Author: Jane Bringolf

Universal design and psychosocial disabilities

The COVID 19 pandemic has given rise to new thoughts about planning and design of the built environment including public transportation. People with psychosocial disabilities respond in different ways to situations. Travelling was easier for some because of less crowding, but others feared contamination. Facial masks increased anxiety in some, but others found that people not wearing masks a problem. This is where a universal design approach can help.

” … universal design should include the social and organisation environments, in addition to physical design, in terms of making the transport system accessible to everyone.”

A man stands on a train platform looking at his smartphone. He is wearing a hat and has a bright yellow backpack.

Between 20% and 25% of the population have a mental illness at any given time. People with psychosocial disabilities travel less than others leading to social isolation and worsening symptoms. The World Health Organization (WHO) estimates that by 2030 mental health conditions will be the leading burden of disease.

Improving travel with universal design

Few studies include mental health with reference to universal design. Anja Fleten Nielsen’s study asks “How can a broad understanding of universal design be used to improve travel for people with psychosocial disability?” She investigated the impact of COVID-19 and the main barriers to using public transport.

Nielsen’s study involved in-depth interviews focusing on barriers, travel behaviour during the pandemic and suggested solutions. Recruiting participants was difficult in terms of getting written consent – signing a consent form could raise anxiety levels. Nielsen explains more about methods and the literature review.

The key results are fell into: physical environment, social environment, organisational environment, and individual aspects.

The roadway is marked with the words "bus stop" in yellow lettering.

Physical environment: Crowding, important information during the journey, lack of toilet facilities and sensory overload.

Social environment: Negative experiences with fellow passengers and interaction with transport personnel, and being afraid to ask for help.

Organisational environment: Availability and ease of access, and lack of seamlessness between modes with long waiting times.

Individual level: Planning difficulties, travel induced fatigue and financial barriers.

COVID-19 made barriers more apparent

Nielsen’s paper discusses each of the four aspects in detail. The pandemic increased symptoms in many participants and has made them more visible to transport planners. To answer the question about universal design, Nielsen claims that environmental factors are of greater importance. This is because the individual factors are related to special and customised solutions.

The title of the study is, Universal design for people with psychosocial disabilities – The effect of COVID-19.

Planners and designers need to look beyond physical impairments. Universal design is just as relevant for people with psychosocial disabilities. Social and organisational environments are of equal importance for this group. These are factors that also improve journey experiences for the travelling public.

From the abstract

During and after the pandemic, most informants travelled less and/or used their car more than before. Some stopped using public transport due to fear of contamination, while others found it easier to travel during the pandemic due to less crowding.

Use of facial masks were perceived by some as an additional problem increasing anxiety, while others found it more problematic with fellow passengers not wearing masks. In general, findings support prior studies in terms of barriers related to crowding, lack of seamlessness, financial issues, problems with staff, lack of access in rural areas, and low knowledge of support systems.

Lack of toilet facilities, negative experiences with other passengers, sensory overload, travel-induced fatigue, and problems related to planning are considered problematic. Station areas may pose a barrier for people with former drug addictions. Hence, universal design should include the social and organisation environments, in addition to physical design, in terms of making the transport system accessible to everyone.

Evaluating universal design in built environments


What’s the best way to evaluate the application of universal design principles in a project? Is it a checklist? A professional opinion? Or something else? And what kind of evaluation are we talking about? Surely evaluation is about the usability of the building from a user perspective. A group of researchers decided to find out how stakeholders were evaluating universal design in their projects.

“Evaluating universal design requires knowledge in many areas … Should not be done by a single person (e.g., architect), but by a board of people knowledgeable in the building environment, universal design, and of course representative users with varied ranges of disabilities.“

Architect plans with a rule and other drawing instruments.

The Australian researchers undertook an extensive study involving 157 participants. More than half reported experience of disability, either themselves or a family member. Academics and access consultants represented the largest number of participants. When asked who is involved in universal design evaluation, the most common response was access consultants (45%). Disability advocates represented almost thirty percent (29.8%).

The research paper explains the processes used and the data gathered. Participants used specific tools or methods with checklists being a favourite, followed by access audits. This is where the understanding of universal design comes into question. However, some respondents were incorporating user feedback from the design conception stage.

Overall, almost all participants rated evaluation of universal design as being important. When asked who should do the evaluation, building users, building construction stakeholders and multiple stakeholders were identified. There was a trend towards access consultants being the people to do the evaluation.

Conclusion

The researchers claim that evaluation of universal design is being called for and carried out in practice. The results appear to divide into two camps. Those who think of universal design as a standard, and those who understand universal design as an iterative process.

However, evaluation from the perspective of meeting standards (did it comply?), or meeting the project scope (deliverables) does not tell you if the design is usable. The researchers conclude the paper with this sentence:

“[We need to] … better understand how people with disability can effectively participate in design processes, and what factors serve as barriers and facilitators to participation.”

Not sure that more research on how stakeholders evaluate universal design is the issue. Understanding the difference between access standards and universal design is still the key point.

The title of the paper is, Evaluating universal design of built environments: an empirical study of stakeholder practice and perceptions. The researchers are based at Deakin University.

From the abstract

Universal design aims to reduce environmental barriers and enhance usability of buildings for all people, particularly those with disabilities.

This study aimed to gather information on current practice and what stakeholders perceive as important to universal design evaluation. A mixed methods approach was employed, and data were collected via online survey (n = 157) and semi-structured interviews (n = 37).

Participants included industry professionals, policy makers, government officials, academics, and people with disabilities. Just over one-third of participants stated that they had experience of evaluating universal design in public built environments.

Checklists were most commonly used, yet participants expressed concern with their suitability for this purpose. Almost all participants perceived evaluation of universal design as important, citing its value to advocacy, professional development and strengthening the evidence base of universal design.

Findings from this study highlight a tension between a checklist approach, and a multidisciplinary method that encompasses the complexity of universal design application.

Inclusive tourism with universal design

Research on the business opportunities in accessible and inclusive tourism is extensive. However, this research is largely sitting on the shelf. A mix of attitudes towards people with disability and a sense of “not knowing where to start” are likely reasons. But you can get inclusive tourism with universal design by co-designing with tourism operators.

” Surprisingly, many cases did not meet the minimal requirements for “older people” and “people in a wheelchair.” … but this result did function as an eye-opener”.

A hotel receptionist is talking to a man and woman across a reception counter. Inclusive tourism.

A research group in Belgium has devised a method to uncover business opportunities through universal design. Collaborating with 17 accommodation providers they came up with a seven step process to integrate universal design into their business model. The process is also a way to increase knowledge and understanding of diverse guests and their experiences.

The research group documented their project in a conference paper. It begins by explaining inclusive tourism as a right, a business opportunity and a challenge. They devised a method to use the potential of universal design as a “business transformer”.

Hotel bedroom with polished floors, orange and red pillows on a couch and textured wallpaper

Co-designing the 7 steps

  • Step 1: We created a literature-based universal design screening based on mindset, management and infrastructure.
  • Step 2: We tested and updated the screening in each of the 17 accommodation providers.
  • Step 3: We analysed the data for each business which was given to them in a report.
  • Step 4: The results were further processed with the participant, who decided on priorities.
  • Step 5: An action plan was devised based on step 4.
  • Step 6: A concise checklist and a guide with relevant information (tools).
  • Step 7: A re-evaluation of the business to assess the actual improvement after interventions. Unfortunately the COVID pandemic impacted this research and the last step was not possible with the downturn in tourism.

The title of the paper is Inclusive Tourism: Co-developing a Methodology to Uncover Business Opportunities through Universal Design. Scroll past the first paper in the conference proceedings to get to this one.

From the abstract

We describe a 2-year project where the possibilities of universal design were explored. The purpose was to structurally uncover and address potential business opportunities.

The method was based on: inclusive customer journey, linking mindset, management and infrastructure, and diverse user needs. We collaborated with seventeen accommodation providers and developed a seven-step process. The process integrates universal design into their business model.

The Disabled Tourist: a book

Here is the overview from the publisher of The Disabled Tourist: Navigating an Ableist Tourism World. It’s an academic text by Brielle Gillovic, Alison McIntosh and Simon Darcy.

This book addresses a growing demand to hear the authentic voices and understand the lived tourist experiences of people with disability. The latest volume in The Tourist Experience series challenges what is arguably an exclusionary, marginalising, discriminatory, and ableist (tourism) world.

Front cover of The Disabled Tourist.

By drawing attention to the ‘dis/’ in ‘disabled’, the authors provoke the need to change binary thinking about people who live with disability so that they may be ‘able’ to assume the role of tourist.

They engage critical tourism and critical disability studies, and their respective theories, perspectives, and debates, around, for instance, models of disability that shape conceptualisations and worldviews, inclusive research and enabling language, and the ethics of care.

These are pivotal to dismantling normative structures to enable a more inclusive, equitable, and socially just tourist experience that promotes a more independent and dignified tourism world for people with disability.

Breaking barriers for inclusive tourism

Breaking Barriers: Designing Inclusive Tourist Destinations is a book addressing European tourism. It is based on the Shaping Inclusive Tourist Experiences (SITE) project. This is an open access publication.

The objective of the book is to identify and address existing barriers that prevent the creation of more inclusive tourism systems.

“Freedom, in general, may be defined as the absence of obstacles to the realisation of desires.” Quote from Bertrand Russell.

Front cover of the Breaking Barriers book showing a long circular wooden ramp in an outdoor setting.

Inclusive tourism is a crucial component of the sustainable future of tourism. The book is a source of information for academics and researchers as well as other tourism stakeholders. It is also a call to action as our populations age, and legislation calls for inclusive practice.

Tourism and Disability: Book review

A woman in a yellow jacket is being assisted onto the tour bus by two men up a ramp.

Tourism and Disability is a new book addressing the existing  challenges and opportunities related to tourism for people with disability. The Booktopia review describes this as an underdeveloped and underestimated niche market. While there is a larger market for family group travel, there is also a market for disability-specific tourism products. 

The book examines the strategies, policies, and initiatives at regional, national, and international levels. The aim is to foster the development of accessible tourism.  It examines the different social, cultural, legal, and information/interactive barriers to inclusion. The book’s focus is on the distinctive travel demands of people with disability and how their needs differ from the preferences of travellers without disability. 

The various chapters provide a multidisciplinary approach to the topic covering management, economics, and statistical analysis. This makes it useful for academics and practitioners alike. 

The Title of the book is Tourism and Disability: An economic and managerial perspective. Published by SpringerLink you can purchase individual chapters online. The book is also available from other suppliers. The editors and most contributors are based in Europe where tourism is a key part of the European economy. 

Front cover of Tourism and Disability.

Research in clear language

The Plain Language Movement is supported by information makers and providers who want more people to read their content. Dense academic language meant for other academics is frustrating for others wanting to learn more. So, it is time for clear language now that more universities are producing open access articles.

“… the plain language movement is rooted in the ideal of an inclusive society… ” Language is not for those with social privilege.

An empty page in a notebook with a pencil and sharpener. Doing plain language is a process

Plain language summaries are a good start and sometimes a requirement of research funding. These summaries are often shown as four or five short bullet points before the academic abstract. And now we have a new acronym: Knowledge Mobilization (KMb). The requirement for plain language summaries has given rise to yet another area of research.

Sasha Gaylie at the University of British Columbia explains more about this in her article Clear Language Description. There is a little confusion whether plain language and clear language are the same things. Consequently, there is a move to create an international standard.

The International Plain Language Federation defines plain language as “wording, structure, and design are so clear that readers can easily find what they need”. Easy Read, Easy English or Easy Language, which is for a specific group of readers, is not the same thing. It’s good to see universal design in language as a relatively new frontier in inclusive practice.

Five focus areas for plain language

Gaylie lists five focus areas for that offer a structure for grouping individual recommendations briefly listed here:

  • Audience: The benchmark is 8th grade reading level*.
  • Structure: The most important information should appear first.
  • Design: White space and headers to break up text, and also helps screen readers.
  • Expression: Use an active voice and avoid jargon.
  • Evaluation: Peer review by a non-expert for best feedback.
A blank page of a spiral notebook and and fountain pen.

*Note that Easy English aims for an average of 2nd grade, and Easy Read aims for around 5th grade.

Inclusive descriptions

This is a growing area of language. Words can hurt and harm. We already see how language has changed when we look at old texts. For example the use of “man” and “he” when meaning all humans.

“A term need not be intentionally harmful to cause harm; the act of description is not neutral, and even when using the “plainest” of language, inherent bias affects output.”

A mosaic of many different faces and nationalities

Sasha Gaylie’s article concludes with a practical guide based on the five focus pointed mentioned earlier.

From the Editor: Writing in plain language is a skill-set that challenges a writer to think really carefully about what they want the reader to know. It is not about what the writer wants to say. Doing plain language is a process. Writing complex ideas in a straightforward way takes time and effort. And it also makes me think about my relationship to the topic.

Plain language summaries – good for everyone

What are Plain Language Summaries? These are an invaluable adjunct to abstracts in academic papers. They help more readers understand the content of the article, especially if the topic is unfamiliar. Beth Myers and Teukie Martin provide a good example when explaining why they use these summaries:

What are Plain Language Summaries?

  • Plain language summaries are short summaries of research articles.
  • They communicate the main ideas of the article and are easy to understand.
  • They are also used by the government, doctors, and places like banks and utility companies.
A blank page of a spiral notebook and and fountain pen.

Why are they important?

  • Research articles can be hard to read and understand.
  • They make research accessible to more people.
  • Everyone should have access to information that impacts their lives.

Plain language writing is clear, succinct, and jargon-free, and is organized in a way that helps understanding. It is a reader-centered way of writing so that readers can access, comprehend, and utilise information. Plain language writing benefits all readers while ensuring crucial access for some. It’s universal design – good for everyone.

The title of the article is, Why Plain Language? Linguistic Accessibility in Inclusive Higher Education. The journal is clearly living the message of inclusion in writing up research. As such, this is a short document with all the key information without jargon. 

Example of a plain language summary

Plain Language Summaries are not quite the same as Easy Read or Easy English documents which use simplified language. The wording and pictures in these documents are carefully placed on the page as well. 

Governments often fund research, so we should all have access to this new knowledge. But if you want to rise in the ranks of academia you need to follow the “rules” for publishing. You also need to show that you know the language and jargon. There is no need to change this. What we need are additional plain language summaries.

The picture below shows an example: Co-designing the Cabriotraining: A training for transdisciplinary teams. It begins with an “Accessible Summary” followed by the regular abstract. 

The front page of the academic article showing how the Accessible Summary is presented.

Academic papers begin with an abstract – an outline of what the paper or article is about. It usually says what the problem is, what they researched and what they found. A plain language summary of the abstract gives the same information but in less words.

Accessible summary – an example

The image above reads as follows:

  • The research was conducted by a team of researchers. Some of the researchers have experience of living with a disability.
    • The researchers created training for other research teams that include experts by experience.
    • The training has six parts. To decide what happened in the training, the researchers read articles and asked the research teams they trained about what problems they had and what they wanted to know about.
    • The article tells why and how the training was made. It also says what training is needed for researchers with and without disabilities to learn and work together in a way that feels safe and useful.
    • In developing and providing the training, it was very crucial to search for a safe and welcome space for all people involved (Figure 8). As we don’t know what is “safe” for the other, this means we have to search together, in respect and with enough time to get to know each other.

Editor’s note: Great to see an academic paper translated into key points that many more people can understand. From my experience, writing succinctly and plainly is a rare skill in academia. I was delighted to see this example. It’s universal design!

Architecture and disability experience

Many followers of universal design will have critiqued the entry to Museum M in Leuven, Belgium as dangerous. Unfortunately, a Google image search on “universal design” includes images of this entry as examples of universal design. While this design might be architecturally creative, it is not architecturally inclusive or safe for everyone.

The entry steps to Museum M are mistakenly taken as an example of universal design. Consulting people with disability after construction revealed many concerns for safety.

Museum entrance with steps and ramp integrated. The tiles are a light colour and the way the light falls the whole thing looks very confusing. Architecture and disability.

An article by three Belgian researchers gives both sides of the design story. The classic design ideas and objectives of the architects, and the user experience. The article first discusses disability and the built environment from a justice perspective. They emphasise how architect’s human senses are not the same as everyone else. Museum M is used as a case study to explore the differing values of architects and users with disability.

“The descent before entering Museum M is supposed to symbolise its accessibility and openness to all people. When we mention this openness to Philip, he understands the idea, but for him it does not make
the museum more accessible.”

Entry to the museum where the sunlight makes the steps look like a flat white plane even to people with good vision.

The architect thought it a good idea if visitors didn’t have to separate at the entrance. He could see no problems for wheelchair users by crossing the ramp through the stairs. This design is sometimes called “stramps” With no kerbing to the ramp, wheelchair users would need to be careful not to run off the grade into the steps. Although some wheelchair users might find this workable, it is not the case for people who are blind.

What Charlotte and Philip said

Charlotte is a wheelchair user and Philip has a vision impairment: their experiences are at odds with the grandiose ideas of the architect. Philip understands the idea of the stramps but it does not make the museum more accessible for him. The break in the handrail to accommodate the ramp section means he doesn’t know where the next handrail is.

The colour of the entrance is also causing an obstacle. The white colour when the sun is shining onto the floor it looks like one flat surface. Philip can’t make out the steps and combining it with ramp makes it more confusing. Charlotte isn’t comfortable about entering either because the ramp is not entirely visible for wheelchair users.

The title of the article is Enriching our Understanding of Architecture Through Disability Experience. It was published in 2013 but is still relevant as an example of what happens when you don’t co-design.

Beaches and water

Australians are known for their love of beaches and water. Beach accessibility has improved greatly in recent years. Strip matting, specialist water wheelchairs and accessible change facilities have made a significant difference for wheelchair users. But beach access needs constant maintenance.

“…beach access has many more challenges due to the uncontrollable nature of the movement of sand, water and wind… storms [also] play havoc on accessible paths of travel.” Jane Bryce

A man holds the hand of a small girl as they wade into the water on the beach. Travel and tourism.


The latest access consultants association magazine, Insight, is all about beaches, water and access. The lead article by Jane Bryce looks at the damage done by storms and the erosion of once accessible beach access

Derek Mah covers the accessibility of aquatic facilities from an architect’s perspective. Access for swimming pools was first introduced in 2011. But the standard for the public domain (AS1428.1) is inadequate for ramps and stairs in pools. Mah discusses the issues of design and certification of swimming pools and some of the assistive equipment.

Shane Hryhorec provides a wheelchair user perspective. Going to the beach is not just a fun thing, it also enables social inclusion for individuals and families. Shane is the founder of Accessible Beaches Australia which has a directory of accessible beaches.

“Going to the beach is a quintessential part of the Australian way of life”, says Accessible Beaches Australia chairperson and founder, Shane Hryhorec.

A beach wheelchair at the end of matting on the beach.

Italian beach fun

For those wanting to travel there’s an extra feature on the accessible beaches in Italy. Stefano Sghinolfi is an Italian accessible tourism operator. Lots of pictures show great beaches. “To make up for the shortcomings of national policies on accessibility, there are associations and private companies. Hard work has been done by these private groups to make part of the Italian coast accessible to wheelchair users.” It’s worth noting that all accessible beaches in Italy are private.

Technical insights

As usual, Howard Moutrie adds the technical insights and background information. The purpose of this feature is to promote thought and discussion and answer members’ questions. Swimming pools are covered in the National Construction Code when it is part of another building. But there are exceptions. Swimming pools can be part of an apartment complex, an hotel, and a regular back yard. This is where it all gets tricky. Howard works his way through these in the article.

You can access the magazine online on the ACAA website where you can also download the 6.8MB PDF version or view online.

Water activity, low vision and blindness

There’s a related research paper, Practical Applications of Aquatic Physical Activity, Swimming, and Thereapy for People with Visual Impairment or Blindness.

London Street Accessibility Tool

The City of London Street Accessibility Tool is like an educational access audit report. It shows street designers how street features impact on the different needs of pedestrians. The focus is on people with mobility impairments and wheelchair users, which means everyone wins.

The tool recognises that there are sometimes competing needs: what’s good for one group might not be good for another. Co-design is the best way to find the trade-offs to prevent unintended exclusion.  The tool comes in three parts: two Excel spreadsheets and a PDF downloadable from the City of London website. 

A photo showing a footpath lined with black bollards with white tops from the Street Accessibility Tool.
Road and footpath image from the City of London Street Accessibility tool.

Two photos from the “Instructions for Use” PDF document.

Doing the analysis

The PDF document begins with a table of different pedestrian types with and without assistive mobility devices. They cover mobility, sensory and neurodiverse conditions. There are three steps for using the tool.

The case study for the tool is London Wall, a street in London. A 500m long section is analysed for accessibility and is split into six sections. Each section has detailed access advice for improvements with photographs overlaid with dimensions and text to illustrate issues.

Down to the detail

The first spreadsheet has detailed dimensions, colours, and placements for elements such as tactiles, street furniture, and kerbs. All the necessary technical detail is here. 

What pedestrians said

The second spreadsheet is a route analyser and has a column of photos with user feedback about the issues they see. The feedback sheet highlights the “why” of planning and design. It provides insights for planners and designers in a way that that is missed in 2D drawings.

The direct quotes from people with disability provide the necessary insights for planners and designers. However, those responsible doing the actual construction should also have this information. All the access planning and designing goes awry if the “why” isn’t understood by all involved. 

Here are two quotes from the spreadsheet on route comments:

I feel quite wary. This is an unmarked crossing as far as I can see, I can’t see any wait signs. Somebody has stopped for me I can see a cyclist, I’m now onto some more tactile paving, this is the sort of crossing I am totally unfamiliar with. Person using a white cane

This is all fine but the paving stones are a little even so I’d be looking down and watching my speed so I don’t knock into one. Person using a wheelchair

A page of photographs of a section of London Wall in the City of London Street Accessibility Tool.
A page from the London Street Accessibility Tool

Ross Atkin Associates and Urban Movement for the City of London Corporation developed The City of London Street Accessibility Tool (CoLSAT).

The London Legacy Development Corporation (LLDC) is similar to the Sydney Olympic Park Authority. Both focus on maintaining the benefits of hosting the Olympic and Paralympic Games. Sydney claimed the title of “most accessible games ever” and then the title went to London. Inclusive design is a priority in all developments related to the Olympic precinct, and these Standards are designed to assist.

“Venues excelled in their inclusive design and the story could have ended there. However, LLDC embraced this approach and made ‘Championing equalities and inclusion’ one of their four corporate priority themes.” Baroness Grey-Thompson LLDC Board Member. Image from the front cover of the guide

Two people walk either side of a woman using a wheelchair. They are on a wide path in a parkland area. Inclusive Design Standards front cover.

London’s inclusive design standards

Inclusive design is the favoured term in the UK while other countries and the United Nations use universal design. They mean the same thing – creating inclusive societies.

A Standard not a Guide

The Inclusive Design Standards begin with all the relevant legislation and standards followed by a page on how to use the document. The standards have four key parts: inclusive neighbourhoods, movement, residential, and public buildings. Each part has two sections – the design intent and the inclusive guidelines. The guidance is just that and design teams can create solutions that achieve the same outcomes.

This is clearly a standards document and not a guide. It has numbered clauses for designers to reference. As such, it is not an accessible document itself. The language and size of text makes for detailed reading. A summary document with the key points would be useful as a starter.

Inclusive healthcare practice

Almost everyone finds themselves in hospital at some time whether as a patient or a visitor. Consequently, we are talking about the whole of our diverse population. But how well is diversity, equity and inclusion considered in healthcare practice? If the statistics are anything to go by, we are not doing well. Marginalised groups experience poorer health outcomes. The conditions in which people live – referred to as the “social determinants of health” – are the main reason for this.

Thirteen people were involved in devising 12 Tips for Inclusive Practice in Healthcare Settings.

A man in a white hospital shirt is wearing a blue face mask and has a stethoscope around his neck. He is looking into the camera and is posing with a thumbs up sign.

Appropriate terminology is a major feature in the list of 12 tips. Non-judgmental factual terms are preferred. Labels such as “obese” or “schizophrenic” can imply blame or non-compliance. And some patients will want to use non-binary gender terms when referring to themselves. Using the person’s preferred terms is recommended in all situations as these can vary. For example some people say they are autistic and others will say they have autism. Then there are people with multiple identities (intersectionality).

The 12 Tips for Inclusive Practice

Here is a brief outline of the the 12 tips.

Tip 1: Beware of assumptions and stereotypes: An individual might have multiple diverse characteristics. In the absence of early information it is easy to assume some things by default. A wheelchair user might conjure up assumptions about the health and ability to make decisions. A person accompanying a patient may be assumed to be a partner or family member.

Tip 2: Replace labels with appropriate terminology: The main point here is to keep up to date with best-practice terminology. For example, guidelines for preferred language for First Nations people is shifting and evolving. Some terms considered derogatory are now embraced by some (queer, autistic).

Tip 3: Use inclusive language: words can exclude and “other” people when they deemed to be different to oneself.

Tip 4: Ensure inclusive physical spaces: Accommodating physical, sensory and cognitive needs improves patient experience. Inclusive design goes beyond legislated minimum access requirements for buildings. For example gowns, furniture, and blood pressure cuffs, should accommodate all sizes.

Tip 5: Inclusive signage and symbols: A rainbow flag or First Nations flag will make people feel welcome. However, the use of these signs needs to be accompanied by inclusive care to avoid disappointment.

Tip 6: Appropriate communication methods: This is where body language and auditory input come into play. Not everyone processes these cues well and sometimes information is better put in writing.

Tip 7: Adopt a Strengths-Based Approach: This approach avoids stereotyping and acknowledges patients’ capacity for resilience and builds on their strengths.

Tips 8 – 12 focus on the health system and healthcare delivery and encourages health workers to advocate for improvements.

The title of the Australian open access article is Inclusive Practice in Healthcare Settings.

Abstract

This paper outlines practical tips for inclusive healthcare practice and service delivery, covering diversity aspects and intersectionality. A team with wide-ranging lived experiences from a national public health association’s diversity, equity, and inclusion group compiled the tips, which were reiteratively discussed and refined. The final twelve tips were selected for practical and broad applicability.

The twelve chosen tips are: (a) beware of assumptions and stereotypes, (b) replace labels with appropriate terminology, (c) use inclusive language, (d) ensure inclusivity in physical space, (e) use inclusive signage, (f) ensure appropriate communication methods, (g) adopt a strength-based approach, (h) ensure inclusivity in research, (i) expand the scope of inclusive healthcare delivery, (j) advocate for inclusivity, (k) self-educate on diversity in all its forms, and (l) build individual and institutional commitments.

The twelve tips are applicable across many aspects of diversity. They provide a practical guide for all healthcare workers and students to improve practices. These tips guide healthcare facilities and workers in improving patient-centered care, especially for those who are often overlooked in mainstream service provision.

The 12 tips for inclusive healthcare with five underpinning concepts: diversity, equity, inclusion, intersectionality, strengths based approach.

Who do we include in co-design?

Traffic light icon with Problem in red, Analysis in Yellow, and Solution in Green. Academics talk about “vulnerable groups” based on ethics approval language. But what they mean is, people who have difficulty participating because they have a disability, illness, or some other condition. Indeed, some ethics requirements are so protective of “vulnerable groups” that they make it difficult to include them from research projects. Consequently their voices are silenced. So how do we include them in co-design and when? While co-design is the new buzz word, participatory design has been around in academia for many years. Involving communities in decision-making is now recognised as being responsive to community needs. That means going beyond a one-size-fits-all approach to design. 

Participatory design

Participatory design, or co-design, is about genuine inclusion. That is, not just informing the design, but being participants in the design process. However, involving people with complex needs poses some challenges. It’s easy to make assumptions about their capacity to participate and collaborate. However, this comes down to the way the participation process is designed.  Participatory design and the inclusion of vulnerable groups is the topic of an article from Finland. They use three projects to compare how participatory design might work best. The first explored co-design activities with people with intellectual disabilities living in supported housing. The second focused on culturally diverse young people experiencing crisis situations. The third dealt with nursing students with learning disabilities adapting to work in the health sector.

Challenges and power dynamics

The article covers the challenges, the power dynamics and their methodology. Each of the three projects is documented in detail. The findings show some similarities between the projects, but when it came to users, there were different outcomes and processes. Participatory design became more challenging when there were more pronounced differences in power dynamics. These three projects provide good information for involving vulnerable groups in participatory design processes. Questions of equality and genuine inclusion is about both the design activities and how the entire project is planned.  The title of the article is, Whom do we include and when? participatory design with vulnerable groups

From the abstract

This article makes three contributions to participatory design (PD) research and practice with vulnerable groups:
    1. A framework for understanding stakeholder engagement over the course of a PD project.
    2. Approaches to making user engagement and PD activities more inclusive.
    3. An analysis of how the design and power dynamics of PD projects affect vulnerable groups’ participation.
A map of engagement evaluates stakeholder involvement from initial problem definition to design outcome.  The first looks at codesign activities to support decision-making in the context of intellectual disabilities. The second looks at culturally diverse youth navigating crisis without adequate assistance from public services. The third examines nursing students adapting to work in the health sector without accommodations for learning disabilities. Comparing the projects reveals patterns in project planning and execution, and in stakeholder relationships. The article analyses how users are defined, engaged and supported in PD; how proxies shape vulnerable groups’ involvement and PD projects as a whole; and opportunities for greater inclusion when the entire PD project is taken into account.

What does co-design mean? How does it work?

Two men look at a document. One is a doctor the other is a patient. The term co-design is being used more frequently, but what does co-design mean and how does it work? Well, that depends on the context. It could mean a design group working together. Nothing difficult about that concept. Or it could mean involving end users in the design process. This is where it gets more tricky and more questions arise. At what point do you involve users? Which users do you involve? Will the users have the required knowledge and experience to contribute constructively? Will designers have the skills to be inclusive and listen to users? Participatory action research incorporates both designer and user learning. But these projects are necessarily long and usually have research funding attached. However, they usually produce knowledge and results useful in other settings.  A related concept is co-design in quality improvement, for example, in a hospital setting. Both staff and patients have a role to play in advancing quality improvement. Differing levels of understanding between staff and patients can lead to tokenism. So how can we equalise knowledge so that everyone’s contribution is constructive?  A research team in a Brisbane hospital grappled with this issue. Their research report is written in academic language and not easy to read. Nevertheless, they conclude that effective patient-staff partnerships require specific skills. Briefly, it means adapting to change, and generating new knowledge for continuous improvement.

A framework

The researches developed a framework that includes ten capabilities under three key headings.  Diagram of the Co-design Framework.
    1. Personal attributes:
      • Dedicated to improving healthcare
      • Self-aware and reflective
      • Confident and flexible
2. Relationships and communication attributes:
      • Working and learning as a team
      • Collaborating and communicating
      • Advocating for everyone
3. Philosophies/Models:
      • Organisational systems & policy
      • Patient and public involvement best practice
      • Quality improvement principles.
These nine points are connected with the overarching theme of sharing power and leadership. Title of the article is, “Co-produced capability framework for successful patient and staff partnerships in healthcare quality improvement: results of a scoping review”. Other posts on co-design include The right to participate and co-design, and Co-design is another skill set. 

Do web accessibility overlays work?

Accessibility Overlays - What are they & why are they so bad? - YouTube
First screen of the YouTube video

This site has a web accessibility overlay or add-in widget. It’s the circle icon next to our logo on the website. If you click on it, it has a dropdown accessibility toolbar. That’s because the platform, WordPress, isn’t inherently accessible. So like the tacked on ramp to a building, it is an afterthought. But really, it advertises that the website platform isn’t really accessible and there are good reasons why. 

Website add-ons for accessibility go back to the 1990s with products like Browsealoud and Readspeaker. They added text to speech capabilities on the website. More products arrived in the market with similar aims. To the layperson these features seem beneficial, but their practical value is overstated. That’s because the people who need these features will already have the software on their devices to access the web and other software. The Overlay Fact Sheet by Karl Groves explains more: 

Overlay Fact Sheet logo - black background and an orange circule.
From the overlay fact sheet

“It is a mistake to believe that the features provided by the overlay widget will be of much use by end users because if those features were necessary to use the website, they’d be needed for all websites that the user interacts with. Instead, the widget is —at best—redundant functionality with what the user already has.”

Do overlays meet compliance?

While an overlay might improve compliance in some respects, full compliance cannot be achieved using this method. That’s because the products are unable to “repair” all possible issues. In some cases, the overlay can conflict with the users software and cause problems. And ironically, some overlays are inaccessible. So that means it’s back to the programmer and designer to get it right. 

The video below gives examples of overlays and graphically shows how they don’t work. You only need to look at the first three minutes to get the idea. 

We all have a responsibility to make our digital information accessible. Beware any web developer who says they’ve solved the accessibility problem with an overlay or widget. Indeed, you are showing your inaccessibility by having an “accessibility” overlay and icon on your site. 

Web designers might think the international web standards are sufficient. But they are not – just like the standards for access and mobility in the public domain are not enough. 

By the way, CUDA uses the WordPress platform’s free version and continues to do so because we do not receive financial support for the website and want to keep it open access. As with everything universal design – it is a work in progress. “Do the best you can with what you have at the time and strive to improve next time.”