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The wider picture in [inclusive] design

by Ana Correia de Barros

The traditional approach of inclusive design has been about focusing on a pyramid-shaped model of human needs, which led to designs being helpful in fulfilling needs at the base, but not so much in helping people to make their way into fulfilling other needs which are considered to be higher up the pyramid.

In this paper we argue that such a hierarchical conception of human needs no longer fits inclusive design for the 21st century, and that more integrated approaches are needed. This is consistent with how Max-Neef and many others, including some developmental psychologists, have argued against any relativist or hierarchical schema of needs fulfilment, emphasising that priorities change with time and context. We argue that the focus should probably be put in how these needs may be satisfied, which consists in considering opportunities rather than assets alone.

From the discussion we conclude by arguing for two different yet complementing paces for a sustainable and integrated design practice which should consider the human being in all its dimensions in order to allow and provide for sustainable and inclusive development.


Prelude

What follows is an excerpt from the interview we conducted with Mr. J, a former gardener and a Portuguese stroke victim who is hemiplegic. Mr. J lives alone with his wife who is impaired due to medical conditions, and he has a monthly income around 630 € (the minimum wage in Portugal stands at 485 €).

Mr. J: Just the transportation. Forty euro: twenty down there and 20 back up again. And each time I went there the price for the [physical therapy] session was 57.5 €. So I went to the doctor and said to her: “But Doctor, that way I just can't. Because, look: 40 € back and forth (20 for each trip), and... How many days?". And she said I could start by going from Monday through Friday. "I can't, then". And so she told me: "Look, go to social security and ask if they can lend you a hand". And I said: "But, Doctor, how can I go to the social security for help if they already come home to bring me food, clean the house and all that? And the money I earn is not enough for both things. And, look, back at the hospital I learned to do like this". And she said: "OK, then look, you are going to take the medicine you brought from the hospital, and you will come and get the recipe once every now and then; (...) You just keep doing those exercises you do at home and that's it". So, that's what I'm doing, see? I quit. I quit going there because it was a lot of money. Fifty-seven and a half euro each time I went there. (...) Now imagine: from Monday through Friday. I didn't have enough money, because I pay a bit over 400 € every month to homecare.

Mr. J has conflicting needs. He was put in a position to choose between subsistence and physical recovery. Being prevented from physical recovery is affecting many aspects of his life, particularly his concern for taking care of his wife. It affects his ability to perform household tasks and he sees himself entering a vicious circle where the impediment from physical recovery will, amongst other things, increase his expenses with homecare support/social security.

We were interviewing stroke victims to understand their ability to cope with daily tasks and their use of assistive products. Our concern was about how design, particularly how product design, could provide better living conditions for people in these situations. But we were often faced with the fact that the primary problems people face are related to (1) the system (e.g., assistive products allocation system, health system, social security system) and to (2) social relationships and care. It was difficult at first to understand after all what design could do for these people. Apparently it could not do much until other problems were fixed. It appeared, one should instead engage in a Herculean task of redesigning the system.

Development, freedom and quality of life
In recent years the world has witnessed a shift in what is regarded as 'development', from a focus on growth of resources to a more human-centred and sustainable concept of development concerned with opportunities. In Sen's view development is closely related to human freedoms, and should be mainly concerned with 'the removal of major sources of unfreedom'.1 These freedoms are related to many different aspects of one's life; so they might concern, amongst other things, the right and access to health, education or political participation. Since development, for Sen, should be 'concerned with enhancing the lives we lead and the freedoms we enjoy'2, the concept also relates to 'quality of life'.

The World Health Organization (WHO) defines quality of life as 'individuals' perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns'3. So, quality of life is subjective, for it is based on individual perceptions, and relative because it varies, and can change with historical, social and cultural contexts.4

This poses challenges in how to measure development and quality of life. In the view of Max-Neef, development is measured by the increase in people's quality of life. 5 Quality of life, in turn, 'depends on the possibilities people have to adequately satisfy their fundamental human needs'.6 This leads to the question: what are these fundamental needs? Furthermore, regarding our concern with assistive products, this raises the question of how assistive products help fulfil these fundamental needs whatever they might be. Yet, Max-Neef tells us that development 'is not about objects'.7 Since the main focus of this paper is on product design, we will be returning to this last premise after we have discussed some important concepts which will hopefully help us interpret this statement.


'Unfreedoms'

In order to provide a common language within healthcare – particularly within disability studies – the WHO has developed a classification of terms. Currently, this goes by the name of International Classification of Functioning, Disability and Health (ICF).

According to the ICF8, disabilities are indicative of a poorly suited environment to human diversity. This poor suitability leads to activity limitations, where activities are seen as the individual's execution of tasks or actions, and participation restrictions, where participation is regarded as an involvement in a life situation.

The environment the WHO mentions encompasses social and cultural factors, but also the built environment. And this is where product design plays its role. Activity limitations and participation restrictions are 'unfreedoms' people with disabilities experience. Poorly designed objects, i.e. products which do not account for human diversity, indeed affect quality of life and may restrict the ability one has to exercise his/her freedoms.


Products: assistive or inclusive?

Assistive products are usually defined as products to be used by people with disabilities in order to compensate, neutralize or monitor disabilities.9 We came to regard assistive products as being in fact tools10 – these are, in the end, products to compensate for body limitations in order to accomplish a certain end. Regarding things in this light helps us to see that although tools and assistive products serve the same purpose of compensating for body limitations, the latter are defined as being only for people with disabilities. We need tools to interact with the natural world, but we also need tools to interact with artificial products. Occasionally, artificial designs require that we use tools to make use of those initial artificial designs (e.g. removing a cap from a bottle). We do not focus on our body limitations when using a bottle cap opener, but we do turn our attention to them when we lack that tool and we certainly would turn our attention to them if we were not, for some reason, able to use that tool.

This takes us from assistive products, to tools, to inclusive design. Inclusive design aims to get mainstream products to be usable by the widest possible range of people, regardless of abilities or age. At the same time, it also aims at bringing assistive products to mainstream.11

Some inclusively designed products have become famous due to their commercial success. Single-head mixer taps, for example, were initially designed for the disabled, but have become standard equipment in many kitchens and bathrooms.12 This demonstrates that assistive products may not only be used, but also desired by many. There are other products, however, which though not often mentioned in design literature, are also examples of inclusive design from which many people benefit. Although not eye-catching , egg packaging is a good example put forward by the EIDD Design for All Europe.13 The reason for mentioning this example lies in the grace of its use being taken for granted. Along with milk or bread, eggs are, in many parts of the world, an important part of human nutrition. The traditional egg carton not only allows for a better grip, but also for easy identification on shelves and efficient stacking in transportation and display.

Our previous research has shown that many people who have suffered a stroke did not have any kind of disability prior to their stroke. While recovering, their main goal is to return to the state they found themselves in prior to the cerebrovascular accident. This entails being able to access and use tools for accomplishing tasks without having to turn their attention to their body limitations or to other contextual constraints. It means being able to take tasks, access and the ability to use tools for granted.

In arguing for inclusive design as the best possible approach to design, some issues are often raised, such as the ever growing number of people with disabilities and elderly people; that today's younger generations will in the future demand more and better solutions; or the money argument that follows the first two and relies on current statistical data to show that elderly people are the ones spending more money on solutions to make their daily lives not only easier, but more enjoyable.14 Indeed, as Breckenridge and Vogler state, 'no one is ever more than temporarily able-bodied.'15

Approaching the design of assistive products by focusing too much on 'basic needs', can lead to designing products which are not, after all, inclusive. Take the example given by Gheerawo and co-workers16 of mobile phones 'for the elderly' advertised at the same time as 'inclusive products': a mobile phone which is only able to memorize four contacts assumes elderly people to be restricted to a circle of four acquaintances. While focusing too hard on accessibility and usability, or on one singular need, some designers seem to have forgotten all the activities which gravitate around a phone and its possibilities, thus loosing track of people's quality of life, and what, in fact, makes them human. So, this mobile phone might ultimately be blocking opportunities and capabilities. On the other hand, when trying hard to comply with all existing norms around accessibility, some products end up being a confusing pile of information which precludes usability.17 Access to inclusive packaging (e.g. eggs) may not be an issue; access to health-related products, on the other hand, is. At another economic scale, if manufacturers are not focusing too hard on functional requirements and standards, they are focusing on institutional demands for low-priced, robust, one-size-fits-all products.18


Human needs

Our reasoning up until now has revolved around human needs. Traditionally, needs were regarded in a hierarchical fashion, following Maslow's theory .19 Considering human needs within a framework of human development, Max-Neef20 has questioned Maslow's theory, proposing instead a matrix of intertwining needs (axiological and existential needs, in which the first are representations of the latter), whose priority changes in time and context. By placing axiological and existential needs in a matrix, intersections are created between each which can be filled with what the author calls satisfiers (Figure 1). So, this framework helps us pose questions such as, for instance, 'what do people need to have or do in order to achieve freedom or affection?'. We have found that having assistive products may indeed be a satisfier for many axiological needs, such as subsistence, protection, understanding or participation.21 In much the same way, inclusively designed products may act as satisfiers people might have at their disposal in order to fulfil axiological needs. These appropriately designed products (assistive and inclusive ones) may thus be the creators of opportunities and possibilities for people's enjoyment of freedoms.




Figure 1. Max-Neef's matrix of human needs and types of satisfiers.


This also implies looking at products not as ends in themselves but as means to an end. According to Max-Neef's framework, people might need assistive products in order to. Returning to Max-Neef's statement about development not being 'about objects', we are now in the position of better interpreting his argument which is in tune with Sen's vision: the sole provision of material resources will not guarantee individual freedoms, quality of life and development – these are merely instrumental. Beyond assistive products, people need qualities, actions and environments to fulfil each fundamental need as characterised by Max-Neef. Furthermore, these products need to comply with people's attitudes, values and expectations. In the case of assistive products, stigma is a well-known barrier to their acceptance and use.22 The simple fact that people who have scarce financial resources will be provided with an affordable assistive product will not guarantee that people will be willing to own and use it. People's needs are in relation to their goals and, sometimes, these goals might be conflicting (e.g. being independent vs. preserving self-image). Product design needs to account for all these variables.

Expanding on his matrix, Max-Neef has also proposed that there are five types of satisfiers and that, in some cases, those which seem to satisfy a need might, for instance, block the opportunity to fulfil a different need. Using Max-Neef's categories of satisfiers, we can now see that the example of the mobile phone discussed above falls into the category of inhibiting satisfiers, since it adopted a paternalistic approach to elderly people. The remaining categories of satisfiers are those of: violators or destroyers, pseudo-satisfiers, singular satisfiers and synergetic satisfiers. We argue for the adoption of the last within inclusive design, since these are the ones which by fulfilling one need help to fulfil others.


A wider picture

If applied to design, Max-Neef's framework would not only allow posing the right questions to the problems, but also help designers not lose track of the wider picture. This wider picture integrates functional and emotional requirements and combines different needs, but it also relates to inclusive development. In 2004, people from various sectors in the Latin American societies adopted the Rio Charter for Inclusive Design. The document refers to inclusive development in the following terms:

'We acknowledge the value of the emerging concept of Inclusive Development, which attempts to expand the vision of development, recognizes diversity as a fundamental aspect in the process of socioeconomic and human development, claims a contribution by each human being to the development process, and rather than implementing isolated policies and actions, promotes an integrated strategy benefiting persons and society as a whole. Inclusive Development is an effective tool for overcoming the world's prevailing social exclusion and thus for achieving progress in eradicating poverty.'23

The authors also found four main challenges to the adoption of these principles. The first of them was:

'How to apply the principles of Universal Design when there are people whose main concern is not "tomorrow", but the uncertainty as to their next meal ... or who lack housing and the most basic health care?'

So, this poses another challenge which has to do with the urgency in providing better and more suitable situations for people who are currently being prevented from fulfilling their fundamental needs and enjoying their freedoms. Again, needs, so construed, might change in time and in accordance to the context.

Inclusive development is a strategy for a more sustainable human development. Beyond product design it is also concerned with the use of appropriate and local resources, promoting employment and socio-economic development. But even though it might produce results in the long run, there will still be many people in the meantime at the end of the chain who lack urgent solutions to their daily challenges.


Beyond functionality

Marketing studies have shown that the user groups we have been addressing in this paper are not even homogeneous.24 One cannot predict individual needs, preferences or goals just by looking, for instance, at 'the elderly' as a singular category. Depending on each person's situation, issues vary and one should not engage in design from a starting point of pre-conceptions or stereotypes. If anything, one could look at wider themes which are common to all human beings, like quality of life, and provide for possibilities and opportunities in each case which will allow for that quality of life.

Pre-conceptions, stereotyping and labelling of people within pre-set groups have been previously reported to interfere in judgements about assistive products.25 When associated with a stigmatised group, assistive products may be rejected by consumers in general. But if the same product manages to escape from that association it may have the potential to thrive in the market, provided that it actually affords possibilities and opportunities for an enhanced quality of life.

If designers focus too hard on available knowledge about disabilities and consider people in terms of pre-determined user-groups, they will lose perspective on the wider scenario. The important issue is to determine what is currently preventing people with disabilities and elderly people from living independent and fulfilling lives.

For instance, it is known that, mainly due to difficulties in access to employment, people with disabilities are generally more economically disadvantaged than other groups26. This means that designing expensive products will not, in the end, help to solve their problems. If one is to think about the wider impacts of living with a disability, one could start looking into other issues, such as poverty or 'design for the base of the pyramid'. Stroke victims are generally elderly people, so one would start thinking about 'design for the elderly population'. Acquired disabilities and natural ageing decline can also prompt us to think in terms of 'design for health'. What would be a better approach to solving Mr J's problems?

There has been a proliferation of terms around design, like socially responsible design, design for the majority, sustainable design and others. In our view, these terms, including that of inclusive design, boil down to ethics and to keeping sight of the wider picture. Focusing on one aspect of product design, such as cost, usability or inclusivity in its traditional approach will always leave out other dimensions of human needs which are equally important. This implies considering the human person in all her dimensions, while keeping in mind human diversity as well.


Two parallel courses of action

If we are to look at individuals, this will entail a very cautious process. In our view, focusing solely on functional requirements is closer to a medical model of disability which is most likely obsolete in the 21st century.27 Nowadays, the WHO supports the use of a bio-psycho-social model, precisely to account for all human dimensions.

In 2004 the Council of Europe published a report about people with disabilities entitled 'Citizens not patients'. The medical view of people with disabilities and elderly people as being ill might have blurred our view about how we should approach these persons' 'individual needs, preferences, entitlements and circumstances'.28

The report further states:

'A country which is well managed will promote solidarity with, and empathy for, disabled people as fellow human beings, and there is a broad consensus that respect for human rights, integration and equal citizenship form the core of morally coherent policies. Universal rights and entitlements, such as to health care and benefits are one cornerstone of this commitment but service provision should then be designed to meet the needs of individual disabled people and their families and shaped by demand rather than offered as monopoly provision to everyone regardless of their needs or wants.'29

As stated by The Council of Europe report, thinking in terms of citizens rather than patients means acting towards citizens' empowerment where they can have a say and a choice in how to make use of products and services.

This approximation to citizens and, particularly, the approximation to individuals, might demand two parallel courses of action: one being a strategy which accounts for a wider picture based on ethics to improve people's quality of life, and the other a serious attempt to solve urgent needs which are blocking opportunities and possibilities, as those experienced by Mr. J. These, in our view, will forcibly rely on local courses of action designed in articulation with people themselves. There have already been theoretical models30 and attempts to engage in this local approach has had successful results31 which not only helped to solve urgent problems, but also helped to shed some light on what the wider strategy of inclusive development might be like.32

Despite being concerned with including as many people as possible, inclusive design might not suffice if it is to solely rely on the study of body limitations and what these entail for user-product interaction, and on grouping people into stereotypes. Portugal is within the so-called 'developed countries', yet our interviewees had an average monthly income of 375.8 €, were poorly educated and they often lived in social isolation. These conditions are preventing people from experiencing a better quality of life, and design is not being able to respond to these needs in an appropriate way. This is particularly appalling if we think that 40 years ago Papanek33 had already called attention to this design failure. In the meantime, people are still trying to make-do by themselves, as stated by another interviewee of ours, Mrs. A:

Mrs. A: You know? People having needs, needing this or that, they have to have ideas. They look over at one side, look over at the other and they see that they can only use that thing at hand for the intended purpose. (...) And this is how they take it.

Conclusion

While one cannot hope to change the system overnight, many people are facing unmet needs which urgently cry for solutions. Meanwhile, design could be looking at how to provide access to products and services not by casting affordable products at people, or focusing on institutional/wide market demands for that matter, but rather by understanding them in all the dimensions which make them human beings and taking these dimensions as design requirements. Thinking of design as instrumental and about products as a means to an end, to a higher-level end (meaning not only a task itself but also the possibilities and opportunities it allows for), might help start this process.


Acknowledgments

The author would like to thank the valuable help of the two anonymous reviewers who have helped make a more congruent final version, and especially to Anne-Marie Willis for her outstanding work and patience.




last modified 20120625