research matters through a snapshot of 10 studies published since the 2016 Healthcare Design Expo & Conference. Serving as a sneak peek of an upcoming session at the 2017 HCD Expo, the blogs will identify why this research matters and help readers ride the waves of an ocean of research without drowning. 

The research
A 2017 study by Su Jin Lee and colleagues looks at accessibility standards and offers findings that suggest how alternative grab bar configurations can improve toilet transfers.

Why does it matter?
When designing for accessibility, one of the first considerations that comes to mind is the grab bar. The Americans with Disabilities Act (ADA) Accessibility Standards have specific requirements for the configuration of grab bars around toilets in public facilities. Contrary to popular belief, studies have shown that configurations that meet these standards do not adequately support toilet transfers for the majority of people who use them. A slip or fall during a toilet transfer can lead to injury, hospitalization, or even death.

There have been few changes since the establishment of the initial 1961 American National Standards Institute accessibility standards and the U.S. federal government’s minimum guidelines and requirements for accessibility design. These early requirements were based on the needs of younger adults with a single disability, and not the older adults and their caregivers who are the primary users today. Studies like this one by Lee and colleagues can help shed light on the specific dimensional requirements that would support a wide range of people with functional limitations, and evidence that will perhaps warrant an update to ADA standards.

How was the study done?
The research team for this study built an adjustable aluminum framing system for simulation testing of multiple configurations in order to identify the optimal configuration of grab bars to support both independent and assisted transfers performed by older adults and caregivers. More than 130 residents and three dozen caregivers from 11 skilled nursing and assisted living facilities participated in this two-phased study.

In Phase 1, the researchers tested three types of transfers (independent, one-person assisted, and two-person assisted) for three different grab bar configurations:

  • Modified ADA configuration (one grab bar mounted on the side wall at ADA-defined dimensions; a rear grab bar required by ADA was omitted based on previous research that consistently showed it rarely used)
  • Typical bilateral fold-down configuration
  • User-defined configuration (participants adjusted their own configuration until they felt they had reached an optimal set-up)

For each of these set-ups, users provided feedback in terms of safety, ease of use, comfort, and helpfulness.

In Phase 2, researchers aggregated data from Phase 1 to validate results and identify one configuration that would address most user’s needs. Older adults and caregivers tested this set-up and reported how effective it was during transfer in terms of functional performance measures such as grab bar location, grab bar type, feelings of safety, and adequacy of space.

What was learned?
In Phase 1, both residents and caregivers gave the user-defined configuration significantly higher ratings compared to the other two options for all three types of transfers. Despite the fact that different residents and caregivers selected different settings for the customized third grab bar configuration, there was great consistency across the board in the grab bar type, distance from the toilet, height, extension, and amount of space between the toilet and the wall. The optimal configuration includes fold-down grab bars on both sides of the toilet, 14 inches from center line of the toilet, 32 inches above the floor, and extended a minimum of 6 inches in front of the toilet with one side open and a sidewall 24 inches from the center line of the toilet on the other side.

In testing the optimal user-defined configuration (Phase 2), feedback was significantly positive for independent and one-person transfers, and slightly lower (although still positive) for two-person transfers. The authors suggest that while 60 percent of residents and caregivers preferred the overall configuration, findings indicate the two-person assist might require more than 24 inches between the center line of the toilet and an obstruction. This phase of the study confirmed that bilateral grab bars are significantly more effective than those that comply with current ADA standards.

Are the results definitive?
Further research is needed to better understand the specific configurations for grab bars to support safe and comfortable toilet transfers for different users in different scenarios. For instance, while the overall results were favorable for the customized set-up, especially for independent and one-person transfers, there were a high number of neutral or negative responses among users involved in two-person assisted transfers.

It is worth noting that the set of configurations tested in this study did not include a “true” ADA configuration (with a rear grab bar). While this decision to omit the rear grab bar was justified by findings in previous studies, user responses may have been different if they were allowed to compare the complete ADA setup to the other configurations.

The takeaway
Results provide a starting point for a better grab bar configuration for older adults in independent and assisted toilet transfers. We can look to this study for specific dimensional attributes for an improved grab bar configuration, but the findings suggest that adaptable configurations that can be tailored to the needs of individuals (which are likely to change over time) may be the ideal solution.

In general, there is a need to design entirely different support systems that can support a wider range of transfer methods for a wider range of users. This study also highlights a disconnect between accessibility standards and reality. Guidelines and standards do not always meet the needs and capabilities of users, but systematic studies like this can provide evidence for change. And for facilities not covered under ADA, such as single-family housing, the findings can be used as guidance for home modifications.

Interested in the topic? Visit The Center for Health Design Knowledge Repository for more.

Summary of:Lee, S. J., Sanford, J., Calkins, M., Melgen, S., Endicott, S., & Phillips, A. (2017). Beyond ADA Accessibility Requirements: Meeting Seniors’ Needs for Toilet Transfers. HERD: Health Environments Research & Design Journal, 1937586717730338.