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Universal Design and the Built Environment: Occupational Therapy and Interprofessional Design Teams—A Scoping Review

2019; Volume: 2; Issue: 4 Linguagem: Inglês

10.3928/24761222-20190625-04

2476-1230

Debra H. Young, Amy Wagenfeld, Heather Vander Veen Rocker,

Cerebral Palsy and Movement Disorders

Review freeUniversal Design and the Built Environment: Occupational Therapy and Interprofessional Design Teams—A Scoping Review Debra Young, MEd, OTR/L, SCEM, FAOTA, , , MEd, OTR/L, SCEM, FAOTA Amy Wagenfeld, PhD, OTR/L, SCEM, FAOTA, , and , PhD, OTR/L, SCEM, FAOTA Heather Vander Veen Rocker, OTR/L, , OTR/L Debra Young, MEd, OTR/L, SCEM, FAOTA , Amy Wagenfeld, PhD, OTR/L, SCEM, FAOTA , and Heather Vander Veen Rocker, OTR/L Annals of International Occupational Therapy, 2019;2(4):186–194Published Online:June 25, 2019https://doi.org/10.3928/24761222-20190625-04PDFAbstract ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInRedditEmail SectionsMoreAbstractBackground:This study was undertaken to determine whether occupational therapy practitioners (OTPs) serving on interprofessional design teams for universally designed built environments influence outcomes for clients without illness, injury, and/or disability.Method:Arksey and O'Malley's 5-step Scoping Study Framework (2005) was used to conduct a scoping review of 38 articles from eight online databases, public agencies, and the literature. Thematic and content analysis was completed.Results:Reviews yielded three themes: role/distinct value of OTPs in universal design of the built environment; outcomes of involvement of OTPs serving on interprofessional teams; and facilitators and barriers to interprofessional participatory design processes. Based mainly on expert opinion, the findings suggest that involving OTPs in creating universally designed environments maximizes occupational performance. Despite the potential benefit, however, lack of evidence-based research limits efficacy and outcomes.Recommendations:Increasing the involvement of occupational therapy in universal design through stronger evidence is imperative to support the American Occupational Therapy Association's Vision 2025 (American Occupational Therapy Association, 2016). [Annals of International Occupational Therapy. 2019; 2(4):186–194.]IntroductionEngagement and participation in occupation take place within the social and physical environment situated within context (American Occupational Therapy Association [AOTA], 2017). Occupational therapy practitioners (OTPs) recommend changes to the environment to support the ability to engage in occupations (AOTA, 2017). Occupational therapy practitioners practicing in environmental modifications address the occupational performance limitations of persons with illness, injury, or disability. Although lesser known by external professionals, OTPs also participate in design of the built environment to provide enriched contextual and activity experiences to enhance performance in the natural contexts of life for clients without illness, injury, and/or disability (AOTA, 2017; Jenkins, Yuen, & Vogtle, 2015; Larkin, Hitch, Watchorn, & Ang, 2015; Young, 2013b). Occupational therapy practitioners practicing in environmental modification bring a unique skill set to this specialty practice area and offer a distinct value to the design of spaces based on consideration of the human life span, development, and varying levels of ability. The application of universal design (UD) principles is one method used by OTPs practicing in environmental modification (AOTA, 2017). Professionals outside of occupational therapy use the principles of UD as well. Although occupational therapy can provide valuable contributions to design for persons without illness, injury, and/or disability, OTPs are not always included on interprofessional design teams. The focus of this study was to determine what is known about the ways in which participation of OTPs on interprofessional design teams influences and/or improves outcomes for the end users of universally designed built environments.Background LiteratureThe expertise of OTPs enables them to collaborate with design/build professionals when designing environments that meet the needs of persons without illness, injury, and/or disability (Young, 2013b). A science-driven education provides practitioners with holistic knowledge of human development across the life span; the effect of age-related changes, illness, injury, and/or disability; and the effect of the environment on participation in meaningful activities (Young, 2013a). The Person-Environment-Occupation (PEO) model is widely used in occupational therapy practice (Law, Cooper, Strong, Stewart, Rigby, & Letts, 1996). Through this model, OTPs recognize the complex relationship between the environments in which people must act, the occupations (activities) in which individuals engage, and the personal factors that affect their performance in these occupations in various environments (Law et al., 1996). Optimal function, or occupational performance, results from a good person-environment-occupation fit (Law et al., 1996). An underpinning of the PEO model is environmental press, which is the interplay between how the environment affects an individual and how well the individual is able to interact with the environment (Lawton, 1977). Person-centered design and environmental press align with UD.Universal design is "the design of products and environments to be usable by all people, to the greatest extent possible, without the need for adaptation or specialized design" (Mace, 1985, p. 147), accommodating a wide range of users, regardless of age, ability, or preference. This concept encompasses a myriad of human factors, addressing usability holistically and integrating features into the environment that provide ease of use, convenience, and safety. When done well, the features of UD integrate seamlessly into the overall design of spaces or products (Young, 2013b) to accommodate diverse users. Universal design, also known as life span design, inclusive design, and/or design for all, was introduced in the 1970s by the architect Ron Mace and a team of product designers, engineers, and environmental designers. Much of the pioneering research in UD arose from the Center for Universal Design at North Carolina State University (Young, 2013b). The seven principles of UD assist with the evaluation of space, guidance in the design process, and education on features that provide increased usability of products, services, and environments (Young, Van Oss, & Wagenfeld, 2014). These seven principles are equitable use, flexibility of use, simple and intuitive use, perceptible information, tolerance for error, low physical effort, and size and space for approach and use (Center for Universal Design, 1997).Integration of UD features can be seen across a spectrum of housing types, ranging from multifamily to single-family housing, and including rental and affordable housing properties. An example of an affordable multi-family housing project that uses integrated UD features is 6th North in St. Louis, Missouri. The complex integrates market rate and affordable rental housing, all of which was built in accordance with UD principles. The authors are not aware of any evidence-based literature on outcomes for the end users of these types of multifamily units.There is synergy among the Occupational Therapy Practice Framework (AOTA, 2017), the PEO model, and UD. The background literature provides evidence, although limited, to OTPs involvement in interprofessional participatory design teams. What is not clear is to what degree the involvement of OTPs on interprofessional design teams influences and/or improves outcomes, such as prevention, health and wellness, and well-being for the end users of built environments that integrate UD features. Blending the skill sets of occupational therapy with design disciplines such as architecture, landscape architecture, interior architecture, and urban planning as well as with building professionals sets the stage for well-balanced outcomes intended to enable clients of all ages and abilities to remain in their homes and participate in their communities (Young et al., 2014). The end products of interprofessional design projects are also well suited for evidence-based research to measure the effectiveness of environmental modifications on the person-environment-occupation fit of the clients (Young et al., 2014).PurposeDesign affects all aspects of the environment, including individual and population health, well-being, and engagement in occupations. Occupational therapy practitioners understand how environments can facilitate or impede client performance and participation (Baum & Christiansen, 2005; Kielhofner, 1995; Law, Steinwender, & Leclair, 1998). Providing clients with equitable and optimal environments to conduct their lives as they choose is a basic tenet of the American Occupational Therapy Association (AOTA, 2010). The occupational therapy profession is well positioned to meet society's occupational needs through its own merits and through strategic interprofessional collaboration supported by UD (Young et al., 2014). However, because no reviews have determined how an OTP on an interprofessional design team affects project outcomes, there is a gap in knowledge and evidence of the involvement of OTPs on interprofessional design teams when designing for persons without illness, injury, and/or disability.MethodThe authors undertook a systematic review of the literature on occupational therapy, UD, and the interprofessional participatory design process. Use of the hierarchy of Sackett et al. (1996) to assign levels of evidence to studies meeting the criteria for inclusion in the review showed a predominantly low level of available evidence. This finding showed that the most effective way to approach this project was with a scoping review rather than a systematic review. Scoping reviews are not as rigorous as systematic reviews, but can ultimately inform further investigations (Armstrong, Hall, Doyle, & Waters, 2011). Possible uses of scoping reviews include identifying research gaps (or lack of research) and summarizing research findings (Twomey, 2014). Standage and Randall stated that a "scoping review allows for a broader approach and attempts to capture all the literature irrespective of the quality of the data or method" (2014, p. 89). The authors used the Arksey and O'Malley 5-step Scoping Study Framework (2005) as a guide to identify available evidence and potential gaps in the literature on the participation of OTPs on interprofessional design teams and the use of UD for built environment projects. A summary of the literature search process, as described by Arksey and O'Malley (2005), is shown in Figure 1.Figure 1. Search strategy and selection process.1. Identifying the Research QuestionThe objective of this scoping review was to systematically search the literature and critically appraise and synthesize the applicable findings to address this question: What is known about the ways in which participation of OTPs on interprofessional design teams influence and/or improve outcomes— such as prevention, health and wellness, and well-being—for the end users of universally designed built environments?2. Identifying Relevant Studies, Gray Literature, and Expert OpinionTo prepare this review, the authors jointly determined search terms and each completed searches of articles containing the following terms: occupational therapy, UD and physical environment, physical access, accessibility, barrier-free design, inclusive design, and/or built environment.Information sources were as follows: Electronic databases: MedLine, PubMed, ProQuest, One File (GALE), SAGE Journals and Publications, Directory of Open Access Journals, Wiley Online Library, InformaReview of the literature for additional articlesPublic Agencies: U.S. Department of Justice Civil Rights Division ( ADA.gov)English language literature published between 1991 and 2017 relating occupational therapy to UD of the built environment was included. Literature on occupational therapy and UD of products and toys as well as the use of UD for learning and curricular design was excluded. Articles that did not incorporate content on occupational therapy and UD and/or occupational therapy and an interprofessional collaborative design process were also excluded.3. Study SelectionThe authors communicated exclusively through telephone conferences to discuss the initial search terms and findings, remove duplicates, and divide the articles for initial screening. Then the authors identified the articles that met the initial criteria for inclusion.4. Charting the DataThe articles identified for inclusion were initially categorized by relevance of the content and divided among the authors for data extraction. Data were entered into spreadsheets for further organization and analysis. The authors followed a uniform approach, recording information as follows: (a) authors, publication year, study title; (b) study participants; (c) study design; (d) aim of the study; and (e) results. This information was ultimately assigned to three spreadsheets, as described later.5. Collating, Summarizing, and Reporting the ResultsThe authors used the spreadsheets as a reference to perform thematic analysis by first coding the data. The codes were then used to collate the articles. Content analysis was used to identify frequently occurring themes. The authors cross-checked the data for accuracy and developed three final themes. Discrepancies were resolved through discussion among all three authors.Results and DiscussionThe 38 publications selected related to occupational therapy and UD and/or occupational therapy and an interprofessional collaborative design process (selected publications listed in Table A, available in the online version of this article). From this selection, three major themes emerged: Role and distinct value of OTPs in UD of the built environmentOutcomes of involvement of OTPs serving on an interprofessional teamFacilitators and barriers to the interprofessional participatory design processOf the 23 articles published in occupational therapy publications, seven were published in peer-reviewed publications and 16 in trade publications. The 15 other publications included in the review were articles published in peer-reviewed public health, interprofessional care, older adult, higher education, and disability and rehabilitation journals; dissertations or position statements; and articles published in non-occupational therapy trade publications or book chapters.Based on the five levels of evidence described by Sackett et al. (1996), four (10.5%) of the reviewed articles were Level I systematic reviews, scoping reviews, and/or randomized controlled trials; one (2.6%) was a Level II two-group nonrandomized study; two (5.3%) were Level III one-group nonrandomized studies; three (7.9%) were Level IV descriptive studies; and 21 (55.3%) were Level V case studies or expert opinions. Seven (18.4%) of the studies were qualitative designs. Within each of the three themes, the levels of evidence varied, as noted in Table 1.Table 1 Study Levels of Evidence by ThemeThemeLevel ILevel IILevel IIILevel IVLevel VQualitativeRole and distinct value of occupational therapy practitioners in universal design of the built environment3101113Outcomes of involvement of occupational therapy practitioners serving on an interprofessional team100220Facilitators and barriers to the interprofessional participatory design process002084Thematic AnalysesRole and distinct value of OTPs in UD of the built environment. Of the publications identified, 18 articles and one book chapter, including two Level I systematic reviews of the literature, one Level I scoping review, one Level II cohort study, one Level IV survey, one Level V case study, 10 Level V expert opinion commentaries/narrative reviews (including one book chapter), and three qualitative studies, were relevant to findings about the role and distinct value of OTPs in UD of the built environment.According to the literature, barriers in the built environment should be remediated by incorporating UD into the design process to provide for physical access to outdoor environments, play spaces, public spaces and buildings, and public transportation (Hauser & Bemke, 2009; Klinger, Moore, Berardi, Miller, Lukman, & Golverk, 2014; Layton & Steel, 2015; Moore & Lynch, 2015; Sanderson, 2014; Wiley & Stern, 2014). The role of occupational therapy in the design process is important in linking participants to their environment to maximize engagement. Application of UD principles is consistent with the distinct value of the use of a client-centered approach by OTPs (Auriemma, Faust, Sibrian, & Jimenez, 2000; Hauser & Bemke, 2009; Rickerson, 2009; Vrkljan, 2005).Occupational therapy practitioners uniquely understand diseases/disabilities and life span development and how these processes affect function, and more specifically, how improving home and community environments through UD and accessibility enhances functional ability outcomes (Auriemma, Faust, Sibrian, & Jimenez, 2000; Shamberg, 2012; Young, 2011, 2013a). Knowledge of the ability-disability continuum and the effect on person-environment fit affords a holistic, client-centered approach to assessing how a person functions in an environment and participates in meaningful activities (Layton & Steel, 2015; Vrkljan, 2005; Rickerson, 2009; Young, 2011).With increased demand for environmental solutions, particularly to enable older adults and individuals with disabilities to remain in their homes and wider communities (Auriemma et al., 2000; Bright, 2011; Faid, 2014; Young, 2011, 2013b), action must be taken. Since designers often do not have direct access to the perspective of the people for whom they design, OTPs can share their expertise about human disability within context (Heylighen, 2014; Young, 2013a) to address the demand for universally designed homes and communities. Survey research has shown that OTPs use UD to "increase environmental access and increase use of products, equipment, and/or environments for all users" (Gradziel, 2007, p. 70). Further, OTPs use UD "to increase an individual's independence, safety and function" (Gradziel, 2007, p. 71).With regard to outdoor spaces, OTPs have a unique understanding of child development; the overlay of childhood illness, injury, and/or disability; and the importance of good fit between a person, the environment, and valued occupations. This knowledge allows these practitioners to assist with establishing guidelines for UD in playgrounds to increase inclusion and maximize engagement of all children (Hauser & Bemke, 2009; Moore & Lynch, 2015; Prellwitz & Skär., 2007; Sanderson, 2014; Wagenfeld, Young, & Westley, 2014; Wiley & Stern, 2014). The role of UD in benefiting the quality of the built environment and the capacity of occupational therapy to apply this knowledge are important factors to consider when establishing design teams.Findings further suggest the distinct contribution of OTPs in understanding diversity and inclusion and skills in advocacy (Ainsworth & de Jonge, 2014b; Klinger et al., 2014; Larkin, Hitch, Watchorn, & Ang, 2015; Layton & Steel, 2015). One example of how these skills can be applied is "participation in legislation and policy-making" to promote the use of UD principles in the built environment (Liu, 2014, p. 4). Occupational therapy practitioners can raise public awareness and advocate for UD, Americans with Disabilities Act guidelines, and aging in place by implementing these concepts in cost-effective home and environmental modification and design collaborations (Faid, 2014; Rickerson, 2009; Shamberg, 2012; Young, 2011). For example, OTPs who work in community-based home modification and design settings must consider their audience when conveying knowledge and advocating for UD so that these considerations will become appropriately associated with an augmented quality of life rather than a superficial fix for declining function (Bright, 2011).Universal design thinking is best introduced at the beginning of the design process and equally implemented by all involved, including OTPs, architects, designers, developers, policy makers, and end users/clients (Larkin et al., 2015). This is achievable via a shift in design focus that empowers collaboration and embraces the capacities of each discipline. Jenkins et al. (2015) suggested using UD as a framework to enhance usability and access in public spaces and suggested that the involvement of OTPs in built environment design is vital. Further, Sanderson (2014) suggested that OTPs must become familiar with policies that influence UD, advocate for selecting to work with designers who understand and incorporate UD approaches, and educate clients and the public on the value of UD for all end users. Application of UD to community access and mobility to increase participation is a role that OTPs can support.Outcomes of involvement of OTPs serving on an interprofessional team. Five articles, including one Level I systematic review of the literature, two Level IV surveys, and two Level V expert opinion/narrative literature reviews of the topic and/or consensus statements, were relevant to the findings on the outcomes of involvement of OTPs on interprofessional teams.Ideally, the design of outdoor spaces should be approached from a collaborative, interprofessional viewpoint, with UD as the overarching framework (Wagenfeld et al., 2014). As with collaborative design of outdoor spaces previously described, there are many reasons for involving OTPs in collaborative efforts to achieve "UD for livable communities" (Young, 2013b, p. 3) with designers, planners, and policy makers (Di-Nur, 2014; Liu, 2014; Young, 2013b).For instance, as more people hope to age in place, lack of future visioning in home and community usability and safety is apparent. To address this challenge, a university-community-retail partnership model that included faculty and students in occupational therapy, interior design, and gerontology, the Ohio Department of Aging, and employees of large retail stores was formed. This partnership led to a service learning course that was open primarily to students in interior design and occupational therapy. The outcome was a community education pilot program on UD for consumers as well as workshops and a training curriculum. This teamwork approach was unique in the number and variety of partners involved, the valuable assets that each partner provided, and the resulting momentum and creativity. The topic and the distinctive contributions of each partner led to statewide implementation of the model and substantial interest in the community education program (Price, Zavotka, & Teaford, 2004).Cooper, Cohen, and Hasselkus (1991) completed a critique of the occupational therapy literature on barrier-free design, noting that the demand for accessible environments is increasing, particularly to enable older adults and persons with disabilities to remain in their homes and communities. In an effort to improve barrier-free design, the American National Standards Institute standards and the associated Enabler model developed by Steinfeld and Maisel (2012) offered a broader, more inclusive conceptualization of disability and identified barriers in the design of built environments (Cooper et al., 1991). The authors concluded that the Enabler model may provide a link to the multidisciplinary team, suggesting that OTPs and design/build professionals can work together to enhance and strengthen design decisions and create inclusive environments for elderly and disabled persons (Cooper et al., 1991).Another interprofessional project called DOT (Design + OT), focused on individuals with multiple sclerosis. The design team included seven second-year design students, one second-year occupational therapy student, and two young adults with multiple sclerosis (Dong, 2010). The brief was to co-design a "design opportunity" to improve the quality of life for individuals with multiple sclerosis (Dong, 2010, p. 242). Two groups, one that included design students and an end user and one that included design students, the occupational therapy student, and an end user, completed an eight-item open-ended questionnaire at three points in the study: before the start of the process, at the onset, and 3 months after completion of the project. Although all participants indicated that the process was enlightening and helpful, the group that included the occupational therapy student reported a greater appreciation for the occupational therapy client-centered processes (Dong, 2010).Acknowledging the applicability of UD for both occupational therapy and architecture, there is limited research on its value as a training tool and a means to foster a collaborative approach to addressing design obstacles (Watchorn, Larkin, Ang, & Hitch, 2013). Using a combination of real-life and virtual reality simulation tasks, the Second Life avatar program, first-year architecture students and third-year occupational therapy students engaged in a one-semester course focused on UD and its application to individuals with physical impairment (Watchorn et al., 2013). Survey findings showed that integrating UD into an entire interdisciplinary course rather than providing it as a standalone unit is a preferable approach for learning its purpose and applicability to varied situations in the home and community (Watchorn et al., 2013). These descriptive studies support the value of including occupational therapy in design projects from the outset of professional training, despite logistical obstacles.Facilitators and barriers to the interprofessional participatory design process. The final theme, facilitators and barriers to the interprofessional participatory design process, included a review of 14 articles. Of this total, two Level III quasi-experiments, one Level V position paper, seven Level V expert opinion/narrative literature reviews of topics and/or consensus statements, and four qualitative articles were determined to be relevant to the theme of facilitators and barriers to the interprofessional participatory design process.Facilitators. Two recurring themes were noted as facilitators to the interprofessional participatory design process. The first was that the expertise of OTPs enables them to make a positive contribution to this field. The literature suggests that OTPs' understanding of the physical, social-emotional, sensory, and cognitive facets of the person and the transactive relationship among the person, the environment, and occupations and the subsequent outcome of developing individualized, client-centered solutions, can facilitate the creation of partnerships to advocate for and collaboratively adapt environments (Ainsworth & de Jonge, 2014a; Canadian Association of Occupational Therapists, n.d.; Coppola, Sakornsatian, Thongkuay, & Trevittaya, 2012; Heylighen, 2014; Larkin et al., 2015; Young et al., 2014). This expertise helps to bridge the knowledge gap of design/build professionals (Heylighen, 2014) to "intersect with the shared goal of maximizing human performance by minimizing unnecessary environmental complexity" (Lenker & Perez, 2014, p. 13).Combined with distinct professional knowledge, the path of OTPs to more robust consultative relationships with design and community agencies involves receiving additional training in residential construction concepts, project management, building codes, standards, and guidelines to allow all participants to share a common language (Canadian Association of Occupational Therapists, n.d.; Shamberg, 2012; Thompson, 2014).Barriers. The literature suggests poor collaboration between stakeholders as a barrier to the wider practice of UD (Hitch, Larkin, Watchorn, & Ang, 2012) through three reoccurring themes. Although the education and training of OTPs may prepare them to be valuable partners in interprofessional UD projects, this belief is not widely held within the design community, and this is observed as early as during academic training. The Readiness for Interprofessional Learning Scale was used to measure students' impression of a semester-long collaboration between first-year architecture students and third-year occupational therapy students (Larkin, Hitch, Watchorn, Ang, & Stagnitti, 2013). Initially, the architecture students reported more negative impressions of interprofessional collaboration compared with the occupational therapy students. However, on posttest, the occupational therapy students' impression of the collaboration process declined, and neither group showed an increase in a positive impression of the collaboration (Larkin et al., 2013). Results of semi-structured interviews with 12 occupational therapists and design professionals showed that, although occupational therapists may have the capacity to be integral partners in UD projects, the group as a whole perceived occupational therapists as having limited qualifications and skills to participate as design partners (Semple, Blowes, Steggles, & Baptiste, 2010). Descriptive research by Wagenfeld, Reynolds, and Amiri (2017) corroborated these findings. A statistically significant finding was that designers are less inclined to believe that OTPs belong on UD project teams. However, despite these findings, OTPs must continue to advocate for their role in creating UD spaces and products as the distinct value of their expertise makes them well placed to make a positive contribution to this field.The second barrier to interprofessional collaboration addressed in the literature is the perception of UD as a separate specialty area (Hitch et al., 2012; Imrie, 2012). The literature also identified a third barrier: UD is not a high priority in prevailing architecture education or the design and construction communities at large (Heylighen, 2014). Despite the applicability of UD for both occupational therapy and architecture, the lack of research on its value