Annals of International Occupational Therapy

Review Supplemental Data

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

Debra Young, MEd, OTR/L, SCEM, FAOTA; Amy Wagenfeld, PhD, OTR/L, SCEM, FAOTA; Heather Vander Veen Rocker, OTR/L

Abstract

Background:

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.]

Abstract

Background:

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.]

Engagement 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 Literature

The 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).

Purpose

Design 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.

Method

The 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.

Search strategy and selection process.

Figure 1.

Search strategy and selection process.

1. Identifying the Research Question

The 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 Opinion

To 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, Informa
  • Review of the literature for additional articles
  • Public 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 Selection

The 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 Data

The 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 Results

The 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 Discussion

The 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 environment
  • Outcomes of involvement of OTPs serving on an interprofessional team
  • Facilitators and barriers to the interprofessional participatory design process
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Table A.

Article summations by theme.

Of 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.

Study Levels of Evidence by Theme

Table 1:

Study Levels of Evidence by Theme

Thematic Analyses

Role 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 as an interdisciplinary training tool limits opportunities to foster a collaborative approach to solving design problems (Watchorn et al., 2013).

Limitations

This scoping review may not have identified all relevant studies in the published and gray literature, despite attempts to be as comprehensive as possible. The search included 13 terms via eight electronic multidisciplinary databases. Searches with other terms and other databases may have yielded more or different sets of articles for review. The authors found a preponderance of articles on occupational therapy, accessible design, and environmental modification. It was difficult to find articles specific to occupational therapy, UD, and the interprofessional participatory design process. The challenge to capture this information identified a gap in the literature.

This scoping review was a first step in determining what the literature reports on the efficacy of occupational therapy in UD projects in the built environment. A predominance of literature describes the training and skills that OTPs have to enable participation in UD projects. The literature is limited by its level of evidence because much of it is composed of expert opinion and case study reports.

Future studies performed with more rigorous methods beyond expert opinion and case study research are necessary. When seeking participation in interprofessional collaborative UD project research, drawing on higher-level research findings may yield results that OTPs can refer to as evidence for the distinct value of inclusion on interprofessional design teams to improve outcomes, such as prevention, health and wellness, and well-being for the end users of the universally designed built environments and products. Lacking this solid base of evidence limits the potential for designers to view OTPs as necessary partners on design teams.

Implications for Occupational Therapy Practice and Research

By virtue of the scope of occupational therapy, practitioners are well positioned to share their expertise in design projects.

Stronger evidence-based findings supporting the contributions of occupational therapy to end users of universally designed spaces may be the catalyst for design/build professionals to include OTPs in design projects.

As society continues to increase in complexity (e.g., a graying population living longer, with a shortage of appropriate housing), interprofessional collaborative design solutions are needed to allow people to live active, meaningful lives.

The role and distinct value of OTPs on interprofessional design teams can affect population health, specifically when considering environment-level factors (e.g., the effect of the design of the built environment on health).

Conclusion

Limited rigorous evidence-based research and an expansive quantity of anecdotal findings suggest that the involvement of occupational therapy in UD projects in the built environment maximizes occupational performance. Despite the potential benefit, because of the lack of evidence-based research, efficacy and outcomes are not fully understood. Engagement in quantitative and qualitative methodological study is necessary to measure long-term effects on outcomes such as prevention, health and wellness, and well-being along with enhanced participation and engagement in daily activities. More evidence is needed to support the distinct value that OTPs bring to interprofessional design teams when designing for persons without illness, injury, and/or disability and to articulate the importance of these contributions to external professionals and stakeholders.

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Study Levels of Evidence by Theme

ThemeLevel ILevel IILevel IIILevel IVLevel VQualitative
Role and distinct value of occupational therapy practitioners in universal design of the built environment3101113
Outcomes of involvement of occupational therapy practitioners serving on an interprofessional team100220
Facilitators and barriers to the interprofessional participatory design process002084

Article summations by theme.

Theme One: Role and distinct value of occupational therapy practitioners in universal design of the built environment
Citation, Year of PublicationParticipantsResearch MethodAims of Study and Results
Ainsworth, L. & de Jonge, D. (2014)N/ALevel V Expert opinion and commentaryCommentary on Livable Housing Australia (LHA), Australian design approach guidelines for “visitable housing.” Formed to address future housing needs of diverse populations including aging and/or disabled. The occupational therapist's role in LHA includes reviewing plans and buildings under construction and recommending modifications for certification to bear the Livable Housing logo, advocating for changes in legislation to support Livable Housing guidelines for the public, advocating for patient needs in their housing, continuing research in housing best practices, and development of nationwide resources related to home modification for occupational therapists, design, construction professionals, and their clients.
Auriemma, D., Faust, S., Sibrian, K., & Jimenez, J. (2000)N/ALevel V Expert opinion and consensus statementsA discussion of the current body of research in home modifications for older adults and the psychosocial implications of home modification interventions and concerns that arise during the home modification implementation process are explored. Authors further discuss the high number of Americans who need assistance with daily tasks and to solve the problems of everyday living, the public has turned to architects, engineers, interior designers and urban planners. This group traditionally lacks the knowledge of the functional capacities of older adults, may also have progressive or chronic disorders. Occupational therapy practitioners are suggested as knowledgeable resource persons. Occupational therapy practitioners use a client-centered approach. Further, the OTPF incorporates the performance context and cultural context, which can be a critical difference between if services are accepted or refused by a client.
Bright, D. (2011)N/ALevel V Expert opinion and commentaryBaby boomers are the population segment with the most dramatic market potential for UD feature benefits in their homes. Universal design is often explained in professional terms of disease and disability, therefore occupational therapists in community-based home modification and design must learn to speak baby boomer ‘consumer-ese’ when conveying their knowledge and advocating for universal design. In so doing, occupational therapists will help UD residential design become the norm rather than unique, and be associated with augmented quality of life rather than disability and disease.
Faid, P. (2014)N/ALevel V Expert opinionOccupational therapists can play a unique role in increasing public awareness about UD as beneficial to all people. With eyes toward his family's future, the author incorporated UD solutions in his “empty nester” home including residential elevator, zero-step entries/thresholds, wide doors with lever handles and wide hallways. Additional indoor improvements included maximizing natural light and including specific task lighting for aging eyes, low-pile carpeting and flush transitions between floor surfaces, and anti-scald devices on taps and showers. In addition, the outdoor areas of the home were taken into consideration by installing low maintenance exterior siding and building raised garden beds.
Gradziel, D.J. (2007)190 occupational therapistsLevel IV SurveyThe online survey based on the Canadian Model of Occupational Performance (CMOP) and the Canadian Association of Occupational Therapy 2003 UD position statement sought to understand the overall perceptions of Ontarian occupational therapists who incorporate UD principles into clinical reasoning. Results indicated that most respondents believe that it is “highly important, important, or somewhat important to apply universal design principles” (p. 81) to products and environments and that “occupational therapists are using universal design to increase client access to environments” (p. 70). Survey research also found occupational therapy practitioners are using UD ‘to increase an individual's independence, safety and function’ (Gradziel, 2007, p. 71).
Hauser, A. & Bemke, B. (2009)N/ALevel I Systematic reviewThrough a review of the literature on UD playgrounds and occupational therapy involvement, many findings suggest that in order to enable all children to participate in play equitably, UD principles are important to incorporate in design processes. The role of occupational therapy in the design process is important in terms of linking participant to their environment to maximize engagement.
Jenkins, G., Yuen, H.K., & Vogtle, L.K. (2015)48 state chapter/associations presidents or committee members of the (U.S) National Federation of the Blind. All had visual impairments.Qualitative Open ended survey questionsAnalysis of two open-ended survey questions directed at understanding whether for people with visual impairment, sensory characteristics in the built environment assisted or hindered people community navigation. Three overarching themes, barriers, supporters, and context-dependence were derived to explain respondent's experiences with multisensory experiences in the built environment. Findings suggested that multisensory environmental experiences are not supportive or inhibiting of participation and engagement but are context-dependent. A case was made for using UD as the framework to enhance usability and access to public spaces, occupational therapy involvement in the design process is necessary, based on understanding of the transactional relationship between embedded sensory characteristics of the built environment, occupations, modification, and disabling conditions. The authors suggest that involvement of rehabilitation professionals, such as occupational therapists, in built environment design is vital.
Klinger, L., Moore, B., Berardi, N., Miller, E., Lukman, N., & Golverk, D. (2014)N/ALevel I Systematic reviewThis review of accessibility on post-secondary campuses finds that accessibility issues continue to negatively impact and limit the overall post-secondary educational system for individuals with disabilities. The authors discuss two publically available measurement assessment tools, the University Campus Accessibility Measure and the Physical Accessibility Measure for Schools as being valuable in identifying the areas on campuses that don't reflect accessible or universal architectural design standards. Occupational therapists are noted as important resources for advocacy on issues concerning accessibility on post-secondary campuses.
Larkin, H., Hitch, D., Watchorn, V., & Ang, S. (2015)28 participants experienced in building and accessibility reporting a mean of 20.22 years working in the field.Qualitative Focus group or individual telephone interviewsFour themes emerged from the focus groups and interviews related to policy, political and regulatory factors that influence the uptake of UD in Australia: 1-difficulties of definition, 2- push and pull of policy and regulatory influences, 3- role of formal minimum standards and 4-shifting the focus of design thinking. The study indicates that the major facilitators for enacting future UD in the built environment includes a shift in focus away from disability, greater collaboration with diverse users during the design process, and a diversification of strategies used to support the necessary changes. Results also indicate that occupational therapists are well placed to make a positive contribution to this field with their understanding of diversity and inclusion, and growing skills in advocacy and political practice.
Layton, N.A. & Steel, E.J. (2015)59 females and 41 males with any impairment and/or living situation, aged 18+ who use assistive technology, environmental modifications, and/or personal support (systems/services)Level II Cohort studyIn this Australian Assessment of Quality of Life (AQoL) cohort study, individuals with any impairment and in any living situation aged 18+ who use assistive technology (AT) environmental modifications, and/or personal support (systems/services) were surveyed. Data was collected via both survey and open fields to record information about the impact of AT environmental interventions, and personal care to everyday living/function. The study demonstrated that individuals with disabilities use an average of 13 supports to their lives, usually drawn from multiple funding sources. The majority of participants identified unmet needs, and that barriers were reported by over half of the participants, and the need was greatest for universal design of and physical access to outdoor environments and buildings, and accessible public transport and public space. Survey responses demonstrated the link between impairment and environmental barriers in creating disability and AQoL scores significantly contrasted with the Australian population mean.
Liu, L. (2014)N/ALevel V Expert opinionWhile practitioners understand UD, clients and communities commonly equate UD with “accessible,” a subset of universal design. Universal design goes beyond minimum standards. It refers to accommodations made through design to enhance quality of life for individuals other than an intended user. Visitability” refers to three features of a home that make it accessible to anyone: a no-step entrance into the house; wide doorways and clear passage; and an accessible main floor bathroom. Occupational therapists and design industry experts should continue to recommend UD concepts/products, but actual usability of an environment or product is ultimately determined by the consumer because he/she know what works best for him/her.
Moore, A. & Lynch, H. (2015).N/ALevel I Scoping reviewThe design of environments can either facilitate or impede a child's ability to play freely. Universally designed play spaces are advocated for by researchers from various disciplines and are dictated in part as a result of political and societal objectives. The purpose of this study was to carry out a comprehensive scoping review examining “accessibility and usability of playgrounds for children under age 12 of all abilities” (p. 333). It was determined that while this is a burgeoning area of inquiry, further more rigorous quantitative and qualitative methodological study, particularly with regard to “social inclusion and occupational justice” (p. 341) and establishing guidelines for UD playgrounds is recommended.
Prellwitz, M., & Skär, L. (2007).Children aged 7–12 years with disabilitiesQualitative Semi structured interviewsOccupational therapists should be involved in the programming of playgrounds, and serve as advocates for creation of UD playgrounds to increase inclusion. The study includes a descriptive semi-structured interview process looking at the responses of twenty children age 7–12 years with various disabilities. Through content analysis distinct themes emerged, all of which support the children's perception of the value of playgrounds, but also the inequities these children face when trying to participate in or on them.
Rickerson, N. (2009)N/ALevel V Expert opinion and consensus statementsThe author of this book chapter discusses the seven principles of UD and how each can be applied to occupational therapy interventions as a means to reduce need for adaptations. The author discusses that the application of the principles of UD are consistent with OT values of client-centered care. While concepts of UD are familiar to OTs, UD is seldom incorporated in occupational therapy interventions regarding assessment and planning of environmental adaptations. Therefore, when applied to intervention as standard, clients may need fewer specific adaptations.
Sanderson, K. (2014)N/ALevel V Expert opinionTo better ensure that all children are afforded equitable opportunity to play, occupational therapists can be involved by becoming familiar with stakeholders who have “necessary policies in place to meet the Annex H requirement [a Canadian Statute]” (p. 25) and to advocate for selecting designers who understand and incorporate UD approaches in their work. Occupational therapists can get involved and participate in committees directed to children's outdoor spaces, and develop social media strategies to disseminate the word about the value of UD and methods to measure its effectiveness for all users and creators of play spaces.
Vrkljan, B.H. (2005)N/ALevel V Expert opinionUniversalism recognizes disablement as a continuum, meaning that variance in health and ability are inherent to the human species and as such, social policy should respect the range that exists along this ability-disability continuum. Author ‘contents that the universalistic perspective provides a comprehensive framework that can be used by occupational therapists to address issues related to disablement at a societal level. The author further provides a comparison of occupational therapist's recognition of the ability-disability continuum and alignment with UD and cautions against adopting a UD perspective. Occupational therapy practitioners are advised to support social policies that embrace differences between people and advocate for policies that provide for individualized and client-centered assessments to fully empower occupational performance. The author considers that when taking on a “universalistic perspective of disablement” (p. 58), the needs of the individual may be downplayed when developing social policies intended to serve the majority.
Wiley, R., & Stern, S. (2014)Mother of child with disabilityLevel V Expert opinion and case studyAuthors provide a comparison of accessible and universal design playgrounds and suggests that occupational therapy practitioners have a role to advocate for more inclusive playgrounds. They have skills to be an integral part of the planning and design process for playgrounds as it relates to the importance of the occupation of play for children. A case study highlights the inspiration and subsequent installation of a UD playground spearheaded by the mother of a young child with muscular dystrophy.
Young, D. (2011)N/ALevel V Expert opinion and consensus statementsOccupational therapists specializing in environmental modifications bring a unique perspective to aging in place and home modification teams, in assessing how a person functions in their home and participates in activities of daily living. Through additional ADA Accessibility Guidelines, aging in place and UD training, client's accessibility, independence and safety within their home can be greatly improved. Integrating UD into home modification improves understanding of how clients may benefit from individualized recommendations for safe and independent living.
Young, D. (2013)N/ALevel V Expert opinionAuthor presents a review of the integration of UD within community design/development and the role of the occupational therapist in the process. Occupational therapists are particularly qualified and well suited to consult with architects, planners, and community agencies, as well as local, state, and federal policymakers with regard to UD for livable communities. Interprofessional collaboration is needed to best meet client/resident needs with regard to aging in place in livable communities.
Theme 2: Outcomes of involvement of occupational therapy practitioners serving on an interprofessional team
Citation, Year of PublicationParticipantsResearch MethodAims of Study and Results
Cooper, B.A., Cohen, U. & Hasselkus, B.R. (1991)N/ALevel I Systematic reviewDemands for accessible environments are increasing, particularly to enable older adults and persons with disabilities to remain in their homes and communities at-large. Seeking to improve barrier-free design, the ANSI standards and associated Enabler model developed by Steinfeld et al. offers a broader, more inclusive conceptualization of disability and identifies barriers in the design of built environments. These ideas translate to occupational therapy practices by addressing concepts of safety, accessibility, mobility, and performance from the perspective of the person and disability.
Di-Nur, S. (2014)N/ALevel V Expert opinion and consensus statementsIn 2004, an inter-professional group of occupational therapists, designers, and planners known as the Universal Design Network, formed. It was the result of a Canadian Association of Occupational Therapy, Newfoundland and Labrador Occupational Therapy Association, and Canada Mortgage and Housing Corporation conference on accessibility issues, and in particular, a key seminar presented by occupational therapist Jan Pringle on UD. In accordance with Canada's Newfoundland and Labrador 2012 decision to require basic UD features such as lever door handles and wheeled mobility accessible bathrooms on first floors of all affordable housing units, the author believes the UD movement will grow in Canada.
Dong, H. (2010)Occupational therapy and engineering students and individuals with multiple sclerosisLevel IV SurveyThe author implemented the DOT (Design + OT) interdisciplinary vocational design project pilot studies with engineering design and occupational therapy students, and individuals with multiple sclerosis as end users of the design project. One brief was to co-design a “design opportunity” to improve the quality of life for individuals with multiple sclerosis (p. 242). While all participants indicated that the process was enlightening and helpful, the group that included the occupational therapy student indicated a greater appreciation for the occupational therapy individual and client-centered processes.
Price, C., Zavotka, S., & Teaford, M. (2004)College students, mainly occupational therapy and interior designLevel IV SurveyAs more people hope to age in place, lack of future visioning in home and community accessibility, usability, and safety is apparent. Recognizing this challenge, a university-community-retail partnership model comprised of faculty and students in occupational therapy, interior design, and gerontology, the Ohio Department of Aging, and employees of big box stores was developed. As a result, a university-wide service-learning course was created and open to students in mainly interior design and occupational therapy. The outcome was a community education pilot program focused on UD for consumers, workshops, and a training curriculum. The number and variety of partners involved, the valuable assets each partner provided, and the momentum and creativity that resulted from this teamwork approach was unique. The UD topic as well as the distinctive contributions of each partner led to statewide implementation of the model and substantial interest in the community education program.
Wagenfeld, A. Westley, M., & Young, D. (2014)N/ALevel V Expert opinionPlay is the primary occupation of childhood and inaccessible playgrounds limit children with any type of disability or disorder to participate, thus denying them the enjoyment of both social interaction and personal development. It is ideal to approach the design of play-spaces from a collaborative, interprofessional viewpoint between occupational therapy and landscape architecture, with UD as the overarching framework. Occupational therapy's understanding of child development, disabling conditions and the importance of landscape architecture's understanding of designing outdoor spaces seems to make for a successful partnership.
Theme 3: Facilitators and barriers to the interprofessional participatory design process
Citation, Year of PublicationParticipantsResearch MethodAims of Study and Results
Ainsworth, E. & DeJonge, D. (2014)N/ALevel V Expert opinionThe authors consider how the occupational therapy practitioner can contribute to the UD process and influence emerging home modification trends in architecture and design. Occupational therapists' considerable experience developing solutions to support a client's individual and tailored needs when implementing each designed intervention and the transitive relationship between the person, environment, and occupation helps to contribute to the design process.
Canadian Association of Occupational Therapy. (n.d.)N/ALevel V Position paperThe second edition of the Canadian Association of Occupational Therapy position paper on UD, originally published in 2003, provides support for occupational therapy engagement in UD projects with design professionals.
Coppola, S., Sakornsatian, S., Thongkuay, S., & Trevittaya, P. (2012)N/ALevel V Expert opinionAccessible and inclusive tourism is a well-suited area of study for occupational therapy students. The associated fieldwork experiences can be used to expand this innovative area of emerging practice. An occupational therapy practitioners' unique understanding of the various physical, social, emotional, sensory, and cognitive facets that comprise a person can create ideal partnerships when collaborating on adapting environments to enhanced tourism. Building on the three pillars of sustainability, social, environmental, and economic, occupational therapy practitioners' expertise in activity analysis and environmental modification, human function and environmental engagement can benefit the travel experience for persons with disabilities, enhance occupational experiences, and support local travel economies.
Heylighen, A. (2014)Educators in Flemish architectural schoolsQualitative InterviewsThe author addresses the skepticism participants with regard to UD. Interviewees considered universal design to be a utopian and ambiguous concept, perceived as an element of design overall, but not a singular directive. Author also considers that the perceived impossibility to achieve design for all is in inherent to the field of design itself, and that UD is currently not a high priority in prevailing architectural education or the design and construction communities at-large. Rehabilitation specialists, including occupational therapists consider context as they understand disability as originating in the interaction between an individual's or group's unique client factors and their environment. Because designers typically lack direct access to the perspective of the people for whom they design, rehabilitation specialists can help bridge this gap by sharing their expertise about human disability within context and assessing whether architectural designs are universally accessible.
Hitch, D., Larkin, H., Watchorn, V., & Ang, S. (2012)28 individuals with expertise in universal design, identified by a steering committee and through snowball sampling; 16 in focus groups and 12 in telephone interviewsQualitative Focus groups and semi structured telephone interviewsThe purpose of the study was to explore views of key stakeholders involved in design project on roles of occupational therapy and architecture in UD of built environment. Three themes emerged: “form versus function, earlier the better, and universal design as a specialist area” (p.35). Each profession has unique expertise to share in collaborative education and practice. The authors further discuss barriers to interprofessional participatory design process such as 1-Poor collaboration between stakeholders as a barrier to the wider practice of universal design, 2-perception of UD as a separate specialist area.
Hitch, D., Larkin, H., Watchorn, V., Ang, S., & Stagnitti, K. (2013)44 occupational therapy and 96 architecture studentsLevel III Quasi-experimentThe Readiness for Interprofessional Learning Scale (RIPLS) was used to measure impressions of a collaboration between first year architecture and third year occupational therapy students. The RIPLS was administered at week one and week twelve of the semester. Findings showed that architecture students were more negative initially in their impressions of interprofessional collaboration than occupational therapy students. At post-test, occupational therapy students' impression of collaboration process declined, and thus neither group showed an increase in a positive impression of collaborative ventures. Gender did not appear to influence results.
Imrie, R. (2011)N/ALevel V Expert opinion/commentaryThe UD movement highlights the interrelationship between human development throughout the course of life, individual abilities, and interactions with everyday products and environments. To be effective, experts believe that the principles of UD must be translated into design and technology practices that recognize and respond to socio-cultural and political diversity. Authors also discuss how design discrimination requires social value and attitudinal changes in order to facilitate an equality of accessibility in the built environment to realize universal objectives relating to access for all. Lastly, the authors discuss the perception that UD subscribes to a model of professional expertise.
Larkin, H., Hitch, D., Watchorn, V., & Ang, S. (2015)28 participants experienced in building and accessibility reporting a mean of 20.22 years working in the field.Qualitative Focus group or individual telephone interviewsFour themes emerged from the focus groups and interviews related to policy, political and regulatory factors that influence the uptake of universal design in Australia: 1-difficulties of definition—the lack of commonly agreed terminology was identified as a barrier to progressing design practice that includes the needs of the broadest range of people and embraces diversity of ability and backgrounds, 2-the push and pull of policy and regulatory influences, 3- the role of formal minimum standards and 4-shifting the focus of design thinking. The study indicates that the major facilitators for enacting future UD in the built environment includes a shift in focus away from disability, greater collaboration with diverse users during the design process, and a diversification of strategies used to support the necessary changes. Results also indicate that occupational therapists are well placed to make a positive contribution to this field with their understanding of diversity and inclusion, and growing skills in advocacy and political practice.
Lenker, J. & Perez, B. (2014)N/ALevel V Expert opinionThe authors, both on staff at the University of Buffalo Center Inclusive Design and Environmental Access (IDEA), discuss strategies for occupational therapy practitioners to become involved with the UD process. Beginning as a student and continuing into professional practice, occupational therapists connecting with designers makes great sense as environmental design seeks to maximize human performance. While training differs as does scope of practice, the authors indicate that occupational therapy and design “intersect with their shared goal of maximizing human performance by minimizing unnecessary environmental complexity” (p. 13).
Semple, K., Blowes, B., Steggles, E., & Baptiste, S. (2010)12 occupational therapists and designersQualitative Semi-structured interviewsInterviews of occupational therapy and design professionals reveal how occupational therapy is an integral partner in UD projects, and how many do not view occupational therapists as qualified to be involved in UD projects. It is also perceived that an occupational therapist's skills preclude partnerships in the design process. Occupational therapists must continue to advocate for their role in creating UD spaces and products.
Shamberg, S. (2012)N/ALevel V Expert opinion and consensus statementsVisitability describes the features of private homes that provide a minimal level of accessibility, allowing people with mobility impairments to visit safely. Visitability solutions and UD concepts can be thoughtfully and cost-effectively implemented to create a visitable first floor living space within the typical home. With training in specialized assessment and consulting with design/build professionals, occupational therapists can provide valuable input into the design and construction of an accessible, safe, and adaptable environment to meet the needs of aging adults, persons with disabilities and caregivers.
Thompson, S. (2014)N/ALevel V Expert opinionAuthor discusses why it is important to involve an occupational therapist in the construction or renovation of a home or commercial project. Discussion includes educating the importance of training occupational therapists in residential construction, project management, building codes, standards and guidelines. Occupational therapists gain immense knowledge when working directly with professionals in other disciplines, and that occupational therapists must get more involved by establishing networks and joining interest groups and committees.
Watchorn, V., Larkin, H., Ang, S. & Hitch, D. (2013).49 occupational therapy and 114 architecture studentsLevel III Quasi-experimentDespite the applicability of UD for both occupational therapy and architecture, the lack of research on its value as a training tool hinders opportunity to foster a collaborative approach to solving design problems. Using a combination of real life and virtual reality simulation tasks, students engaged in a semester long interdisciplinary course focusing on universal design and its applicability when creating spaces and designing communities for those with physical impairments. Findings of the surveys were that the interdisciplinary teaching model was positive, as was integration of virtual and real world design situations.
Young, D., Van Oss, T. & Wagenfeld, A. (2014)N/ALevel V Expert opinion and consensus statementsUniversal design strategies are essential and of ethical importance when pursuing environmental modification or design projects, as such consideration ensures a process that meets the user's cultural, medical, and safety needs. Interprofessional participatory design processes enables occupational therapists to contribute their understanding of person, environment, and occupation to best enable clients to most efficaciously engage in daily activities in environments that best meet their needs.
Authors

Ms. Young is Founder/Owner, EmpowerAbility® LLC, Newark, Delaware. Dr. Wagenfeld is Associate Professor and Capstone Coordinator, Occupational Therapy Doctorate Program, Johnson & Wales University, Providence, Rhode Island. Ms. Rocker is Inpatient Rehabilitation Occupational Therapist, Holland Hospital, Holland, Michigan.

The authors have no relevant financial relationships to disclose.

Address correspondence to Debra Young, MEd, OTR/L, SCEM, FAOTA, Founder/Owner, EmpowerAbility® LLC, 107 Syracuse Drive, Newark, DE 19713 ; e-mail: dyoung@empowerability.com.

Received: May 31, 2018
Accepted: April 22, 2019
Posted Online: July 03, 2019

10.3928/24761222-20190625-04

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