Stress and exclusion: principles and tools for inclusive design

The Journey Stress Calculator is one of the tools that Loughborough University is developing as part of the Accessibility and User Needs in Transport for Sustainable Urban Environments (AUNT-SUE) project. The ambitious aim of this tool is to model the psychological stress that 100 people would experience during any public transport journey. Assessing whole journey accessibility in this way has been born out of a fresh perspective on the causes of social exclusion. This paper provides an introduction to psychological stress theory and proposes two key principles. The exclusion transaction explains how individual instances of exclusion occur, whilst stressor elimination is the mechanism that reduces exclusion. The potential benefits of understanding exclusion in this way are discussed and it is suggested that the aim of inclusive design should be the elimination of stressors that associated with products and systems. Practical implementation of this approach would rely on the availability of techniques that can be easily integrated into design and policy making processes. The Journey Stress Calculator is one example of how this may be achieved, but simpler and more generally applicable tools are also proposed

Validation of the HADRIAN system with a train station design case study

The HADRIAN (Human Anthropometric Data Requirements Investigation & Analysis) human modelling system is under development at Loughborough University as part of the EPSRC funded AUNT-SUE (Accessibility and User Needs in Transport for Sustainable Urban Environments) project. The HADRIAN system aims to foster a ‘design for all’ ethos by allowing ergonomists and designers to see the effects of different kinds of disability on the physical capabilities of elderly and disabled people. This system is based upon the long established SAMMIE system (System for Aiding Man Machine Interaction Evaluation), and uses data collected from 102 elderly and disabled individuals (Joint range of motion and anthropometry, ability to use steps and stairs, lifts escalators etc.). The HADRIAN system allows three dimensional CAD data of new products to be imported, with subsequent analysis using all of 102 sample members. The 102 sample includes a stature range of 1st% UK female to 99th%ile UK male, and also includes a range of disabilities that have been assessed using scales from Martin et al (1994). In this way the needs of people with specific conditions, such as arthritis, can be demonstrated and where possible, design accommodation can be improved. This paper describes the validation activity that is underway with the HADRIAN system. The validation reflects the transport focus of the AUNT SUE project by using HADRIAN to analyse the user interaction points that people encounter when using the Docklands Light Railway in London. This includes the use of ticket machines, the use of the train station infrastructure such as lifts and steps and stairs, and the use of ATMs to obtain cash. The validation is being performed by comparing the predicted results from HADRIAN and the abilities of users when performing real life tasks such as retrieving a ticket from a machine, or pressing a floor button when in a lift

A design ergonomics approach to accessibility and user needs in transport

This paper describes research carried out into the area of accessibility and 'design for all'. The Accessibility and User Needs in Transport (AUNT-SUE) project was initiated to develop and test sustainable policies and practice that would deliver effective socially inclusive design and operation in transport and the public realm. Loughborough University's role in the project focuses on the provision of data on users that is accessible, valid, and applicable and a means of utilising the data to assess the accessibility of designs during the early stages of development. These needs have led to the development of the authors' inclusive design tool called HADRIAN. Data were collected on 100 people the majority of whom are older or have some form of impairment. These data include size, shape, capability, preferences and experiences with a range of daily activities and transport related tasks. These are partnered with a simple task analysis system. The system supports the construction of a task linked to a CAD model of a design to be evaluated. The task is then carried out by the virtual individuals in the database. Accessibility issues are reported by the system allowing excluded people to be investigated. Thus HADRIAN supports designers and ergonomists in attempting to 'design for all' by fostering empathy with the intended users, meeting their data needs through an accessible and applicable database and providing a means of gaining some of the feedback possible with a real user trial at a much earlier stage in the design process

The psychological stress perspective: a unifying view of accessibility in public transport and beyond

Making public transport accessible to all is important because of its role in social inclusion and environmental sustainability. The UK public transport network is a complex system with a multitude of operators providing services on different scales with different vehicles. A single journey can put a variety of demands on a person wishing to travel and these demands that can exclude people from using public transport take many different forms. A range of physical, sensory, cognitive, and emotional factors effect how people with different of abilities, ages, genders, ethnicities and socioeconomic status use public transport. This complexity makes the task of assessing access to the system problematic. This paper proposes that all the factors that contribute to people’s non-participation in public transport and other human systems can be regarded as stressors. Psychological stress theory provides a language to explain exclusion and a unifying perspective with which all accessibility barriers can be viewed in the same way. A method called Human System Stressor Analysis (HSSA) has been devised to identify, assess and compare stressors that are found in a system. An example of HSSA being applied to public transport use is provided. This was used to identify an opportunity for a product design solution and led to the design of a journey planning kiosk. An understanding of psychological stress was applied throughout the design process with two new tools used to inform design decisions: the Panic Matrix to generate empathy and STUD Tables (Stressors as a function of Time, Uncertainty and Difficulty) to compare alternative solutions. The AUNT-SUE (Accessibility and User Needs in Transport for Sustainable Urban Environments) project is currently developing a tool that applies the stress perspective to journey accessibility assessment. This tool is intended to model journey stress for a range of individual people in the HADRIAN (Human Anthropometric Data Requirements Investigation and Analysis) database. Finally it is suggested that the psychological stress perspective could be used as a unifying measure throughout ergonomics, the potential benefits and problems with this approach are discussed and opportunities for further research to establish its validity and practicality are identified

Digital human modelling for virtual fitting trials

A recognised difficulty with the conventional use of Digital Human Modelling (DHM) systems is that they typically use percentile data to describe anthropometry and joint constraints. Hence any model is a synthesis of the set of data rather than a representation of any particular human. Implicit in this is that an acceptable degree of correlation exists between body dimensions whereas it has long been known that only weak correlations exist. The consequences are obvious in that products are designed/evaluated against models of humans that do not exist. An alternative approach is to use pre-defined families of manikins that together ‘enclose’ and represent the necessary diversity of human form. In the real world, rather than the digital world, ergonomists use real people in ‘fitting trials’. These people might be selected on the basis of the need for diversity covering the range of anthropometry that is thought necessary for the product evaluation but the practical considerations rarely allow an exhaustive evaluation. This paper describes an amalgam of the two approaches where the anthropometry and other aspects of more than 150 people has been collected experimentally. This data is used within the HADRIAN system as discrete sets of data rather than as the basis for a percentile representation. i.e. the data is maintained as sets relating to each individual and used to construct digital models of individuals. This is combined with a task description language that is used to drive the product or workplace evaluation in a way that is analogous to a physical fitting trial. The approach is being used within AUNT-SUE (Accessibility and User Needs in Transport – Sustainable Urban Environments) a wide–ranging research project looking at exclusion in public transport systems. The use of the HADRIAN approach is illustrated through a focus on the creation of a journey planner that meets the needs of a diverse range of people including the elderly and disabled

Why are eligible patients not prescribed aspirin in primary care? A qualitative study indicating measures for improvement

BACKGROUND: Despite evidence-based guidelines, aspirin prescribing for the secondary prevention of stroke is sub-optimal. Little is known about why general practitioners do not prescribe aspirin to indicated patients. We sought to identify and describe factors that lead general practitioners (GPs) not to prescribe aspirin to eligible stroke patients. This was the first stage of a study exploring the need for and means of improving levels of appropriate aspirin prescribing. METHOD: Qualitative interviews with 15 GPs in the West Midlands. RESULTS: Initially, many GPs did not regard their prescribing as difficult or sub-optimal. However on reflection, they gave several reasons that lead to them not prescribing aspirin for eligible patients or being uncertain. These include: difficulties in applying generic guidelines to individuals presenting in consultations, patient resistance to taking aspirin, the prioritisation of other issues in a time constrained consultation and problems in reviewing the medication of existing stroke patients. CONCLUSION: In order to improve levels of appropriate aspirin prescribing, the nature and presentation risk information available to GPs and patients must be improved. GPs need support in assessing the risks and benefits of prescribing for patients with combinations of complicating risk factors, while means of facilitating improved GP-patient dialogue are required to help address patient uncertainty. A decision analysis based support system is one option. Decision analysis could synthesise current evidence and identify risk data for a range of patient profiles commonly presenting in primary care. These data could then be incorporated into a user-friendly computerised decision support system to help facilitate improved GP-patient communication. Measures of optimum prescribing based upon aggregated prescribing data must be interpreted with caution. It is not possible to assess whether low levels of prescribing reflect appropriate or inappropriate use of aspirin in specific patients where concordance between the GP and the patient is practised

General practitioners and tutors' experiences with peer group academic detailing: a qualitative study

<p>Abstract</p> <p>Background</p> <p>The Prescription Peer Academic Detailing (Rx-PAD) project is an educational intervention study aiming at improving GPs' competence in pharmacotherapy. GPs in CME peer groups were randomised to receive a tailored intervention, either to support a safer prescription practice for elderly patients or to improve prescribing of antibiotics to patients with respiratory tract infections. The project was based on the principles of peer group academic detailing, incorporating individual feedback on GPs' prescription patterns. We did a study to explore GPs and tutors' experiences with peer group academic detailing, and to explore GPs' reasons for deviating from recommended prescribing practice.</p> <p>Methods</p> <p>Data was collected through nine focus group interviews with a total of 39 GPs and 20 tutors. Transcripts from the interviews were analyzed by two researchers according to a procedure for thematic content analysis.</p> <p>Results</p> <p>A shared understanding of the complex decision-making involved in prescribing in general practice was reported by both GPs and tutors as essential for an open discussion in the CME groups. Tutors experienced that CME groups differed regarding structure and atmosphere, and in some groups it was a challenge to run the scheme as planned. Individual feedback motivated GPs to reflect on and to improve their prescribing practice, though feedback reports could cause distress if the prescribing practice was unfavourable. Explanations for inappropriate prescriptions were lack of knowledge, factors associated with patients, the GP's background, the practice, and other health professionals or health care facilities.</p> <p>Conclusions</p> <p>GPs and tutors experienced peer group academic detailing as a suitable method to discuss and learn more about pharmacotherapy. An important outcome for GPs was being more reflective about their prescriptions. Disclosure of inappropriate prescribing can cause distress in some doctors, and tutors must be prepared to recognise and manage such reactions.</p

Development of a volumetric projection technique for the digital evaluation of field of view

This article was published in the journal, Ergonomics [© Taylor & Francis] and the definitive version is available at: http://dx.doi.org/10.1080/00140139.2013.815805Current regulations for field of view requirements in road vehicles are defined by 2D areas projected on the ground plane. This paper discusses the development of a new software-based volumetric field of view projection tool and its implementation within an existing digital human modelling system. In addition, the exploitation of this new tool is highlighted through its use in a UK Department for Transport funded research project exploring the current concerns with driver vision. Focusing specifically on rearwards visibility in small and medium passenger vehicles, the volumetric approach is shown to provide a number of distinct advantages. The ability to explore multiple projections of both direct vision (through windows) and indirect vision (through mirrors) provides a greater understanding of the field of view environment afforded to the driver whilst still maintaining compatibility with the 2D projections of the regulatory standards. Practitioner Summary: Field of view requirements for drivers of road vehicles are defined by simplified 2D areas projected onto the ground plane. However, driver vision is a complex 3D problem. This paper presents the development of a new software-based 3D volumetric projection technique and its implementation in the evaluation of driver vision in small- and medium-sized passenger vehicles

Putting prevention into practice: qualitative study of factors that inhibit and promote preventive care by general practitioners, with a focus on elderly patients

<p>Abstract</p> <p>Background</p> <p>General practitioners (GPs) have a key role in providing preventive care, particularly for elderly patients. However, various factors can inhibit or promote the implementation of preventive care. In the present study, we identified and examined factors that inhibit and promote preventive care by German GPs, particularly for elderly patients, and assessed changes in physicians' attitudes toward preventive care throughout their careers.</p> <p>Methods</p> <p>A qualitative, explorative design was used to identify inhibitors and promoters of preventive care in German general medical practice. A total of 32 GPs in Berlin and Hannover were surveyed. Questions about factors that promote or inhibit implementation of preventive care and changes in physicians' perceptions of promoting and inhibiting factors throughout their careers were identified. Episodic interviews, which encouraged the reporting of anecdotes regarding daily knowledge and experiences, were analyzed using ATLAS/ti. Socio-demographic data of GPs and structural information about their offices were collected using short questionnaires. The factors identified as inhibitory or promoting were classified as being related to patients, physicians, or the healthcare system. The changes in GP attitudes toward preventive care throughout their careers were classified as personal transitions or as social and health policy transitions.</p> <p>Results</p> <p>Most of the identified barriers to preventive care were related to patients, such as a lack of motivation for making lifestyle changes and a lack of willingness to pay for preventive interventions. In addition, the healthcare system seemed to inadequately promote preventive care, mainly due to poor reimbursement for preventive care and fragmentation of care. GPs own attitudes and health habits seemed to influence the implementation of preventive care. GPs recognized their own lack of awareness of effective preventive interventions, particularly for elderly patients. GPs were motivated by positive preventive experiences, but often lacked the necessary training to counsel and support their patients.</p> <p>Conclusions</p> <p>German GPs had positive attitudes towards prevention, but the implementation of preventive care was neither systematic nor continuous. Identification and elimination of barriers to preventive care is crucial. Further research is needed to identify effective practice-based approaches to overcome these barriers.</p

A systematic review of patient reported factors associated with uptake and completion of cardiovascular lifestyle behaviour change

Background: Healthy lifestyles are an important facet of cardiovascular risk management. Unfortunately many individuals fail to engage with lifestyle change programmes. There are many factors that patients report as influencing their decisions about initiating lifestyle change. This is challenging for health care professionals who may lack the skills and time to address a broad range of barriers to lifestyle behaviour. Guidance on which factors to focus on during lifestyle consultations may assist healthcare professionals to hone their skills and knowledge leading to more productive patient interactions with ultimately better uptake of lifestyle behaviour change support. The aim of our study was to clarify which influences reported by patients predict uptake and completion of formal lifestyle change programmes. Methods: A systematic narrative review of quantitative observational studies reporting factors (influences) associated with uptake and completion of lifestyle behaviour change programmes. Quantitative observational studies involving patients at high risk of cardiovascular events were identified through electronic searching and screened against pre-defined selection criteria. Factors were extracted and organised into an existing qualitative framework. Results: 374 factors were extracted from 32 studies. Factors most consistently associated with uptake of lifestyle change related to support from family and friends, transport and other costs, and beliefs about the causes of illness and lifestyle change. Depression and anxiety also appear to influence uptake as well as completion. Many factors show inconsistent patterns with respect to uptake and completion of lifestyle change programmes. Conclusion: There are a small number of factors that consistently appear to influence uptake and completion of cardiovascular lifestyle behaviour change. These factors could be considered during patient consultations to promote a tailored approach to decision making about the most suitable type and level lifestyle behaviour change support