Background

Housing adaptations and home modifications constitute important and common interventions in occupational therapy practice worldwide. This kind of intervention is based on the theoretical notion that occupational performance is the outcome of ­person–environment–occupation (Christiansen and Baum 1997) transactions (Fänge and Iwarsson 2007). Environmental intervention has its roots in a post-World War II philosophy, when clients and rehabilitation practitioners discovered that despite successful functional training , war victims were not able to live independently outside the hospital setting without environmental modification (Steinfeld and Tauke 2002). Such interventions aim at reducing the demands of the physical environment in the home and its close surroundings, in order to enhance activity and participation and to promote independence (Fänge and Iwarsson 2005). In a broader sense, the goal is to promote health, well-being, and quality of life (Ainsworth and de Jonge 2011).

Definitions

The term housing adaptation is often used interchangeably with home modification , although the latter tends to be used as a broader term, including housing adaptation and other interventions in the home environment, such as home-hazard counseling and provision of assistive technology (see, e.g., Sheffield et al. 2013). Wahl et al. (2009) defined home modification as “all efforts to improve a given physical home environment with the aim to make it better suitable to the functional needs of a given person.” Thus, to differentiate among different kinds of interventions in the home, the following definition has been suggested for housing adaptations , that is, modifications to the built and natural environment:

The alteration of permanent physical features in the home and the immediate outdoor environment; i.e., the objective is to reduce the demands of the physical environment in the home and its close surroundings, in order to enhance daily activities, and promote the ability to lead an independent life. (Fänge 2004, pp 8–9)

The concepts of accessibility , design for all, universal design , and usability are often used interchangeably and without explicit definition and differentiation (Iwarsson and Ståhl 2003). These concepts have different roots (Steinfeld and Tauke 2002). To nurture the use of consistent terminology in this field, the following definitions are recommended.

Accessibility

Accessibility is a relative concept, implying that accessibility problems should be expressed as a person–environment relationship. In other words, accessibility is the encounter between the person’s or the group’s functional capacity and the design and demands of the physical environment. Accessibility refers to compliance with official norms and standards, thus being mainly objective in nature (Iwarsson and Ståhl 2003).

Usability

The concept of usability implies that a person should be able to use, i.e., to move around, be in, and use, the environment on equal terms with other citizens. Accessibility is a necessary precondition for usability, implying that information on the person–environment encounter is imperative. However, usability is not only based on compliance with official norms and standards; it is mainly subjective in nature, taking into account user evaluations and subjective expressions of the degree of usability. Usability is a measure of effectiveness, efficiency, and satisfaction. Most important, there is a third component distinguishing usability from accessibility, viz. the activity component (Iwarsson and Ståhl 2003).

Universal Design

Universal design is synonymous with “design for all” and represents an approach to design that incorporates products as well as building features which, to the greatest extent possible, can be used by everyone. Universal design is the best approximation of an environmental facet to the needs of the maximum possible number of users. Universal design is ultimately about changing attitudes throughout society, emphasizing democracy, equity, and citizenship. Universal design denotes a process more than a definite result (Mace 1985, cited in Iwarsson and Ståhl 2003).

Purpose

The purpose of housing adaptation is to adapt the housing environment to the clients’ needs, given their functional capacity and needs and wishes for optimal occupational performance. Usability and independent occupational performance in activities related to the home constitute the most appropriate primary outcomes of housing adaptations .

Method

Candidates for the Intervention

Housing adaptation is applicable to all clients with disabilities who have problems performing daily activities in their home setting, where the interventions are aimed at improved usability and increased independence in occupational performance in activities related to the home by means of alterations of the physical environment.

Epidemiology

Research and available statistics show that the vast majority of housing adaptation clients are older people (Boverket 2005), most often with functional limitations due to the normal process of aging, such as difficulty in bending, kneeling, poor balance, and limitations in stamina, in turn leading to dependence on mobility devices (Fänge 2004). Housing adaptations for older people are normally not expensive in each case. However, because of current population compositions, the cost may aggregate to huge total sums. For example, in Sweden, the total annual public expenditures for housing adaptations grants exceed SEK 1 billion (Chiatti and Iwarsson 2014).

Younger adults living with disabilities caused by neurologic diseases or injuries (e.g., multiple sclerosis or spinal cord injuries) , rheumatic diseases (e.g., rheumatoid arthritis), or other chronic conditions often need quite expensive housing adaptations (Fänge 2004).

Children with disabilities due to cerebral paresis, juvenile rheumatoid arthritis, or muscular dystrophy often require extensive and expensive housing adaptations, which entails repeated interventions as they grow and develop.

Settings

Housing adaptations are initiated by occupational therapists (OTs) in all kinds of settings, and the prerequisites for such interventions vary from country to country. In countries where community-based practices are well developed, such interventions are most commonly effectuated by practitioners employed in primary health care, and are run by county councils or municipalities. In countries where OTs run their own enterprises, housing adaptations are often part of their intervention ­arsenal. In many countries, no public grants are provided. Thus, clients have to pay for such interventions themselves, or have private insurances to cover the costs for housing adaptations.

The Role of the OT in Applying the Intervention

Housing adaptation is an intervention for which the prerequisites depend greatly on the national legislative framework as well as the housing standards and building traditions of a country. Therefore, it is not feasible to propose basic recommendations that can be generally applicable, and a globally accepted description of the clinical application is not feasible.

Hence, the role of the OT in performing the housing adaptation processes varies considerably. For example, in Sweden, if a healthcare professional (most often an OT) certifies the housing adaptation, the municipality will provide a grant to finance it. The client is the formal applicant and receiver of the grant, and municipality officials administer all applications (Fänge and Iwarsson 2007; Malmgren Fänge et al. 2013). In such a system, the OT’s role is well established but somewhat contradictory in practice, combining that of an official issuing a certificate of needs for an application process governed by specific legislation with that of a registered healthcare professional delivering different kinds of measures intertwined in a client-centered rehabilitation process.

In contrast, delivering housing adaptation interventions in countries where housing adaptation grants do not exist, or depend entirely on whether the client has a private insurance, naturally poses quite different demands on the OT.

In the current practice, the use of systematic procedures for housing adaptations is scarce (Malmgren Fänge et al. 2013), and the intervention, which ­depends very much on the individual therapist, is largely “a black box” (Fänge and Iwarsson 2007).

Results

Clinical Application

Housing adaptation interventions constitute a complex process that includes a number of specific stages, including several home visits (see Ainsworth and de Jonge 2011). Interviewing and observing the client and inspecting the home environment is mandatory.

The systematic collection of data for identification of the client’s problem should be based on a person–environment–occupation transactional perspective. It requires the use of valid and reliable assessment instruments as well as qualitative data collection. For example, the Housing Enabler instrument (Iwarsson et al. 2012) can be used to structure the objective assessment of functional capacity and environmental barriers. In addition, perceived aspects of housing (Oswald et al. 2006), for example usability (Fänge and Iwarsson 1999), should be included in the data collection and respected in the planning of the individualized intervention. That is, the home must be approached as a place of meaning, and when recommending housing adaptations the measures should be as closely associated with normality as possible. Most important, housing adaptations should not be prescribed but negotiated with the clients to take into account their personal needs and preferences. Analysis of the data leads to the planning of the housing adaptation, which requires the active involvement of the client and his or her family.

Measures such as removal of thresholds, installation of shower stalls instead of bathtubs, and installation of handrails, grab bars, and ramps (Fig. 13.1) are among the most common. It is necessary to consider the ergonomic working environment aspects for clients where formal or informal helpers are involved.

Fig. 13.1
figure 1

Installation of ramps at entrances is among the most common housing adaptation measures. (Photograph: S. Iwarsson; reproduced with the subject’s approval)

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Housing adaptation as intervention places great demands on OTs, because they are acting upon the most private domain of a person’s living environment. Potential conflicts of interest are inherent in the process (see, e.g., Chiatti and Iwarsson 2014).

Evidence-Based Practice

As the quite diverse systems across countries make comparisons between studies difficult, it is hard to evaluate the literature for scientific evidence regarding housing adaptations and home modifications . The majority of published housing adaptation evaluations lack theory-based definitions of core concepts and outcomes. According to the Cochrane reports (Gillespie et al. 2003; Lyons et al. 2003), the scientific evidence of the effects of housing adaptations and home modifications is limited. Yet, according to a literature review, including studies with mainly older people (Wahl et al. 2009) there is substantial evidence of positive effects. Positive effects were indicated on (1) functional decline (Mann et al. 1999), (2) fear of falling (Cumming et al. 1999; Heywood 2004), (3) pain and depression (Heywood 2004), (4) satisfaction and performance in daily activities (Gitlin et al. 2001; Stark 2004), and (5) costs of healthcare and social services (Mann et al. 1999). Most recent studies on housing adaptations and home modifications show promising results (see e.g., Sheffield et al. 2013). However, regarding health economy outcomes, the scientific evidence is nonexistent (Chiatti and Iwarsson 2014).

Discussion

Housing adaptations and home modifications should be recommended as interventions that support the maintenance of independence in activities of daily living (Wahl et al. 2009) and occupational performance in general (Fänge and Iwarsson 2007). Still, there are critical methodological challenges for practice and future ­research (Malmgren Fänge et al. 2013). As the quotation at the start of this chapter demonstrates, another challenge is to present scientific evidence that would make some individual housing adaptations unnecessary. Applying such a health promotion ­approach, and using experience and knowledge generated from individual housing adaptation cases to be translated into recommendations for housing provision as part of the process of planning a society for all (Ainsworth and de Jonge 2011; Iwarsson 2005), is a challenging but important avenue for future development.