Disability is an umbrella term describing physical or psychological impairments, activity limitations or participation restrictions (367). At least 1 billion people, or 15% of the world’s population, have some form of disability (368). The disabled population is increasing as the world’s population ages (369). Disability disproportionately affects low-income households, and has a higher prevalence in low- and middle-income countries (368). Disability can cause and contribute to poverty (368). People with functional impairment are more likely to be discriminated against when looking for housing, and more likely to pay high costs for housing relative to their income (370).
According to the United Nations Convention on the Rights of Persons with Disabilities, Member States have an obligation to identify and eliminate all barriers to accessibility, including in housing (371).
As functioning and disability result from an “interaction between the person’s health condition and both personal and environmental factors” (372), contextual factors substantially determine whether an impairment is perceived as disabling. Accessible dwelling can improve a person’s domain-specific functioning within their home. Life span housing (also known as life cycle housing, lifetime homes or adaptable housing) can accommodate changes in human functioning over a person’s life span, enabling the occupants to remain in their homes as long as possible. Universal design (or universal housing) is an approach to the design, construction and adaptation of housing to meet the needs of all occupants regardless of their age, functioning or social situation (373).
Most homes are not currently built with accessibility in mind. For example, only about one fifth of public buildings in Enugu city, Nigeria, were found to be accessible for wheelchair users (374). However, there is a high chance that they will be occupied by people with disablities at some time, especially considering the trend of ageing populations. In the United States of America, it has been estimated that there is a 60% probability that any new house will be occupied by a person with a functional impairment over its life span (375). Non-accessible home environments expose people with functional impairments to risk of falls and injuries, restricts social participation, negatively affects quality of life, and increases the burden on caregivers and external social services (376, 377). They limit a person’s ability to manoeuvre in different spaces.
In order to establish clear guidance on maximizing the health gains associated with accessible housing, a systematic review of the evidence on the effects of home improvements for people with functional impairment was commissioned.
Question for the systematic review
Do residents with functional or cognitive impairments living in accessible/ usable home environments have better health/social outcomes than residents with functional or cognitive impairments living in conventional or unmodified home environments?
The systematic review focused on the following priority health outcomes, as ranked by the GDG:
injury rates (especially falls)
well-being/quality of life
mental health/depression
dependency on external social or care services
social participation.
7.1. Guideline recommendation
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| Recommendation | Strength of recommendation |
|---|
 Based on current and projected national prevalence of populations with functional impairments and taking into account trends of ageing, an adequate proportion of the housing stock should be accessible to people with functional impairments. | Strong |
Remarks
People with functional impairments living in accessible home environments have better health and are better able to accomplish everyday tasks and manage living independently than those living in conventional or inaccessible home environments. Implementing agencies should work to ensure that people with functional impairments live in accessible housing, because this is likely to have beneficial effects on health. The recommendation is limited to the effect of housing accessibility on people with functional impairments because of the small number of studies focusing on people with cognitive impairments.
Each implementing agency should determine what percentage of the housing stock is required to be “adequate” to meet the needs of the population with functional impairments. They should do this by considering current and projected national prevalence of people with functional impairments and trends in ageing. A good discussion on estimation methods is available (
378). The level required for “adequate” provision will need to be reviewed as the population changes; in particular, as it ages. Given that accessible housing is not exclusively occupied by people with functional impairments, it is likely that the proportion of accessible housing stock would be higher than the proportion of households that include people with functional impairments.
Implementing agencies can draw on a range of existing programmes that target an increase in the supply of accessible dwellings.
The GDG assessed the certainty of the evidence to indicate the extent to which the research supports the recommendation and, in general, the certainty of the evidence for interventions to improve the accessibility and usability of the houses of people with functional impairment is moderate, supporting the decision to provide a strong recommendation. This overall certainty arises from a consideration of the accumulated evidence as a whole, which suggests important benefits for this disadvantaged population even though the evidence is of low certainty for some interventions and outcomes. In relation to specific aspects of the findings from the systematic review and other information, the certainty of the evidence that people with functional impairments are better able to accomplish activities of daily living when living in accessible environments was assessed as low to moderate; the certainty of the evidence that people with functional impairments are less likely to fall and be injured when living in accessible environments was assessed as moderate; the certainty of the evidence that living in accessible environments reduces the mortality rate of people with functional impairments was assessed as low; and the certainty of the evidence that people with functional impairments experience positive psychological effects and improved quality of life when living in accessible environments was assessed as low to moderate.
Having considered the certainty of the evidence, the balance of benefits to harm related to increasing the supply of accessible dwellings, and the feasibility of increasing the supply of accessible dwellings, the GDG made a strong recommendation.
7.2. Summary of evidence
This recommendation was informed by a systematic review of the evidence on the impact of accessible housing on residents with functional or cognitive impairments. The systematic review and the GRADE tables used to assess the certainty of the evidence are available online at http://www.who.int/sustainable-development/publications/housing-health-guidelines/en/index.html in Web Annex F.
Twenty studies, including six randomized trials, were eligible for the systematic review. Almost all the studies focused on people with functional impairments, with only one study of people with cognitive impairments (379). Interventions implemented to enhance home accessibility features were carried out either as a sole intervention or as part of a multicomponent programme. Home modifications were mainly focused on architectural changes or fitted devices (such as grab bars) targeting mobility issues. Some focused on lighting improvements or adjustments targeting vision.
7.2.1. Activities of daily living
Functional impairments are often operationalized in terms of whether a person can accomplish activities of daily living (ADL) or instrumental activities of daily living (IADL). IADL refers to basic tasks of everyday life such as bathing, dressing, transferring, toileting, continence and feeding. ADL refers to a range of activities that are required for independent living in the community, such as preparing meals, housekeeping, taking medication, shopping, managing one’s own finances, travelling and using the telephone.
Some studies reported the effects of interventions on ADL/IADL related outcomes. Three studies reported considerable decreases in perceived difficulties performing ADL/IADL after home modifications (380–382); but difficulty with mobility/transfer did not change (382). Self-efficacy, which was defined as confidence in managing difficulty, was improved in one intervention group (382). Increased safety with ADL/IADL was also identified 2 months after home modifications among adults with impairments. The greatest safety benefits were in regard to bathroom use and entry access (380) and to difficulty in bathing and toileting (382). In addition, one population-based survey identified a strong association between self-recognized difficulty managing ADL and perceived unmet needs for home accessibility features among people with physical impairments, after adjusting for the severity of their physical limitations (383). This suggests that people who already have difficulties functioning in everyday life can benefit from home accessibility features, possibly delaying further deterioration of their functioning.
One randomized trial involving people with visual impairments did not identify a significant improvement overall in self-rated certainty in performing specific activities 6 months after lighting adjustments (384). In addition, two studies found no significant change in dependence with ADL/IADL at 2 months and up to 9 months after home modifications (380, 385), although it was noted that dependence in bathing was significantly decreased between 2 to 3 months and 8 to 9 months after home modifications (385). These non-significant findings may be because the participants were elderly meaning that the participants’ functions declined so rapidly that specific home modifications had an effect only for a short period of time (386).
Three further studies investigated the impact of interventions on general ADL. One randomized trial involving adults above the age of 60 who had had surgery for hip fracture in Finland did not detect any significant effects on general ADL or IADL (387). However, a quasi-experimental study conducted in Thailand found that home modifications improved abilities in all function areas except for participants with severe degrees of difficulties (388), and a cross-sectional study involving participants from Sweden and Germany showed improvements in various aspects of ADL (389).
The certainty of the evidence that people with functional impairments living in accessible environments are better able to accomplish activities of daily living was assessed as low to moderate.
7.2.2. Falls/injuries
Studies showed that home modifications aimed at reducing the likelihood of falls and injuries for people with functional impairments were successful in doing so. One randomized trial reported 41% fewer falls after 1 year in the home safety programme with a group of older adults with severe visual impairments, compared with those who did not receive this programme (341). A longitudinal prospective cohort study identified a significant reduction in falls at home and post-fall hospitalizations among frail older adults after the use of a light path coupled with tele-assistance (390). Two other studies reported a significantly lower mortality rate in the intervention group over the control group after the implementation of the multicomponent home modification programme. The programme included training to promote healthy behaviours (382, 391).
The certainty of the evidence that people with functional impairments living in accessible environments have reduced fall and injury rates was assessed as moderate.
7.2.3. Mortality
One randomized trial, reported in two papers (382, 391) reported a significantly lower mortality rate in the intervention group over the control group up to 2 years after the implementation of the multicomponent programme, which included home modifications as well as training strategies to promote healthy behaviours. However, there was no statistically significant effect on survival 3 years after the intervention.
The certainty of the evidence that living in accessible environments reduces the mortality rate of people with functional impairments was assessed as low.
7.2.4. Quality of life
Two randomized trials (384, 392) identified the positive effect of interventions on quality of life. Ahmad et al. (2013) found that 2 months after the homes of paraplegic wheelchair users were modified, quality of life was significantly enhanced in the intervention group, compared with the control group (392). Brunnström et al. (2004) found that adjustments to living room lighting increased quality of life and well-being among adults with low vision (384). Conversely, a cross-sectional study with adults with dementia found no association between quality of life and home safety and accessibility factors such as hazards, grab bars and visual cues (379).
The certainty of the evidence that living in accessible environments improves the quality of life of people with functional impairments was assessed as low.
7.2.5. Psychological effects
Three studies identified positive psychological effects of home accessibility interventions for people with functional impairments (382, 393, 394). A randomized trial found that older adults with functional difficulties reported significantly less fear of falling following a multicomponent home intervention (382). A quasi-experimental study from Sweden found a significant decrease in fear of falling at 3 months but not at 6 months after the intervention (394). Heywood (2004) reported that 62% of people whose homes had modified for accessibility (through for example installing handrails and grab-rails), reported “feeling safer from accidents” and 77% perceived a positive effect on their health (393).
The certainty of the evidence that people with functional impairments living in accessible environments experience positive psychological effects was assessed as moderate.
7.2.6. Participation
One cross-sectional study conducted in Sweden concluded that accessibility problems were significantly associated with less participation and autonomy and more participation problems (395).
7.3. Considerations for implementation of the guideline recommendation
A report from New Zealand concluded that it would be approximately 22 times more cost-efficient to build housing that includes key accessibility features than to retrofit when an unplanned need arises (396). However, in 2006, only 56% of countries had accessibility criteria in their building standards (397). Introducing such national regulations in a large number of countries could therefore lead to more inclusive societies and avoid extensive expenditures on retrofitting. It needs, however, to be noted that globally only a very small proportion of the housing stock will be newly built, while most of the housing stock requires retrofitting. Accessibility needs therefore to be ensured in regulation both for existing and new dwellings. The international standard “ISO 21542:2011 Building construction – Accessibility and usability of the built environment”, published by the International Organization for Standardization, specifies a range of requirements and recommendations including on construction aspects of housing accessibility (398). Information on low-cost home modifications to increase housing accessibility in low-income settings is available from community-based rehabilitation programmes in India, using guidelines for care and community integration after spinal cord injury produced by the Government of India and the WHO Community-based rehabilitation guidelines (399).
Besides the public sector, the private sector is a major partner in promoting accessible housing. One such a multistakeholder collaboration has been initiated by the National Cooperative Housing Union in Kenya by linking government, disability groups and the private sector to identify available land and providing technical assistance and loan capital to facilitate accessible housing construction (400). In Australia, the housing industry developed a target of having all new homes meet the Australian Liveable housing design guidelines by 2020. Those guidelines describe a number of elements that make a home more responsive to the changing needs of home occupants (401). However, voluntary schemes require extensive education and training programmes to highlight the benefits of accessible housing.
Progress towards increasing the stock of accessible housing should be carefully monitored. If sufficient progress is not being made using a voluntary programme, it may be necessary to introduce a mandatory programme. Such schemes are usually introduced gradually. For example, Portugal’s compulsory scheme was phased in over 8 years (402). In Sweden, every local authority is legally obliged to provide home modifications for people with impairments (380). However, planning for home modification requires consultation with service users as well as health and architectural professionals to ensure the users’ needs are met appropriately. Home modifications that are poorly implemented due to bad planning or administrative errors may have a negative impact on physical and mental health of persons with impairments (393).
Accessible housing should consider other factors related to healthy housing in addition to usability for occupants. If providing a household with an accessible dwelling entails people moving to another location, it could potentially remove them from social networks, child care support, and work or educational opportunities, affecting health and earning opportunities (194).
7.4. Research recommendations
The research reviewed suggests that living in accessible housing supports the health of people with impairments. However, high-quality research in this area is difficult because allocating people to a comparison group is not always possible: the home modifications might be mandated under law, or it may be unethical to deny or delay accessibility improvements. lists the research priorities in this area.
Research recommendations: accessibility.
