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The policy, hailed by researchers as “transformational,” will be fully in place by 2026 and make publicly financed research available immediately at no cost.

By Vimal Patel

Academic journals will have to provide immediate access to papers that are publicly funded, providing a big win for advocates of open research and ending a policy that had allowed publishers to keep publications behind a paywall for a year, according to a White House directive announced on Thursday.

In laying out the new policy , which is set to be fully in place by the start of 2026, the Office of Science and Technology Policy said that the guidance had the potential to save lives and benefit the public on several key priorities — from cancer breakthroughs to clean-energy technology.

“The American people fund tens of billions of dollars of cutting-edge research annually,” Dr. Alondra Nelson, the head of the office, said in a statement. “There should be no delay or barrier between the American public and the returns on their investments in research.”

Advocates for open-research access, like Greg Tananbaum, the director of the Open Research Funders Group, called the guidance “transformational” for researchers and the broader public alike. He said it built off a 2013 memorandum that was also important in expanding the public’s access to research but fell short in some areas.

The 2013 guidance applied to federal agencies with research and development expenditures of $100 million or more, about 20 of the largest agencies like the National Science Foundation and the National Institutes of Health. The guidance announced on Thursday covers nearly all federal bodies, a major expansion that includes about 400 or more entities, several experts said.

The directive also requires that publications be made available in machine-readable formats to ensure use and reuse, a component that open-access advocates hailed as a game-changer for accessibility.

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White House directs health, science agencies to make federally funded studies free to access

By Sarah Owermohle Aug. 25, 2022

T he White House on Thursday directed health and science agencies to make federally funded studies immediately available to the public after publication, a move that open-access advocates have long pressed for but one that threatens to upend the business models of scientific journals.

The guidance from the White House’s Office of Science and Technology Policy effectively ushers in a sea change in the publishing industry, which currently places many federally funded research papers behind a paywall for 12 months.

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While President Biden — and former President Trump before him — had long pledged to open access to federally funded research, the publishing lobby has argued doing so could spell the demise of scientific journals reliant on significant subscription fees to access embargoed papers.

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The White House has told US departments and agencies to make plans by the end of 2025 to release federally funded research papers free to the public on publication. The move has long been sought by President Joe Biden.

Information that will have to be made available to the public immediately when published includes the research paper itself, along with details about its authors, associated funding agencies, and data supporting the paper.

This information will now have to be made available as soon as the paper is peer reviewed for publication. Previous policy allowed such research to remain behind journal paywalls for a year after publication—in effect, a one year embargo before the public gained free access. 1

Alondra Nelson, head of the White House Office of Science and Technology Policy, said, “The American people fund tens of billions of dollars of cutting edge research annually. There should be no delay or barrier between the American public and the returns on their investments in research . . . When …

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Privacy and housing: research perspectives based on a systematic literature review

• Published: 18 March 2022
• Volume 37 , pages 653–683, ( 2022 )

Cite this article

• Priscila Ferreira de Macedo   ORCID: orcid.org/0000-0002-6623-469X 1 ,
• Sheila Walbe Ornstein   ORCID: orcid.org/0000-0002-5684-921X 1 &
• Gleice Azambuja Elali   ORCID: orcid.org/0000-0001-5270-4868 2  

5169 Accesses

9 Citations

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Grounded in psychological and social constructs, the need for privacy is reflected in human socio-spatial behaviour and in our own home. To discuss housing privacy, this article presents a systematic literature review (SLR) that identified theoretical and methodological aspects relevant to the topic. The research was based on consolidated protocols to identify, select and evaluate articles published between 2000 and 2021 in three databases (Web of Science, Google Scholar and Scielo), with 71 eligible articles identified for synthesis. The results showed a concentration of studies in the American, European and Islamic context, and the increase in this production since 2018. This was guided by the inadequacy of architectural and urban planning projects, by new forms of social interaction and, recently, by the COVID-19 pandemic. From a theoretical point of view, the SLR demonstrated the importance of investigating privacy in housing from a comprehensive perspective, observing its different dimensions (physical, social and psychological) and characterizing the issues involved and the context under analysis. Methodologically, the main instruments identified were: (i) to behavioural analysis, questionnaires, interviews and observations; (ii) to built environment evaluation, in addition to the previous ones, space syntax analysis, architectural design and photographs analysis; (iii) for the general characterization of users, the data collection regarding the socio-demographic and cultural context and the meanings attributed to spatial organizations; (iv) to characterize the participants of the investigations, the analysis of personality traits, the ways to personalize the space, user satisfaction/preferences and the influence of social interactions on these perceptions.

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1 Introduction

Understanding privacy, as a basic human need inserted in a psychological and social concept, implies delving into discussions related to different fields of knowledge, especially in studies related to behaviour and its forms of expression in the built environment. In this field, since the separation of public and private, started in the seventeenth century and consolidated in the beginning of the twentieth century, the house has been understood as the core of private life, offering the prospect of family interaction and guaranteeing privacy for the individual.

In view of this, several studies have emerged to conceptualize and identify the factors associated with privacy as a phenomenon to be carefully investigated, whether about the theories that support the concept (Altman, 1975 ; Hall, 2005 ; Warren & Brandeis, 1890 ; Westin, 1967 ), or the current reviews on the topic (Burgoon, 1982 ; Dienlin, 2013 ; Leino-Kilpi et al., 2001 ; Magi, 2011 ; Margulis, 2003a , 2003b , 2011 ; Solove, 2006 ; Westin, 2003 ). However, there is still a small number of specific studies on the problem regarding the privacy needs of users in their homes, although various studies have drawn attention to the users' dissatisfaction in terms of home related privacy issues, such as those carried out in Brazil by Kowaltowski et al. ( 2006 ), Mendonça ( 2015 ), Reis and Lay ( 2003 ), Villa ( 2008 ) and Zago and Villa ( 2017 ).

Such problems became even more evident at the start of the coronavirus pandemic (Coronavirus Disease—COVID-19), especially in small sized apartments, which due to the available space, have restricted carrying out daily activities, particularly in relation to larger families occupying this space. The increase of the severe acute respiratory syndrome of the coronavirus 2 (SARS-CoV-2) required adopting measures to prevent and control the spread of the virus (Dietz et al., 2020 ), such as the known “quarantines”, advocated by the World Health Organization (WHO), which emphasized the importance of social distancing between individuals. Different countries have adhered to these measures by suspending classes and face-to-face work (replaced by remote activities) and restricting access to non-essential activities (such as bars, restaurants, beaches and shopping malls.)

The sudden use of full-time housing (or almost) has prompted the mainstream media and the real estate market to address the impacts of the built environment on housing and on people's quality of life, many of which have emphasized aspects related to mental health and environmental comfort, including issues related to privacy and different forms of sociability (Fragoso, 2020 ; Garber, 2020 ; Garcia, 2020 ; Hipwood, 2020 ; Jornal Nacional, 2020; Kornhaber, 2020 ; Lampert, 2020 ; Moraes, 2020 ). In the academic context, discussions about the relationship between the pandemic and the built environment also increased, with arguments regarding, among others, urban insertion, densities, presence of green areas, housing dimensions and spatial organization (Avetisyan, 2020 ; Barbosa & Neis, 2020 ; Cunha, 2020 ; Dietz et al., 2020 ; Elali, 2020a , b ; Grupo [MORA], 2020; Hosseini, Fouladi-Far & Aali, 2020; Keenan, 2020 ; Megahed & Ghoneim, 2020 ; Tendais & Ribeiro, 2020 ).

In the domestic space, the new reality has changed the forms of sociability inside and outside the home (Nguyen, 2020 ), indicating greater contact between members of the house/family and interaction through non-face-to-face means with those who are outside (neighbourhood/society). As a result, the problems of privacy in the daily lives of families have become even more evident, especially those associated with the lack of space (Merino et al., 2021 ), the ways of negotiating the use of spaces and the division of time (Mcneilly & Reece, 2020 ; Pasala et al. 2021 ) in new domestic activities, such as: work, education and physical activity (Bezerra et al., 2020 ; Goldberg, McCormick & Virginia, 2021 ; Silva et al., 2020 ) and the perceptions of stress, anxiety and solitude (Benke et al., 2020 ; Buecker et al., 2020 ; Gaeta & Bridges, 2020 ; Losada-Baltar et al., 2020 ; Soga et al., 2020 ; Takashima et al., 2020 ).

In view of the dissatisfactions and the worsening of domestic problems due to the pandemic context and starting from a broad notion of privacy that involves human socio-spatial behaviour Footnote 1 (especially aspects related to territoriality, Footnote 2 personal space, Footnote 3 crowding Footnote 4 and solitude, Footnote 5 the theoretical and methodological aspects of the environment and behaviour, which are relevant to the assessments of the housing space, were investigated. To this end, a Systematic Literature Review (SLR), using bibliometric techniques was carried out on the subject. To present this work, this article begins with a return to the concept of privacy in order to support the discussion; then the details of the method used are reported; continuing with the main results obtained by SLR and its brief discussion.

2 Privacy concept: a look at previous reviews

Academic discussions on privacy gained relevance at the end of the nineteenth century, with the publication of the article The Right to Privacy , by jurists Samuel Warren and Louis Brandeis (1890), when privacy came to be understood as a fundamental right to be preserved. Since then, the concept has been discussed by different areas of knowledge and, despite the evolution of the processes, functions and perceptions that involve privacy, the concepts proposed by Alan Westin ( 1967 ) and Irwin Altman ( 1975 ) continue to stand out as the core of contemporary theories on the subject.

Westin ( 1967 ) defined privacy as the right of individuals, groups or institutions to determine when, how and to what extent their information can be communicated to others. In this regard, the author argued that people would continually be involved in a personal adjustment process to balance their desire for privacy with their desire for disclosure and communication with others; these desires vary both in relation to the scale of need (individual, family group or society), as well as the desired state (solitude, intimacy, anonymity and reserve). For him, the adequate regulation of privacy would combine the three scales with the four desired states, allowing the individual to achieve the goals of self-realization and (intra) psychic balance.

As a primary environmental phenomenon, the privacy was also interpreted by different relevant scholars. Simmel ( 1971 ) stated that privacy is associated with the boundaries around ourselves and also by a periodic opening of these boundaries to personal learning and to intimacy. Sommer ( 1973 ) discussed privacy from the concept of the personal space, or the imaginary space bubble area around individuals which communicate desired levels of interaction and protect individual from outside intrusion, which if entered by another person without agreement, implied on a privacy violation. Pedersen ( 1979 , 1997 ) relying on Westin’s states of privacy, identified another two states of privacy and classified it into: solitude, isolation, anonymity, reserve, intimacy with friends and intimacy with family. Wolfe ( 1978 ) linked privacy to choice and control, and defined it as the ability to choose how, under what circumstances, and to what degree an individual relates or does not relate to another. Sundstorm et al. ( 1996 ) found that privacy regulation theory, which included spatial behaviour, crowding and territoriality, suggests a human tendency to seek social interaction partly through use of the physical environment, as many coping behaviour relies on the physical setting (boundaries demarcation).

From the perspective of Environmental Psychology, according to Gifford et al. ( 2011 ), researchers work at three levels of analysis: (i) fundamental psychological processes, like perception of the environment, spatial cognition and personality, as they filter and structure human experience and behaviour, (ii) the management of social space, as personal space, territoriality, crowding, privacy and the physical setting, and (iii) human interactions. From this perspective, Altman ( 1975 ) defined privacy as a dialectical process of regulating interpersonal barriers, varying in relation to time, context, length of contact, and the receiver of the interaction (groups or individuals), with a desired ideal level. For the author, the definition of the desired levels is based on previous experiences and is part of the cognitive process of individual development, so that the ability to control interactions would be closely related to self-development and vice versa. Through an in-depth study of concepts such as permeability of barriers, territoriality, personal space, crowding and solitude, the author presented the mechanisms and behaviours related to the regulation of privacy and the consequences of failures in this system.

Considering the various contemporary views on social interactions and privacy, several studies have been reviewed, compiled and systematized the issues associated with the theme, with the following emphasized by: Leino-Kilpi et al. ( 2001 ), Margulis ( 2003a , 2003b , 2011 ), Westin ( 2003 ), Solove ( 2006 ), Magi ( 2011 ) and Dienlin ( 2013 ). As they promote updating the concept and create different privacy classifications, some of these reviews are briefly presented below.

Leino-Kilpi et al. ( 2001 ) reviewed the literature on the relationship between privacy and the hospital environment. Based on the seminal concepts, they presented ways of approaching privacy and included other theoretical contributions, as the Burgoon model ( 1982 ), based on how they indicated two viewpoints for investigating the subject: a) the perspectives on the concept—which involves social interactions, the level of privacy desired and obtained, and control over communication and information; and b) the privacy dimensions – physical, psychological, social and information.

Also reflecting what was observed in the literature, the authors highlighted the four dimensions for the phenomenon: i) physical—represents the degree of physical accessibility from one person to another; ii) psychological—addresses the human cognitive and affective process and its capacity to form values (associated with the self); iii) social—skills and efforts to control social interactions with a strong cultural connotation, and related to human socio-spatial behaviour, particularly to proxemics Footnote 6 patterns (Hall, 2005 ), states of privacy (Westin, 1967 ) and their control (Altman, 1975 ); iv) information – the right to determine how, when and to what extent information is available to the other or others (Westin, 1967 ).

Margulis ( 2003a , 2003b , 2011 ) reviewed privacy with regard to the evolution of the concept of Westin's ( 1967 ) and Altman's ( 1975 ) theories. The author presented privacy as being “ an abstract skeleton ” of meanings and functions, which implies the definition of access barriers to the individual or group and social and cultural expressions, including those that are not as obvious, such as social power. Regarding the functions of privacy, he stated they reflect its purposes and benefits, appearing as a basis for personal development (formation of the self) and interpersonal relationships. The author also emphasized the dominance of European and American views, which normally emphasize privacy issues. Finally, he pointed out that studies that intend to use behavioural theories about privacy, must determine whether the existing definitions meet their objectives, warning that they must also include social, environmental, cultural, and social-developmental factors.

Westin ( 2003 ) reviewed the protection of informational privacy, in the light of political-social relations, the evolution of technology and the existing legislation. Regarding the proposed conceptual updates, he reaffirmed privacy as a basic need for human life and an individual right to decide what information should be revealed to others, also ratifying the four privacy states developed by him in the 1960s. Faced with a scenario marked by the excessive use of information technologies, with high data storage capacity, the author emphasized that managing personal states of privacy (from healthy solitude to the intimacy of positive self-disclosure) and balancing democratic forms of access to personal data (in a globalized world with threats coming from encrypted systems) will be the greatest challenges for citizens and governments.

Solove ( 2006 ) reviewed privacy from the perspective of activities that can affect it, identifying what they are, how and why they can cause problems or non-trivial damage to people's lives and well-being. The author validated the concept of privacy as an inherent quality of life in society, and which holds a multiplicity of meanings, varying between individuals and contexts. Based on identifying the problems related to privacy and socially recognized in the legal sphere, the author identified the existing connections and divergences between the different privacy problems, understanding what was essential in people's perceptions of privacy and which, therefore, could not be violated.

Magi ( 2011 ) reviewed the literature on privacy in the social and human sciences, in order to identify its inherent benefits. Based on this review, privacy is relevant to the scale of the individual, interpersonal relationships and society. According to the author, the benefits of privacy are reflected in: i) protection against overreached social interaction, affirming individual autonomy, freedom of choice, ability to control interactions and make judgments; ii) possibility of individual redemption, with the development of self-confidence and preserving interpersonal relationships; iii) support for a more just, democratic and tolerant society. Regarding the concept, she considered that privacy should be used as a general term (umbrella) to describe a set of other concepts that are interrelated with various behaviours and that depend on the culture studied.

Dienlin ( 2013 ) reviewed the concept of privacy associated with communication processes and social network sites. By combining different understandings, he defined privacy as a degree of separation from others (Warren & Brandeis, 1890 ), which can be characterized by different states (Westin, 1967 ), by a continuous adjustment of individual barriers (Altman, 1975 ), which occur in four different dimensions (Burgoon, 1982 ). From this perspective, he proposed that privacy should be analysed in relation to the context, the perception of individuals, the behaviour and the available forms of regulation and control.

The results of the review revealed that studies on privacy must consider: (i) the socio-cultural and political context in which the study population is inserted (Dienlin, 2013 ; Hall, 2005 ; Margulis, 2011 ; Westin, 2003 ), the functions of privacy (Altman, 1975 ; Magi, 2011 ; Westin, 1967 ) and the privacy dimensions (Burgoon, 1982 ; Dienlin, 2013 ; Leino-Kilpi et al., 2001 ); (iii) the definitions and demarcations of territorial boundaries and personal space (Altman, 1975 ; Hall, 2005 ); (iv) the types of privacy violation issues (Altman, 1975 ; Solove, 2006 ; Westin, 2003 ); (v) perceptions of solitude and crowding (Altman, 1975 ; Hall, 2005 ; Westin, 1967 ). The results also reinforce the relevance of the research by Altman ( 1975 ) and Westin ( 1967 ), reaffirming that their ideas have stood the test of time.

Actually, the literature shows that find a closed concept of privacy is still far from being achieved as it involves multiples viewpoints (as seen: nursing, political sciences, law), varied context (social, political, demographical, informational) and complex social interactions. Despite this, the different viewpoint of the literature also revealed some relations on privacy that must be considered in any study of the theme. When addressing privacy, we are probably also talking (directly or indirectly) about interpersonal boundaries and their demarcation, territoriality, personal space, intimacy, proxemics patterns and perceptions of solitude and crowding. In turn, such phenomena are expressed by the physical environment, by the cultural, social, demographics and political context, and by the personality traits and individual behaviours. Having reverberation in problems and invasions of privacy, availability of regulation mechanisms and control, and similar situations, these different facets of the question could be revealed by the dimensions of privacy (to be selected in function of the objectives of each study).

Linking those findings with the environmental point of view, this research focuses privacy in a human socio-spatial behaviour perspective, that must involves: (i) the physical dimension, expressed by the elements of physical space, personal space and territoriality; (ii) the psychological dimension, indicated mainly by personality traits, behaviours and perceptions of individual, especially those related to solitude and crowding; (iii) the social dimension, represented by the management of social space, including proxemics patterns, culture, social, demographics and political context, social interactions, control, coping strategies; (iv) the informational dimension, corresponding to the right to determine how, when and to what extent information is available to the other or others.

Based on this understanding, authors such as Newell ( 1995 ), Petronio ( 2002 ), Margulis ( 2011 ) and Dielin (2013) comment on the emergence of several models for the study and understanding of privacy, some centred on physical space, others centred on people's behaviour and, still, those that prioritize the relationship between the two. In the first perspective, privacy is usually discussed in terms of its visual and physical elements. The second perspective involves a personal and a synesthetic perception (Hall, 2005 ). The third perspective seeks to address privacy in a comprehensive sense since it involves an imbricated relation between physical space, psychological perceptions and social relations and interactions. In this last view, our research chose and adapted the Burgoon model (1982) to our goals, as the model fitted on a socio-spatial behaviour perspective.

To understand the state of the art about the phenomenon of housing privacy, the SLR was carried out, using bibliometric techniques. In order to clarify the selection criteria of articles, the method is based on two references: (i) the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), developed by Moher et al. ( 2009 ); (ii) the Sample, Phenomenon of Interest, Design, Evaluation, Research Type (SPIDER), developed by Cooke et al. ( 2012 ).

The PRISMA diagram quantifies the selected articles and is divided into four stages: 1) identification – selection of databases and initial search of key words; 2) screening – definition of exclusion criteria and selection of article by titles and abstract; 3) eligibility – definition of inclusion criteria and identification of papers of interest by reading full article; 4) included—presents the works chosen for the qualitative and quantitative syntheses (meta-analysis).

The SPIDER tool, in turn, proposes the systematization of qualitative syntheses in the form of a table with information on: the sample, the phenomenon of interest, the research design (methods), the evaluation measures and the research type. Due to the subjective and contextual nature of the research theme, some information was also included, as the: journal that published the paper, the research’s objectives and the geographical location of the sample. Furthermore, in order to align the research with the context of existing reviews, the phenomenon of interest used on the SPIDER tool, have been converted into the four dimensions of privacy from Burgoon model ( 1982 ).

The objective of this SLR (Table 1 ) was to identify the theoretical and methodological aspects relevant to housing privacy, and their relationship with human behaviour and the built environment. In this regard, the questions answered were of a conceptual and methodological nature, namely: (1) Which dimensions are relevant to understand the phenomenon of housing privacy? (2) What aspects of the built environment and human behaviour were used to have privacy in the home? (3) What research methods and approaches were used to investigate housing privacy?

The English and Portuguese languages were defined as search criteria and the main database chosen was the Web of Science. Since it mainly contains publications in the English language and, as a consequence of the specific interest in the Brazilian reality, the search for articles in the Portuguese language was also carried out on the Google Scholar and Scielo platform.

As the nature of the investigation involves the intersection between the themes of housing and privacy, the searches were carried out by combining the keywords related to each theme. For the Web of Science database, the keywords for each theme were searched by the Boolean operator “OR”, with the combination of the terms related to “housing” and “privacy” made by the Boolean operator “AND”. The keywords were searched in the “TOPIC” field, including the search by title, abstract, author's keywords and keyword plus. Searches for articles in Portuguese were carried out by searching the keywords related to “habitação” and “privacidade” ( “housing” and “privacy”) with a Boolean operator “ E ” (AND). In Scielo, the option “All indexes” was used, whereas in Google Scholar, as it is a very comprehensive search engine, the search was restricted by “title” (Table 2 ).

The identification, screening and eligibility stages were executed considering the searches carried out on the Web of Science, and it was decided to include the results of Google Scholar and Scielo searches as manual additions in the included stage. Other publications, from the references cited by the selected articles, of prior knowledge, as well as articles related to COVID-19, were also included in the diagram as manual additions.

In the first search, Footnote 7 carried out on the Web of Science database with the combination of keywords, 40,933 results were identified, which reveals the scope of the theme. To obtain relevant data in the screening stage, results were filtered by related areas, namely: architecture, environmental sciences, environmental studies, behavioural sciences, family studies, psychology (development, multidisciplinary or social), social problems. With this restriction, 1,060 articles were selected and their titles and abstracts were read to screening stage.

After that, the exclusion criteria were defined (Table 3 ), indicating the non-incorporation of papers that the object of study were not related with home environment (such as offices or hospitals) or were not related with our main goal (such as territorial planning, energy efficiency, clinical psychology).

Finally, inclusion criteria (Table 3 ) were defined. Criteria to selected one paper as part for our study were: (i) have been produced since the 2000s; (ii) had samples related to urban housing; (iii) had clear methodological instruments related to the built environment or user behaviour; (iv) had the related themes (privacy, territoriality, personal space, crowding and solitude) as the main objective, and not only as one of the criteria of analysis or evaluation.

After defining the inclusion criteria of the 58 articles listed in the eligibility stage, 50 articles were selected for the included stage, to which the articles in the manual additions were added (Fig.  1 ).

Adapted from: Moher et al. ( 2009 )

PRISMA flow diagram.

The Brazilian articles (7 articles), articles in English related to the COVID-19 pandemic (6 articles) and the others cited in publications (8 articles) were included in the SLR as manual additions, totalling 21 additions. At the end of the full reading, 71 articles were selected for quantitative and qualitative synthesis (Fig.  1 ).

4.1 Qualitative synthesis

To facilitate the data collection and to understand the concepts and variables that involve housing privacy, the articles included were separated into four key themes, namely: privacy, territoriality and personal space, Footnote 8 crowding and solitude.

For the qualitative synthesis, the articles of each theme were systematized in tables, originated by the SPIDER tool, which contained information about the journal, authors, year of publication, title, objective, geographic location of the study, studied sample, privacy dimensions, research design (methods), evaluation measures and type of research, as seen in the example (Table 4 ).

The systematization of articles in the tables revealed a variety of studies in different journals and in geographic regions of the planet. The objectives of the studies addressed different natures, with approaches in different scales of coverage such as: individual perception or internal organization of the house and neighbourhood. The samples were also quite variable depending on the cultural context or subjectivity of the topics covered, including qualitative studies with a sample of two families or quantitative studies with more than a thousand participants.

Although most publications focus on a specific theme, in many cases there was an intersection between them, whether related to privacy and personal space, through the assessment of personal objects, or between the correlations of crowding perceptions and levels of user satisfaction with their privacy, for example.

Regarding the privacy dimensions, the physical dimension was largely identified by discussions about spatial organization, architectural elements, Footnote 9 housing typology, neighbourhood, density and personal objects. The social dimension by social interactions, accessibility hierarchy, culture, control, spatial boundaries and coping strategies. Finally, the psychology dimension was recognized by user satisfaction and preferences, stress, meaning of home, social support and personality traits.

Regarding the methodological instruments, in general, the studies sought to capture the users' perception and the specialists’ technical impressions on the environments. The surveys were mostly qualitative, with the combined use of two or more instruments, such as: document analysis, Footnote 10 direct and indirect observations (with capture or analysis of photographs), questionnaires, interviews, focus group, analysis of architectural designs, space syntax analysis and others.

Finally, as regards the evaluation criteria, the studies sought to identify the residents data (social, demographics or both), user satisfaction or preferences, the layout of the spaces and its implicit social relations, distribution of the architectural elements (doors, windows, green areas, etc.), housing density, domestic activities, visuals, smells, noises and objects perceived as relevant by residents, site plan, territories and physical characteristics of the neighbourhood, social interactions (between family, neighbours, visitors or passers-by) inside and outside the houses, personality traits and the levels of control, stress and solitude.

4.2 Quantitative synthesis

The quantitative synthesis of the selected articles sought to demonstrate the general outlook of empirical studies on the subject of housing privacy from the 2000s to the present period. Considering the key themes of the 71 publications, it is observed that (Fig.  2 and Table 5 ): 27 are about privacy (38%), 14 about territoriality and personal space (20%), 14 about crowding (20%) and 16 about solitude (22%).

Publications (in %) by key theme chart (total articles: 71)

Regarding the periodicity (Fig.  3 ), it was decided to use three-year bands Footnote 11 to visualize the frequency of publications by key theme. Discussions about housing privacy, which declined at the beginning of the period (between 2003 and 2008), started to increase after 2012 and are more pronounced in the current period.

Publications per year on key topics (total articles: 71)

The larger production in the early 2000s coincides with the spread of computers and effects on individual perceptions resulting from their use. The period after 2008, and especially since 2012, is consistent with the consolidation of social networks by cell phones and with the expansion of discussions on the protection of personal data, which, despite dealing particularly with the internet, also resonate in daily activities and, consequently, in the home and in the privacy of users.

In the studies from 2018 onwards, the greatest publication period of articles, the themes about crowding, territoriality and personal space are equivalent or surpass those of privacy, a trend that may indicate greater concern regarding the perceptions and demarcations of individual boundaries. The impact of the COVID-19 pandemic period is emphasized in the 2020 and 2021 studies that focus more on the theme of solitude, revealing that this may have been the main challenge encountered by people at home, the quarantine period—a trend that could be accentuated in 2021.

Regarding the data sources, 51 journals were identified, of which 20 were in the area of psychology and 16 in the area of architecture, urbanism and design. Despite the relevant number of journals, 41 present only one published article, while the other 30 articles were published among 10 journals (Fig.  4 ). Although there is a dominance of publications in two journals in the field of psychology, the theme is increasingly relevant in specific journals in the area of architecture, urbanism and design (Fig. 4 ).

Total articles by relevant journals (total articles: 30)

Total articles by countries and key theme (total articles: 71)

Regarding the geographical context (Fig. 5 ), discussions on privacy were found in 25 different countries and another 5 in cross-cultural contexts. The countries with the most published articles were: USA (18), Brazil Footnote 12 (7), Spain (5); Iran (5), United Kingdom (4), Malaysia (3), Japan (3), Iraq (2), Turkey (2) and China (2). The other countries presented 1 publication each.

Given the diversity of countries, the relationship between the approaches given to each key theme and the region where the studies are inserted are noteworthy. The correlations between countries and themes were drawn by cultural similarity, to the detriment of continental division, given the importance of culture related to privacy issues. In this perspective, the countries that dealt with Islam, were grouped as Islamic countries, while Mexico was incorporated into South and Central America. The regional context was divided into: Latin America, Anglo-Saxon America, Europe, Africa, Islamic Countries, Asia and Oceania.

Islamic and Asian countries focused their discussions on the key theme of privacy, probably due to the religious and social importance the phenomenon can assume in the daily life of this culture. Specifically, in the Asian context, there are also studies on solitude in Japan, which may indicate greater westernization in the country. Anglo-Saxon and European countries focus their discussions on the problems of privacy, highlighting crowding and solitude. In Europe, studies on territoriality and personal space are also relevant. Brazilian studies primarily deal with privacy inside the homes and aspects of territoriality, with current studies addressing solitude, the Nigerian studies mention crowding, and the Australian studies mention solitude. However, the sample is limited to trace cultural trends in the discussions of these situations. Finally, cross-cultural studies deal mainly with differences in perceptions of privacy when nationalities or ethnicities differ.

The dimensions of privacy were also correlated to the key themes (Table 6 ). In the privacy-oriented texts, the social and physical dimensions predominated, with less relevance for the psychological dimensions. In turn, due to the nature of the concept, all texts on territoriality and personal space addressed the physical dimensions, with an emphasis also on the psychological dimension and, finally, the social dimension. The psychological dimension predominated in studies on crowding and solitude, indicating its intrinsic condition to both concepts. The articles about crowding also emphasized the physical dimension, with some emphasis on the social dimension, while those related to solitude emphasized the social dimension, with the physical dimension being less relevant. Finally, the information dimension was not relevant to any of the key themes and was observed in only 2 studies (Cetkovic, 2011 ; Chan, 2000 ).

With regard to the criteria and evaluation measures (Table 7 ), 19 variables were identified with four or more occurrences in the total of studies surveyed: spatial organization, architectural elements, neighbourhood, density, personal objects, housing typology, social interactions, culture, hierarchy of accessibility, domestic activities, control, boundaries demarcations, coping strategies, user satisfaction, user preference, stress, meaning of home, social support and personality traits. The other variables, which appear in three studies or less, were not listed.

The main items evaluated (Fig.  6 ) in the physical dimension were: spatial organization (27%), architectural elements (17%), neighbourhood (14%), density (14%), personal objects (11%), housing typology (6%). In the social dimension they were: social interactions (27%), culture (21%), hierarchy of accessibility (17%), domestic activities (11%), control (11%), boundaries demarcation (6%), coping strategies (6%). In the psychological dimension they were: user satisfaction (24%), stress (15%), user preference (13%), meaning of home (10%), social support (8%) and personality traits (8%).

Main evaluation measures (in%), by privacy dimension (total articles: 71). Note Each article can have more than one measure

Finally, the research instruments used were highlighted to identify the methods and techniques used in the field of research on screen. 27 different instruments were identified (Fig.  7 ), the most relevant being: questionnaire (54%), interview (25%), observations (17%), space syntax analysis (13%), document analysis (11%), analysis of photos (8%) and analysis of architectural design (7%).

Main instruments (in%) used in housing privacy surveys (total articles: 71). Note Each article can have more than one instrument

The use of focus groups (6%) and image cards (4%) were identified but with less relevance, while 18 other instruments (25%) such as walkthrough and DNA collection appeared in only one or two articles.

5 Discussion of results

The SLR carried out showed that the housing privacy studies published between 2000 and 2021 focus mainly on the physical, psychological and social dimensions of the phenomenon, and that the information dimension is not relevant to the discussions found. Regarding the key theme of privacy, the physical and social dimensions stand out, revealing greater influence from aspects beyond the individual and linked to culture. For the key themes of territoriality and personal space, the physical and psychological dimensions predominate, demonstrating greater proximity to the self and the individual needs for personalized spaces and sense of belonging. In the case of crowding, the physical and psychological dimensions were also more relevant, especially focusing on the influence of space on users' satisfaction and stress. Finally, in studies on solitude, the social and psychological dimensions predominated, revealing the influence of domestic activities and social interactions on the perceived social support, user satisfaction and stress.

With regard to aspects relevant to the discussion about housing privacy, the studies raised showed they are related to links between human behaviour and the built environment, and must recognize, among others: the meanings of home and privacy of residents, their cultural and personality traits, relations with the family and neighbours; users preferences, satisfaction and expectations regarding the house where they live and the one they would like, the layout of the design attributes and available control resources; the spatial organizational of the house and domestic activities, the personal spaces and objects, the existing territories and neighbourhood; the type and frequency of privacy invasions and the coping strategies adopted by users to protect it, the level of stress, crowding and solitude that can be perceived in their homes.

Regarding the methods and techniques used to investigate housing privacy, the material analysed emphasized the users' perspective, with higher recurrence of using questionnaires and interviews, followed by in loco observations. The instruments used to assess the built environment were also relevant in the samples analysed and, in addition to those mentioned, consisted of technical analysis of architectural designs and photographs and of space syntax analysis. The other instruments were used for more specific purposes and varied according to the objectives of each study.

On the key theme of privacy, mainly questionnaires, interviews, analysis of architectural designs and space syntax analysis were used. The questionnaires and interviews highlighted topics related to socio-demographic data, user satisfaction and preferences, their concepts of home and privacy, and their perceptions about spatial organization of the house and its architectural elements, the invasions of privacy, available facilities (mechanisms regulation) and associated behaviours, family relationships and daily activities. The analyses of architectural designs, photographs and space syntax analysis, in turn, addressed privacy related to the possibilities of physical or visual access to spaces, expressed by the spatial organization, layout of the design attributes and the existing accessibility hierarchies.

On the topic of territoriality and personal space, the most used instruments were questionnaires, observations and interviews. For territoriality, the studies dealt primarily with the neighbourhood scale, with assessments of demarcation and control of territories and the resulting sense of belonging. The personal space assessments addressed the housing interior design, with questions and observations related to characteristics of the individuals and their ways of personalizing the spaces.

With regard to crowding and solitude, the questionnaires were more frequent, and an interview with open-ended questions for evaluations on these themes was identified in only one study (Ruiz-Casares, 2012 ). Regarding crowding, the questionnaires were related to the level of stress, the size and density of the home or specific rooms, especially addressing the internal characteristics of the dwellings and satisfaction of users. Regarding solitude, the questionnaires presented little association with the physical aspects of the home, containing questions more associated with feelings of solitude and social isolation (stress, anxiety and depression), and with perceptions of social support of the family and the community.

Regarding the geographic location of the studies analysed, the results found reinforced Margulis' point about the European and American predominance in privacy-related research (Margulis, 2003a , 2003b , 2011 ). American studies lead the discussions on all the topics considered, with a total of 18 publications, more than double of the country, in second place, in this case Brazil, with 7 studies, followed by Spain and Iran, both with 5 articles. It should be noted that the relevance of Spain has grown with recent studies on the impacts of the COVID-19 pandemic.

The growing discussion about privacy in the context of Islamic housing should also be highlighted. Over the last decades, intensified globalization inserted the western housing design model in these contexts, causing discrepancies between the desired privacy, based on religious customs, and that obtained, expressed by the organization of the Western house. In other words, the physical dimension of privacy does not reflect the social and psychological dimension desired by users. Also on the privacy dimensions, we saw that studies on housing privacy focus on the physical, psychological and social dimensions, with the need to also include the social and/or economic data of residents (Dienlin, 2013 ; Margulis, 2003a , 2003b (a), (b), 2011; Westin, 2003 ).

In housing studies, the privacy problems were addressed by levels of satisfaction, by questions about the types of privacy issues and inconveniences faced, about where and when invasions took place, or about what the ideal home would be like. Thus, it is observed that Solove's ( 2006 ) legal view that understanding privacy protection includes identifying and characterizing the problem is also valid for discussions on housing privacy. Regarding the relationship between the use of technology and impacts on privacy (Westin, 2003 ), only two studies (Cetkovic, 2011; Stepanikova et al., 2010 ) address the theme of using automation or time spent on the internet for housing-related discussions, revealing a gap in the studies about the relationships between technology, privacy and ways of living.

Regarding behaviours, research on housing privacy reinforces contemporary assumptions (Dienlin, 2013 ; Magi, 2011 ; Solove, 2006 ) that users' behaviours vary according to contexts and perceptions of privacy. This is expressed by variations in the hierarchies of accessibility to the environments, by the different meanings of home and privacy associated with the cultural practices and perceptions of the users, but especially by the variations of thematic approaches by region. In Islamic and Eastern countries, it is important to discuss privacy as an essential concept for the formation of society, and it is important to address the means to keep it protected inside the houses or families. In the European and American contexts, on the other hand, it is relevant to understand it from the perspective of individual needs, discussing the consequences of when it is violated, whether in the sense of feeling crowded or isolated.

The benefits of privacy, raised by Magi ( 2011 ), were considered mainly in the introduction of the studies, but not very relevant as evaluation measures. Only in comparative studies on traditional and modern houses or on the addition of space control items, questions related to the benefits that privacy can provide were evaluated in the application of methodological instruments.

Corroborating previous reviews in this field and reinforcing the subjectivity involved in its study, the results of the SLR carried out reaffirm the need to discuss the topic of housing privacy:

Consider a comprehensive perspective, with aspects that involve the social dynamics of the context where housing is inserted and the residents’ individual perceptions (Altman, 1975 ; Dienlin, 2013 ; Hall, 2005 ; Margulis, 2003a , 2003b (a), (b), 2011; Solove, 2006 ).

Include social and demographic factors (Altman, 1975 ; Dienlin, 2013 ; Hall, 2005 ; Margulis, 2003a , 2003b (a), (b), 2011; Solove, 2006 ; Westin, 1967 ), considered as evaluation criteria in all studies that use questionnaires and interviews.

Highlight the privacy role in the development of culture (Dienlin, 2013 ; Hall, 2005 ; Margulis, 2011 ; Westin, 1967 e 2003) and in the human cognitive and affective processes, especially those associated with individual development and communication modes, perceiving and revealing the social environment in which residents are inserted (Altman, 1975 ; Burgoon, 1982 ; Dienlin, 2013 ; Leino-Kilpi et al., 2001 ; Margulis, 2003a , 2003b , 2011).

In addition to alignment with previous reviews, the findings of this research advance in relation to existing studies, bringing as contributions the discussions on housing privacy:

Identifying the importance of the meanings of home, family, neighbourhood (neighbours, neighbourhood features and social support), spatial organization (including its architectural elements and domestic activities), as well as its hierarchy in terms of accessibility, and the satisfaction and preferences of users.

The ever-expanding concern with issues of social isolation due to the pandemic, an essential dimension to understand contemporary times, especially in view of the current multifunctionality assumed by housing.

Clearly demonstrating the recent increase in the interest on privacy as a research topic.

This is, therefore, an open field for new studies, which may expand understanding privacy in the context of housing and increase the consistency and comprehensiveness of these approaches for the housing context.

6 Conclusion

Due to the research criteria, most studies found by conducting the SLR address the privacy key-theme, with productions on territoriality and personal space, crowding and solitude that have almost equivalent quantities of publications, which demonstrates relevance parity between the themes. Regarding temporal terms, there has been a recent increase in studies on crowding and solitude. On the one hand, the growth of studies on crowding may reflect the low quality of housing spaces, which, due to poorly dimensioned internal spaces, inadequate urban insertions or not being culturally adapted to the context of residents, increase the perceptions of users’ stress and dissatisfaction. On the other hand, the growing interest in the topic of solitude seems to be a consequence of new forms of social interaction, associated with digital media and the pandemic.

Regarding the areas of knowledge in which these articles were published, journals in the field of psychology were the most recurrent, although there is an increasing participation of journals in architecture, urbanism and design, especially in the key themes associated with the physical dimension (privacy, territoriality and personal space). This demonstrates that the issue of housing privacy is an expanding approach for the area – which justifies the interest in SLR.

The results obtained also suggest that although the concepts of privacy, territoriality, personal space, crowding and solitude have been widely discussed and conceptualized in different areas of knowledge. Although they are still far from being exhausted as an object of study in discussions about housing, given the subjective characteristics that surround them and the contextual nature of the application of results, which prevent broad generalizations or design recommendations applicable to different contexts.

The SLR on housing privacy has shown it is vital these types of studies evaluate both the context in its broadest form, raising data on the socio-demographic and cultural context of users, and the social meanings attributed to existing space organizations, as well as on the scale close to the individual, evaluating their personality traits, their forms of personalization, their satisfaction and preferences and the influence of social interactions and physical attributes on these perceptions.

It is also important to highlight the limitations of the study. The first refers to the database chosen, only one for studies in English and two for texts in Portuguese. The inclusion of more databases (in relation to the Brazilian context, for example), can expand discussions on the themes, allowing more consistent conclusions on these fields or on the cultural differences of the approaches by countries. Another limitation concerns the type of publication. In this study, we chose to limit the results to scientific articles published in peer-reviewed journals, so future research may include, in addition to other databases, works published in congresses, theses and dissertations. Finally, as the study evaluated mainly the housing unit and its neighbourhood, issues directed primarily at urbanism and housing policies were excluded, and as observed in a UK (Lindsay, Williams & Dair, 2012 ) and American (Day, 2001) study, they may interfere in housing privacy relationships. Thus, it is recommended that future works in this area should consider the urban context and public policies in their analysis.

Regarding future works, even in studies inserted in the scope of architecture and urbanism, few presented the implications of how the research results could be adapted to the conception of new architectural projects. The architectural design adjustment propositions or guidelines found included: i) descriptions of what an ideal home should be (Day, 2000 ; Willems et al., 2020 ); ii) a proposition for the use of environmental control resources (Pable, 2012 ); iii) explicit design recommendations (Al-Kodmany, 2000 ; Fallah, Khalili & Rasdi, 2015 ). Therefore, future research studies could outline guidelines on how to apply the users' perceptions in the design of new projects, or in reforms of existing spaces. Despite the scarce studies, they are of great value for the context of housing projects, especially in the pandemic or post-pandemic period.

Housing privacy permeates different dimensions, analysis variables, research methods and approaches, with research that addresses both the generic characteristics of the context under study, as well as individual physiological or behavioural responses. Therefore, it is recommended that research in the area could present a clear definition of what should be effectively evaluated and the relationships that can be established.

Human socio-spatial behaviour: a generic term to indicate human behaviour related to the use of space “ as part of the interpersonal communication process and as one of the mediators of person-environment interaction ” (Pinheiro & Elali, 2011 , p. 148).

Territoriality: concept derived from ethology, concerns the feeling related to an area (physically defined) in relation to when the person experiences a feeling of possession, even if it is subjective and transitory (Sommer, 1973 ; Pinheiro & Elali, 2011 ) .

Personal space: " emotionally charged area around each person, sometimes described as a soap bubble or aura, and which helps to regulate the spacing between individuals " (Sommer, 1973 , p. X).

Crowding: “ an experiential state in which the restrictive aspects of spatial limitation are perceived by the individuals exposed to them ” (Stokols, 1976 , p. 50); situation in which the person experiences the need for a larger space than what is actually available to him (Hall, 2005 ); “ Knowing one is observed ” (Tuan, 1983 , p.69).

Solitude: non-reciprocity in search for the other; although the person desires a closer contact (or a relationship), the other does not favour him—it cannot be considered synonymous with isolation (a situation in which the person does not seek contact) – (Altman, 1975 ).

Proxemics: study of the relationships of proximity and distance between people during their interactions, understanding the environment as a fundamental component of this process (Hall, 2005 ).

Search conducted in August/2020. After this first identification, an alert was created on the Web of Science website with the established criteria and restrictions, and the publications that appeared after that date were added to the study as manual additions.

Although territoriality and personal space are different concepts, this joint is justified by two main reasons: (i) in daily life, people seem to see those meanings close together, depending on situations; (ii) specifically about housing studies, both themes deal with personal objects, rooms feature and/or residents’ behaviours associated with primary territories demarcations (Altman, 1975 ).

Although they address the organizational structure of the house, it was decided to distinguish the criteria of spatial organization and the architectural elements, the first related to the spatial distribution of the environments considering the complete composition of the house, while the architectural elements primarily cover isolated items such as doors, windows, curtains.

Document research is inherent in the production of articles and, therefore, was present in all articles. However, in the tables, the item document analysis stood out as an instrument, when the evaluation of the samples was based exclusively on these analyses.

As the period considered is 22 years and this article was produced in the beginning of 2021, it was decided to include the year 2021 in the temporal range from 2018.

The studies identified in Brazil are relevant to the context of researchers and that is why they were treated with special emphasis in the work.

Alitajer, S., & Molavi Nojoumi, G. (2016). Privacy at home: Analysis of behavioral patterns in the spatial configuration of traditional and modern houses in the city of Hamedan based on the notion of space syntax. Frontiers of Architectural Research, 5 (3), 341–352. https://doi.org/10.1016/j.foar.2016.02.003

Article   Google Scholar  

Al-Kodmany, K. (2000). Women’s visual privacy in traditional and modern neighborhoods in Damascus. Journal of Architectural and Planning Research, 17 (4), 283–303.

Google Scholar  

Al-Thahab, Ali, Mushatat, S., & Abdelmonem, M. G. (2014). Between tradition and modernity: Determining spatial systems of privacy in the domestic architecture of contemporary Iraq. International Journal of Architectural Research: ArchNet-IJAR, 8 (3), 238. https://doi.org/10.26687/archnet-ijar.v8i3.396

Altman, I. (1975). The environment and social behavior: Privacy, personal space, territory, crowding (Clean&Tight Contents ed.). Brooks/Cole Pub. Co.

Amole, D. (2005). Coping strategies for living in student residential facilities in Nigeria. Environment and Behavior, 37 (2), 201–219. https://doi.org/10.1177/0013916504267642

Arpin, S. N., Mohr, C. D., & Brannan, D. (2015). Having friends and feeling lonely. Personality and Social Psychology Bulletin, 41 (5), 615–628. https://doi.org/10.1177/0146167215569722

Avetisyan, S. (2020). Coronavirus and urbanization: Does pandemics are anti-urban? SSRN Electronic Journal . https://doi.org/10.2139/ssrn.3584395

Barbosa, O. L., & Neis, A. C. (2020). Habitação em meio à pandemia: um debate necessário. Revista Do Pet Economia Ufes, 1 (1), 20–22.

Beadle, J. N., Keady, B., Brown, V., Tranel, D., & Paradiso, S. (2012). Trait empathy as a predictor of individual differences in perceived loneliness. Psychological Reports, 110 (1), 3–15. https://doi.org/10.2466/07.09.20.pr0.110.1.3-15

Benke, C., Autenrieth, L. K., Asselmann, E., & Pané-Farré, C. A. (2020). Lockdown, quarantine measures, and social distancing: Associations with depression, anxiety and distress at the beginning of the COVID-19 pandemic among adults from Germany. Psychiatry Research, 293 , 113462. https://doi.org/10.1016/j.psychres.2020.113462

Bezerra, A. C. V., Silva, C. E. M. D., Soares, F. R. G., & Silva, J. A. M. D. (2020). Fatores associados ao comportamento da população durante o isolamento social na pandemia de COVID-19. Ciência & Saúde Coletiva, 25 (suppl 1), 2411–2421. https://doi.org/10.1590/1413-81232020256.1.10792020

Brunson, L., Kuo, F. E., & Sullivan, W. C. (2001). Resident appropriation of defensible space in public housing. Environment and Behavior, 33 (5), 626–652. https://doi.org/10.1177/00139160121973160

Buecker, S., Horstmann, K. T., Krasko, J., Kritzler, S., Terwiel, S., Kaiser, T., & Luhmann, M. (2020). Changes in daily loneliness for German residents during the first four weeks of the COVID-19 pandemic. Social Science & Medicine, 265 , 113541. https://doi.org/10.1016/j.socscimed.2020.113541

Burgoon, J. K. (1982). Privacy and Communication. Annals of the International Communication Association, 6 (1), 206–249. https://doi.org/10.1080/23808985.1982.11678499

Campagna, G. (2016). Linking crowding, housing inadequacy, and perceived housing stress. Journal of Environmental Psychology, 45 , 252–266. https://doi.org/10.1016/j.jenvp.2016.01.002

Ćetković, A. (2011). Privacy in the house of future . In: The 17th International Symposium on Electronic Art, Istanbul, Turkey . https://cetkovic.com/portfolio/docs/privacyFuture.pdf

Chambers, E. C., Bafna, S., & Machry, H. (2017). The association between apartment layout and depressive symptomology among Hispanic/Latino residents in low-Income housing: The AHOME study. Journal of Urban Health, 95 (1), 51–60. https://doi.org/10.1007/s11524-017-0216-4

Chan, Y. K. (2000). Privacy in the family: Its hierarchical and asymmetric nature. Journal of Comparative Family Studies, 31 (1), 1–17. https://doi.org/10.3138/jcfs.31.1.1

Coelho, A. B. (2011). A privacidade arquitectónica no habitar. Infohabitar , VII (342), Parte I e II. http://infohabitar.blogspot.com/2011/04/privacidade-arquitectonica-no-habitar.html

Connellan, K. (2018). My room, my home, myself. Home Cultures, 15 (2), 103–127. https://doi.org/10.1080/17406315.2018.1610604

Cooke, A., Smith, D., & Booth, A. (2012). Beyond PICO. Qualitative Health Research, 22 (10), 1435–1443. https://doi.org/10.1177/1049732312452938

Corapci, F., & Wachs, T. D. (2002). Does parental mood or efficacy mediate the influence of environmental chaos upon parenting behavior? Merrill-Palmer Quarterly, 48 (2), 182–201. https://doi.org/10.1353/mpq.2002.0006

Cunha, T. A. D. (2020). Espanha, habitação e COVID-19. REVES - Revista Relações Sociais . 3 (3), 207–211. https://doi.org/10.18540/revesvl3iss3pp0207-0211

Daniels, I. (2008). Japanese homes inside out. Home . Cultures, 5 (2), 115–139. https://doi.org/10.2752/174063108x333155

Day, L. L. (2000). Choosing a house: The relationship between dwelling type, perception of privacy and residential satisfaction. Journal of Planning Education and Research, 19 (3), 265–275. https://doi.org/10.1177/0739456x0001900305

Dienlin, T. (2013). The privacy process model. In S. Garnett, S. Halft, M. Herz, & J. M. Mönig (Eds.), Medien und Privatheit (pp. 105–122). Passau, Germany: Karl Stutz. https://www.researchgate.net/publication/266078921_The_privacy_process_model

Dietz, L., Horve, P. F., Coil, D. A., Fretz, M., Eisen, J. A., & Van Den Wymelenberg, K. (2020). 2019 novel coronavirus (COVID-19) pandemic: Built environment considerations to reduce transmission. Msystems, 5 (2), 1–19. https://doi.org/10.1128/msystems.00245-20

Dunstan, F., Weaver, N., Araya, R., Bell, T., Lannon, S., Lewis, G., Patterson, J., Thomas, H., Jones, P., & Palmer, S. (2005). An observation tool to assist with the assessment of urban residential environments. Journal of Environmental Psychology, 25 (3), 293–305. https://doi.org/10.1016/j.jenvp.2005.07.004

Elali, G. (2020a, May 13). Roda de conversa pandemia, ergonomia e acessibilidade [Video]. Facebook. https://www.facebook.com/eneac2020/videos/2615224548753988 .

Elali, G. (2020b, July 23). RODA DE CONVERSA VIRTUAL . Arquitetura em contexto de pandemia: velhas questões. novos caminhos. [Video]. YouTube. https://www.youtube.com/watch?v=l6lWUKA8cpY .

Elmansuri, S., & Goodchild, B. (2019). Tradition, modernity and gender in the Arab home: A study from Tripoli (Libya). Housing Studies, 36 (1), 1–22. https://doi.org/10.1080/02673037.2019.1676401

Evans, G. W., Lepore, S. J., & Allen, K. M. (2000). Cross-cultural differences in tolerance for crowding: Fact or fiction? Journal of Personality and Social Psychology, 79 (2), 204–210. https://doi.org/10.1037/0022-3514.79.2.204

Evans, G. W., Saegert, S., & Harris, R. (2001). Residential density and psychological health among children in Low-Income families. Environment and Behavior, 33 (2), 165–180. https://doi.org/10.1177/00139160121972936

Fallah, S. N., Khalili, A., & Rasdi, M. T. M. (2015). Privacy as a cultural value within traditional iranian housing: Lessons for modern Iranian high density vertical development housing. International Journal of Architectural Research: ArchNet-IJAR, 9 (1), 198. https://doi.org/10.26687/archnet-ijar.v9i1.324

Farkisch, H., Ahmadi, V., & Che-Ani, A. I. (2015). Evaluation of neighborhood center attributes on resident’s territoriality and sense of belonging a case study in Boshrooyeh Iran. Habitat International, 49 , 56–64. https://doi.org/10.1016/j.habitatint.2015.05.012

Fisher-Gewirtzman, D. (2017). The impact of alternative interior configurations on the perceived density of micro apartments. Journal of Architectural and Planning Research, 34 (4), 336–358.

Fragoso, B. (2020). O que muda nos perfis de imóveis após a pandemia . A Gazeta. https://www.agazeta.com.br/imoveis/o-que-muda-nos-perfis-de-imoveis-apos-a-pandemia-0820

Gaeta, L., & Brydges, C. R. (2020). Coronavirus-related anxiety, social isolation, and loneliness in older adults in Northern California during the stay-at-home order. Journal of Aging & Social Policy . https://doi.org/10.1080/08959420.2020.1824541

Garber, M. (2020). Finding privacy during the pandemic . The Atlantic. https://www.theatlantic.com/culture/archive/2020/03/finding-privacy-during-pandemic/608944/

Garcia, D. (2020). Distant space: the architecture of quarantine . Architectural Review. https://www.architectural-review.com/buildings/health/distant-space-the-architecture-of-quarantine

Gifford, R., Steg, L., Reser, J. P. (2011). Environmental Psychology. In: Martin, P. R., Cheung, F. M., Knowles, M. C., Kyrios, M., Littlefield, L., Overmier, J. B., & Prieto, J. M. (Eds.). (2011).  IAAP handbook of applied psychology.  Wiley Blackwell.

Giorgi, S., Padiglione, V., & Pontecorvo, C. (2007). Appropriations: Dynamics of domestic space negotiations in Italian Middle-Class working families. Culture & Psychology, 13 (2), 147–178. https://doi.org/10.1177/1354067x07076604

Givisiez, G. H. N., & Oliveira, E. L. D. (2013). Privacidade intradomiciliar: Um estudo sobre as necessidades de ampliações em residências. Revista Brasileira De Estudos De População, 30 (1), 199–223. https://doi.org/10.1590/s0102-30982013000100010

Goldberg, A. E., McCormick, N., & Virginia, H. (2020). Parenting in a pandemic: Work–family arrangements, well-being, and intimate relationships among adoptive parents. Family Relations, 70 (1), 7–25. https://doi.org/10.1111/fare.12528

Gómez-Jacinto, L., & Hombrados-Mendieta, I. (2002). Multiple effects of community and household crowding. Journal of Environmental Psychology, 22 (3), 233–246. https://doi.org/10.1006/jevp.2002.0236

Gosling, S. D., Craik, K. H., Martin, N. R., & Pryor, M. R. (2005). The personal living space cue inventory. Environment and Behavior, 37 (5), 683–705. https://doi.org/10.1177/0013916504274011

Grupo [MORA]. (2020). [IMPACTOS DA PANDEMIA COVID-19 NA HABITAÇÃO] . pesquisa em habitação housing research. https://morahabitacao.com/2020/08/12/impactos-da-pandemia-covid-19-na-habitacao/

Hall, E. (2005). A dimensão oculta . São Paulo: Martins Fontes.

Hashim, A. H., Rahim, Z. A., Rashid, S. N. S. A., & Yahaya, N. (2006). Visual privacy and family intimacy: A case study of Malay inhabitants living in two-storey low-cost terrace housing. Environment and Planning b: Planning and Design, 33 (2), 301–318. https://doi.org/10.1068/b31053

Hipwood, T. (2020). Coronavirus: an architect on how the pandemic could change our homes forever . The Conversation. https://theconversation.com/coronavirus-an-architect-on-how-the-pandemic-could-change-our-homes-forever-138649

Hosseini, M. R., Fouladi-Fard, R., & Aali, R. (2020). COVID-19 pandemic and sick building syndrome. Indoor and Built Environment, 29 (8), 1181–1183. https://doi.org/10.1177/1420326x20935644

Jornal Nacional. (2020). Procura por imóveis maiores e mais confortáveis cresce durante pandemia . G1. https://g1.globo.com/jornal-nacional/noticia/2020/09/04/procura-por-imoveis-maiores-e-mais-confortaveis-cresce-durante-pandemia.ghtml

Kaya, N., & Erkip, F. (2001). Satisfaction in a dormitory building. Environment and Behavior, 33 (1), 35–53. https://doi.org/10.1177/00139160121972855

Keenan, J. M. (2020). COVID, resilience, and the built environment. Environment Systems and Decisions, 40 (2), 216–221. https://doi.org/10.1007/s10669-020-09773-0

Khachaturova, M., & Nartova-Bochaver, S. (2017). The home environment as a resource of coping behaviour in youth. Psychology Journal of Higher School of Economics, 14 (3), 571–582. https://doi.org/10.17323/1813-8918-2017-3-555-566

Kintrea, K., Bannister, J., & Pickering, J. (2010). Territoriality and disadvantage among young people: An exploratory study of six British neighbourhoods. Journal of Housing and the Built Environment, 25 (4), 447–465. https://doi.org/10.1007/s10901-010-9195-4

Kornhaber, S. (2020, April 1). There are no new friends in a pandemic . The Atlantic. https://www.theatlantic.com/culture/archive/2020/03/there-are-no-new-friends-during-a-pandemic/608653/ .

Kowaltowski, D. C. C. K., Labaki, L. C., Pina, S. A. M. G., Silva, V. G., Moreira, D. C., Ruschel, R. C., Bertoli, S. R., Fávero, E., & Filho, L. L. F. (2006). Análise de parâmetros de implantação de conjuntos habitacionais de interesse social: ênfase nos aspectos de sustentabilidade ambiental e da qualidade de vida. In: Financiadora de Estudos e Projetos (FINEP) (Ed.), Construção e Meio Ambiente, 7 , 128–167. Coletânea Habitare. http://www.habitare.org.br/pdf/publicacoes/arquivos/ct_7_cap5.pdf

Lampert, A. (2020). Busca por imóveis maiores e com áreas verdes aumenta durante a pandemia . Jornal do Comércio. https://www.jornaldocomercio.com/_conteudo/cadernos/empresas_e_negocios/2020/09/755882-busca-por-imoveis-maiores-e-com-areas-verdes-aumenta-durante-a-pandemia.html

Leino-Kilpi, H., Välimäki, M., Dassen, T., Gasull, M., Lemonidou, C., Scott, A., & Arndt, M. (2001). Privacy: A review of the literature. International Journal of Nursing Studies, 38 (6), 663–671. https://doi.org/10.1016/s0020-7489(00)00111-5

Lindsay, M., Williams, K., & Dair, C. (2010). Is there room for privacy in the compact city? Built Environment, 36 (1), 28–46. https://doi.org/10.2148/benv.36.1.28

Losada-Baltar, A., Jiménez-Gonzalo, L., Gallego-Alberto, L., Pedroso-Chaparro, M. D. S., Fernandes-Pires, J., & Márquez-González, M. (2020). “We are staying at Home” association of self-perceptions of aging, personal and family resources, and loneliness with psychological distress during the Lock-Down period of COVID-19. The Journals of Gerontology: Series B, 76 (2), 10–16. https://doi.org/10.1093/geronb/gbaa048

Magi, T. J. (2011). Fourteen reasons privacy matters: A multidisciplinary review of scholarly literature. The Library Quarterly, 81 (2), 187–209. https://doi.org/10.1086/658870

Maia, R. S. (2012). Sobre portas, paredes e afetos: Casa, territorialidade e identidade entre os segmentos populares. Terra Plural, 6 (2), 339–352. https://doi.org/10.5212/terraplural.v.6i2.0010

Margulis, S. T. (2003a). On the status and contribution of Westin’s and Altman’s theories of privacy. Journal of Social Issues, 59 (2), 411–429. https://doi.org/10.1111/1540-4560.00071

Margulis, S. T. (2003b). Privacy as a social issue and behavioral concept. Journal of Social Issues, 59 (2), 243–261. https://doi.org/10.1111/1540-4560.00063

Margulis, S. T. (2011). Three theories of privacy: An overview. Privacy Online . https://doi.org/10.1007/978-3-642-21521-6_2

Matthews, T., Odgers, C. L., Danese, A., Fisher, H. L., Newbury, J. B., Caspi, A., Moffitt, T. E., & Arseneault, L. (2019). Loneliness and neighborhood characteristics: A multi-informant, nationally representative study of young adults. Psychological Science, 30 (5), 765–775. https://doi.org/10.1177/0956797619836102

McNeilly, H., & Reece, K. M. (2020). Everybody’s always here with me! Anthropology in Action, 27 (3), 18–21. https://doi.org/10.3167/aia.2020.270304

Megahed, N. A., & Ghoneim, E. M. (2020). Antivirus-built environment: Lessons learned from Covid-19 pandemic. Sustainable Cities and Society, 61 , 102350. https://doi.org/10.1016/j.scs.2020.102350

Mendonça, R. N. (2015). Apartamento mínimo contemporâneo: análises e reflexões para obtenção da sua qualidade Master Dissertation (Universidade Federal de Uberlândia). UFU Repositório.

Merino, M. D., Vallellano, M. D., Oliver, C., & Mateo, I. (2021). What makes one feel eustress or distress in quarantine? An analysis from conservation of resources (COR) theory. British Journal of Health Psychology . https://doi.org/10.1111/bjhp.12501

Moeller, R. W., & Seehuus, M. (2019). Loneliness as a mediator for college students’ social skills and experiences of depression and anxiety. Journal of Adolescence, 73 , 1–13. https://doi.org/10.1016/j.adolescence.2019.03.006

Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Medicine . https://doi.org/10.1371/journal.pmed.1000097

Moraes, C. (2020). Como a pandemia vai mudar a cara e a organização dos apartamentos . Folha de S.Paulo. https://www1.folha.uol.com.br/sobretudo/morar/2020/07/como-a-pandemia-vai-mudar-a-cara-e-a-organizacao-dos-apartamentos.shtml

Morrison, C. D., Poulin, M. J., & Holman, E. A. (2018). Gender, genes, and the stress-buffering benefits of “home”: Evidence from two national U.S. studies. Journal of Environmental Psychology, 60 , 89–99. https://doi.org/10.1016/j.jenvp.2018.10.007

Mustafa, F. A. (2010). Using space syntax analysis in detecting privacy: A comparative study of traditional and modern house layouts in Erbil city, Iraq. Asian Social Science, 6 (8), 157–166. https://doi.org/10.5539/ass.v6n8p157

Nejadriahi, H., & Dincyurek, O. (2015). Identifying privacy concerns on the formation of courtyards. Open House International, 40 (4), 18–24. https://doi.org/10.1108/ohi-04-2015-b0004

Newell, P. B. (1995). Perspectives on privacy. Journal of Environmental Psychology, 15 (2), 87–104. https://doi.org/10.1016/0272-4944(95)90018-7

Nguyen, V. M. (2020). Alone together. Anthropology in Action, 27 (3), 14–17. https://doi.org/10.3167/aia.2020.270303

Oishi, S., Kesebir, S., Miao, F. F., Talhelm, T., Endo, Y., Uchida, Y., Shibanai, Y., & Norasakkunkit, V. (2013). Residential mobility increases motivation to expand social network: But why? Journal of Experimental Social Psychology, 49 (2), 217–223. https://doi.org/10.1016/j.jesp.2012.10.008

Othman, Z., Aird, R., & Buys, L. (2015). Privacy, modesty, hospitality, and the design of Muslim homes: A literature review. Frontiers of Architectural Research, 4 (1), 12–23. https://doi.org/10.1016/j.foar.2014.12.001

Ozaki, R. (2002). Housing as a reflection of culture: Privatised living and privacy in England and Japan. Housing Studies, 17 (2), 209–227. https://doi.org/10.1080/02673030220123199

Pable, J. (2012). The homeless shelter family experience: Examining the influence of physical living conditions on perceptions of internal control, crowding, privacy, and related issues. Journal of Interior Design, 37 (4), 9–37. https://doi.org/10.1111/j.1939-1668.2012.01080.x

Paiva, D. S., & Mendes, G. R. (2001). "Onde se pode ficar nu ": Territorialidade e privacidade na casa do estudante universitário da UnB. Série: Textos de Alunos de Psicologia Ambiental, 7 , 1–6.

Pasala, S. K., Gumpeny, L., Kosuri, M., Tippana, S., & Sridhar, G. R. (2020). Effect of lockdown on activities of daily living in built environment and well-being. UCL: Open Environment Preprint . https://doi.org/10.14324/111.444/000047.v1

Pedersen, D. M. (1979). Dimensions of Privacy. Perceptual and Motor Skills, 48 , 1291–1297. https://doi.org/10.2466/pms.1979.48.3c.1291

Pedersen, D. M. (1997). Psychological functions of privacy. Journal of Environmental Psychology, 17 (2), 147–156. https://doi.org/10.1006/jevp.1997.0049

Perez-Lopez, R., Aragonés, J. I., & Amérigo, M. (2017). Primary spaces and their cues as facilitators of personal and social inferences. Journal of Environmental Psychology, 53 , 157–167. https://doi.org/10.1016/j.jenvp.2017.07.008

Petronio, S. (2002). Boundaries of privacy: Dialetics of disclosure . State University of New York Press.

Pinheiro, J. Q., & Elali, G. A. (2011). Comportamento socioespacial humano. In S. Cavalcanti & G. A. Elali (Eds.), Temas básicos em Psicologia Ambiental (pp. 144–158). Vozes.

Pinquart, M., & Sorensen, S. (2001). Influences on loneliness in older adults: A meta-analysis. Basic and Applied Social Psychology, 23 (4), 245–266. https://doi.org/10.1207/s15324834basp2304_2

Poggio, L., Fraijo-Sing, B., Aragonés, J. I., & Tapia-Fonllem, C. (2017). The objects that personalize bedrooms and their relationship with attachment and self. Revista De Psicología Social, 33 (1), 1–25. https://doi.org/10.1080/02134748.2017.1385230

Pourvahidi, P. (2020). Privacy cognition of spaces by agraph tools in temperate humid climatic region of Iran. Iconarp International J of Architecture and Planning, 8 (1), 241–261. https://doi.org/10.15320/iconarp.2020.112

Rahim, Z. A. (2015). The influence of culture and religion on visual privacy. Procedia - Social and Behavioral Sciences, 170 , 537–544. https://doi.org/10.1016/j.sbspro.2015.01.055

Razali, N. H. M., & Talib, A. (2013). Aspects of privacy in Muslim Malay traditional dwelling interiors in Melaka. Procedia - Social and Behavioral Sciences, 105 , 644–654. https://doi.org/10.1016/j.sbspro.2013.11.067

Reis, A. T. L., & Lay, M. C. D. (2003). Privacidade na habitação: atitudes, conexões visuais e funcionais. Ambiente Construído, 3 (4), 21–33.

Rollings, K. A., & Evans, G. W. (2019). Design moderators of perceived residential crowding and chronic physiological stress among children. Environment and Behavior, 51 (5), 590–621. https://doi.org/10.1177/0013916518824631

Ruiz-Casares, M. (2012). “When it’s just me at home, it hits me that I’m completely alone”: An online survey of adolescents in Self-Care. The Journal of Psychology, 146 (1–2), 135–153. https://doi.org/10.1080/00223980.2011.604361

Silva, C. E. M. D., Cruz Neto, C. C. D., Bezerra, A. C. V., Santos, R. T., & Silva, J. A. M. D. (2020). Influência das condições de bem-estar domiciliar na prática do isolamento social durante a pandemia da Covid-19. Journal of Health & Biological Sciences, 8 (1), 1. https://doi.org/10.12662/2317-3076jhbs.v8i1.3410.p1-7.2020

Simmel, A. (1971). Privacy is not an isolated freedom. In: Pennock, J. R., Chapman, J. W. (Eds)., Privacy & Personality , (1st ed). New York, Routledge. https://doi.org/10.4324/9781315127439

Sinha, S. P., & Nayyar, P. (2000). Crowding effects of density and personal space requirements among older people: The impact of Self-Control and social support. The Journal of Social Psychology, 140 (6), 721–728. https://doi.org/10.1080/00224540009600512

Sobh, R., & Belk, R. W. (2011). Privacy and gendered spaces in Arab Gulf homes. Home Cultures, 8 (3), 317–340. https://doi.org/10.2752/175174211x13099693358870

Soga, M., Evans, M. J., Tsuchiya, K., & Fukano, Y. (2020). A room with a green view: the importance of nearby nature for mental health during the COVID-19 pandemic. Ecological Applications . https://doi.org/10.1002/eap.2248

Solove, D. J. (2006). A taxonomy of privacy. University of Pennsylvania Law Review, 154 (3), 477. https://doi.org/10.2307/40041279

Sommer, R. (1973). Espaço pessoal , as bases comportamentais de projetos e planejamentos. São Paulo: EPU/EDUSP.

Stepanikova, I., Nie, N. H., & He, X. (2010). Time on the Internet at home, loneliness, and life satisfaction: Evidence from panel time-diary data. Computers in Human Behavior, 26 (3), 329–338. https://doi.org/10.1016/j.chb.2009.11.002

Stokols, D. (1976). The experience of crowding in primary and secondary environments. Environment and Behavior, 8 , 49–86.

Sundstrom, E., Bell, P. A., Busby, P. L., & Asmus, C. (1996). Environmental psychology 1989–1994. Annual Review of Psychology., 47 , 485–512. https://doi.org/10.1146/annurev.psych.47.1.485

Takashima, R., Onishi, R., Saeki, K., & Hirano, M. (2020). Perception of COVID-19 restrictions on daily life among Japanese older adults: A qualitative focus group study. Healthcare . https://doi.org/10.3390/healthcare8040450

Tendais, I., & Ribeiro, Ana Isabel, A. I. (2020). Espaços verdes urbanos e saúde mental durante o confinamento causado pela COVID-19. Finisterra: Revista Portuguesa de Geografia , 115 (55), 183–188. Doi: https://doi.org/10.18055/Finis20184

Thornock, C. M., Nelson, L. J., Porter, C. L., & Evans-Stout, C. A. (2019). There’s no place like home: The associations between residential attributes and family functioning. Journal of Environmental Psychology, 64 , 39–47. https://doi.org/10.1016/j.jenvp.2019.04.011

Tomah, A. N., Ismail, H. B., & Abed, A. (2016). The concept of privacy and its effects on residential layout and design: Amman as a case study. Habitat International, 53 , 1–7. https://doi.org/10.1016/j.habitatint.2015.10.029

Tomás, T., Amérigo, M., & García, J. A. (2016). Bio-psycho-social correlates of the perceived crowding in different contexts. Psicothema, 28 (4), 394–400. https://doi.org/10.7334/psicothema2015.336

Tuan, Yi-fu (1983). Espaço & lugar : a perspectiva da experiência. São Paulo: DIFEL.

Vasconcelos, B. R., Próchno, C. C. S. C., & Silva, L. C. A. D. (2012). Lofts: habitações para além do contexto moderno. Psicologia: Ciência e Profissão, 32 (4), 1014–1027. https://doi.org/10.1590/s1414-98932012000400018

Villa, S. B. (2008). Morar em apartamentos: a produção dos espaços privados e semi-privados nos edifícios ofertados pelo mercado imobiliário no século XXI em São Paulo e seus impactos na cidade de Ribeirão Preto. Doctoral Thesis (Faculdade de Arquitetura e Urbanismo da Universidade de São Paulo [FAUUSP]).

Wang, F., Ruan, H., Chieh Wang, H., Zong, Y., & Zhen, F. (2017). Create, control and have territories or secret places: A comparative study of children’s play territoriality in their daily outdoor environments between Beijing’s urban villages and modern residential areas. Habitat International, 66 , 125–134. https://doi.org/10.1016/j.habitatint.2017.05.012

Warren, S. D., & Brandeis, L. D. (1890). The right to privacy. Harvard Law Review, 4 (5), 193. https://doi.org/10.2307/1321160

Westin, A. F. (1967). Privacy and Freedom . Ig Publishing.

Westin, A. F. (2003). Social and political dimensions of privacy. Journal of Social Issues, 59 (2), 431–453. https://doi.org/10.1111/1540-4560.00072

Willems, S., De Smet, H., & Heylighen, A. (2020). Seeking a balance between privacy and connectedness in housing for refugees. Journal of Housing and the Built Environment, 35 (1), 45–64. https://doi.org/10.1007/s10901-020-09727-7

Williams, K. (2009). Space per person in the UK: A review of densities, trends, experiences and optimum levels. Land Use Policy, 26 , S83–S92. https://doi.org/10.1016/j.landusepol.2009.08.024

Wolfe, M. (1978). Childhood and Privacy. In I. Altman & J. F. Wohlwill (Eds.), Children and the Environment Human Behavior and Environment (Advances in Theory and Research). Springer.

Yaylalı Yıldız, B., Ek, F. P., & Can, I. (2018). Transformation in a housing design story: Reading the spatial typologies of apartment projects in Hatay-Izmir. A/Z ITU Journal of Faculty of Architecture, 15 (3), 123–137. https://doi.org/10.5505/itujfa.2018.26566

Zago, A. P. S. M., & Villa, S. B. (2017). Percepção da qualidade dos espaços de morar: avaliação pós-­ocupação do Residencial Parque Univille – Uberaba. Anais do 4<sup>o CIHEL Congresso Internacional Da Habitação No Espaço Lusófono. </i> 4° Congresso Internacional da habitação no espaço lusófono, Covilhã, Portugal. https://morahabitacao.com/artigos/

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Acknowledgements

The authors Sheila Walbe Ornstein and Gleice Azambuja Elali express their gratitude to the National Council for Scientific and Technological Development (CNPq), Brazil, for their respective productivity grants.

Two authors are productivity fellows from the National Council for Scientific and Technological Development (CNPq). Sheila Walbe Orstein under the CNPq number 304131/2020-2 and Gleice Azambuja Elali under the CNPq number 308280/2018-0.

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This article integrates the partial results of the thesis under development by the doctoral student Priscila Macedo in the Architecture and Urbanism Postgraduate Program at USP, under the guidance of the doctoral professors Sheila Walbe Ornstein (principal advisor, USP) and Gleice Azambuja Elali (co-advisor, UFRN). Specifically in the preparation of this article, Priscila Macedo was responsible for structuring the contents of the Systematic Literature Review; Sheila Ornstein collaborated with the discussion on contemporary ways of living based on her post-occupancy evaluation research in the housing field (both social and aimed at middle-income social strata); Gleice Elali collaborated with the analysis of topics related to privacy and the relationship between the built environment and human behaviour.

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de Macedo, P.F., Ornstein, S.W. & Elali, G.A. Privacy and housing: research perspectives based on a systematic literature review. J Hous and the Built Environ 37 , 653–683 (2022). https://doi.org/10.1007/s10901-022-09939-z

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DOI : https://doi.org/10.1007/s10901-022-09939-z

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Public restrooms, periods, and people experiencing homelessness: An assessment of public toilets in high needs areas of Manhattan, New York

Roles Conceptualization, Data curation, Formal analysis, Investigation, Supervision, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Department of Environmental, Occupational, and Geospatial Health Sciences, Graduate School of Public Health and Health Policy, City University of New York, New York, NY, United States of America

Roles Conceptualization, Investigation, Writing – original draft, Writing – review & editing

Affiliation Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, United States of America

Roles Data curation, Formal analysis, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

Roles Data curation, Investigation, Writing – review & editing

Roles Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, Writing – original draft, Writing – review & editing

• Andrew R. Maroko, 
• Kim Hopper, 
• Caitlin Gruer, 
• Maayan Jaffe, 
• Erica Zhen, 
• Marni Sommer

• Published: June 23, 2021
• https://doi.org/10.1371/journal.pone.0252946
• Reader Comments

Access to safe, clean water and sanitation is globally recognized as essential for public health. Public toilets should be accessible to all members of a society, without social or physical barriers preventing usage. A public toilet facility’s design and upkeep should offer privacy and safety, ensure cleanliness, provide required sanitation-related resources, and be gender equitable, including enabling comfortable and safe management of menstruation. Menstrual hygiene management (MHM) refers to the need to ensure that girls, women and all people who menstruate have access to clean menstrual products, privacy to change the materials as often as needed, soap and water for washing the body as required, and access to facilities to dispose of used materials. Challenges around menstruation faced by people experiencing homelessness, which tend to be greater than those facing the general population, include inadequate toilet and bathing facilities, affordability issues around menstrual products, and menstrual stigma. Public toilets are a vital resource for managing menstruation, particularly for vulnerable populations without reliable access to private, safe, and clean spaces and menstrual products. This mixed-methods study sought to: 1) understand the lived experiences of MHM among people experiencing homelessness in New York City with respect to public toilets; 2) describe general and MHM-related characteristics of public toilets in high need areas of Manhattan and analyze their interrelationships; and 3) examine the associations among neighborhood-level demographics and the public toilet characteristics in those areas. Qualitative methods included key informant interviews (n = 15) and in-depth interviews (n = 22) with people with experience living on the street or in shelters, which were analyzed using Malterud’s ‘systematic text condensation’ for thematic cross-case analysis. Quantitative methods included audits and analyses of public toilet facilities (n = 25) using traditional statistics (e.g., Spearman’s correlations) and spatial analyses (e.g., proximity buffers). Qualitative findings suggest cleanliness, access to restrooms, and availability of resources are critical issues for the participants or prospective users. Quantitative analyses revealed insufficiently provided, maintained, and resourced public toilets for managing menstruation in high-needs areas. Findings also suggest that toilets with more MHM-related resource availability, such as menstrual products and toilet stall disposal bins, were more difficult to access. Neighborhood-level characteristics showed a potential environmental injustice, as areas characterized by higher socioeconomic status are associated with more access to MHM-specific resources in public restrooms, as well as better overall quality.

Citation: Maroko AR, Hopper K, Gruer C, Jaffe M, Zhen E, Sommer M (2021) Public restrooms, periods, and people experiencing homelessness: An assessment of public toilets in high needs areas of Manhattan, New York. PLoS ONE 16(6): e0252946. https://doi.org/10.1371/journal.pone.0252946

Editor: Sean A. Kidd, Centre for Addiction and Mental Health, CANADA

Received: March 1, 2021; Accepted: May 25, 2021; Published: June 23, 2021

Copyright: © 2021 Maroko et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All American Community Survey data used in this study is available from the US Census Bureau https://www.census.gov/programs-surveys/acs or NHGIS (nhgis.org). Locations of homeless encampments/hotspots, related audits, and qualitative interviews are not publicly available due to privacy and safety concerns for the population. The Columbia University Medical Center (CUMC) Institutional Review Board may be contacted for more information ( https://research.columbia.edu/human-research-protection-office-and-irbs ).

Funding: MS is supported by "The Sid and Helaine Lerner MHM Faculty Support Fund.” The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Access to safe, clean water and sanitation is globally recognized as essential for public health [ 1 – 3 ]. In the United States (US) and beyond, readily accessible public toilets are considered modern necessities (even if often ill-provided [ 4 ]), important for accommodating an extremely mobile population, and particularly critical for those with greater needs such as children, the elderly, those with medical conditions requiring increased toilet use, people who are menstruating, and those experiencing homelessness [ 5 ]. Fundamental components of a public toilet include its design, its maintenance, and its accessibility; meaning, for example, a toilet should be accessible to members of the public, without social or physical barriers preventing usage, its design should provide privacy and safety, and its upkeep should ensure cleanliness [ 6 , 7 ]. Additional modifications may be mandated, such as handrails for those with special needs, or as will be discussed in this paper, aspects that enable comfortable and safe management of menstruation.

Menstrual hygiene management (MHM) refers to the need to ensure that girls, women, and all people who menstruate have access to clean menstrual products, privacy to change the materials as often as needed, facilities for disposing of used materials, and soap and water for washing bodies as required [ 8 ]. There is a growing global recognition that public toilets and bathing facilities should provide these fundamentals of MHM [ 9 , 10 ]. Other aspects, such as hooks to hang a bag, adequate lighting, a mirror to check for leaks, and toilet paper or paper towels can further improve these experiences [ 10 ]. Absence of adequate enabling factors for MHM contributes to anxiety, embarrassment, and shame for those who menstruate, especially given ongoing menstrual stigma and taboos [ 11 , 12 ]. This hinders the ability to participate successfully in school, work, and other aspects of daily life, and contributes to perpetuating a gender inequitable society [ 13 – 15 ]. As more than a quarter of the US population is estimated to currently menstruate [ 16 ], access to clean, safe toilets with water, soap, and disposal mechanisms, is essential for ensuring dignified, safe, comfortable MHM for all.

Although the US-based literature remains scarce on how people with limited resources manage their menstruation, evidence from a few studies suggests that the cost of menstrual products presents particular challenges [ 17 – 19 ]. One survey conducted with low-income women in St. Louis, Missouri, including some experiencing homelessness, found that nearly 50% had been forced to choose between buying food and menstrual products in the last year. Many of the women, especially those experiencing homelessness, had no place to change their menstrual products, particularly at night when they felt that public toilets were not safe [ 18 ]. While documentation of the challenges around menstruation faced by people experiencing homelessness are more prevalent in the US media than in the peer reviewed literature, there is an emerging evidence base describing inadequate toilet and bathing facilities for those who live on the street and in shelters, affordability issues around menstrual products, and experienced menstrual stigma [ 17 , 19 , 20 ].

Homelessness represents a long-standing public health crisis in the US in general, and New York City (NYC) specifically. In September 2019, there were over 62,000 people in NYC’s shelter system each night; a number that does not account for the many additional unhoused people living with friends, family, or on the street [ 21 ]. A point-in-time count assessment estimated that there were over 3,500 individuals living on the street in January 2019, a number likely to be an underestimation [ 22 ]. In addition, the shelter system served over 133,000 separate individuals in 2018, a 59% increase over the prior decade [ 21 ]. Access to basic resources is among the many challenges facing this population, including safe and stable shelter, proper nutrition, health care, and toilet facilities. The COVID-19 pandemic has only served to exacerbate these challenges.

Public toilets, or restrooms as they are frequently called, are a vital, but often overlooked, resource for MHM, particularly for vulnerable populations such as those experiencing homelessness who may lack reliable access to private, safe, and clean spaces or menstrual products. Of importance to note, this includes access to public versus private toilets, particularly in large urban environments [ 6 ]. Public toilets are facilities funded by federal, state or local dollars, technically open to anyone. They range from stand-alone restrooms, such as those in parks or on street corners, to those tied to publicly accessible institutions, such as free museums, transportation systems, or libraries. Although in theory open to the public, access to such toilets may be uneven, and limited in practice by the operating hours of the institution or park in which they are located, the “informal gatekeeping” by the staff, and may range in quality (e.g., cleanliness, stocking of toilet paper) depending on how well resourced and maintained such facilities are by the responsible government entity. Private toilets in this paper refer to those owned and maintained by private sector or commercial entities such as restaurants, coffee shops, and other stores. Access to such toilets is often limited to the paying clientele of the institution, or to those who are able to “pass” as paying customers. The passing requirement frequently translates into denial of access to populations experiencing homelessness, including those who are menstruating and in need of more frequent access [ 23 ].

Access and accessibility, as will be applied in this paper to public toilets and related resources for MHM, are concepts that are often constructed from a number of related dimensions. For instance, in health care, the dimensions can be defined as: 1) affordability (e.g., does utilization of the resource result in financial burden); 2) availability (e.g. is there enough of the resource for the demand of the population); 3) accessibility (is the resource geographically accessible and is its distribution equitable); 4) accommodation (e.g., does the resource meet the constraints and preferences of the population); and 5) acceptability (e.g., is the resource appropriate and relevant to the population’s needs and cultural setting) [ 24 , 25 ]. As this relates to public toilets and MHM for people experiencing homelessness, this can be thought of as “are there enough public toilets in high-needs areas?”; “do the existing public toilets supply the requisite resources?” (e.g. stocked supply of soap; menstrual product vending machines; menstrual product disposal bins or trash cans); “are there barriers to utilization of the toilets?” (e.g., security guards screening entry into institution; expectation of payment such as a subway fare; requirement to request a code or key to restroom); and “are the characteristics (e.g., cleanliness and safety) of the toilet facilities appropriate for MHM for this population and on terms acceptable to them?”

An important feature of resource access, be it to toilets or menstrual products, is equity in the spatial distribution of resources. These “spatial justice” issues can be seen in a wide range of phenomena. For instance, the environmental justice literature has exposed many instances where exposures to environmental insults (e.g., air pollution, toxic exposures) [ 26 – 29 ] and more general environmental “bads” (e.g., fast food outlets, vacant and derelict land) [ 30 – 35 ] are increased in communities with higher proportions of people of color, foreign born residents, or lower household incomes or educational attainment. Similar findings have been reported around access to environmental “goods” such as parks and open space [ 34 – 37 ], healthy foods [ 38 , 39 ], and health services [ 40 – 42 ]. However, it is unclear how or if neighborhood-level demographics associate with qualities and characteristics of public toilets.

For our purposes, this is particularly important in considering how public toilet access may impact those experiencing homelessness in relation to managing menstruation. The media has showcased how many large urban areas of the US (e.g., Los Angeles, Seattle), lack adequate public toilets and are grappling with the related implications for populations living on the street [ 43 , 44 ]. In NYC, a recent media inquiry explored the inadequacy of public toilets in the city’s vast subway system (some 420 stations). The reporting described toilets turned into storage closets, variable hours of service, and major challenges in maintenance and cleanliness [ 45 ]. The public at large would likely benefit from improved, safe, clean public toilets. For those living on the street or in shelters–routinely denied access to the numerous private sector toilets in restaurants, cultural institutions, cafes, and shops–the lack of clean, accessible public toilets presents distinct challenges. However, to date, little research has systematically explored access to public toilets in the US for people experiencing homelessness, especially with respect to managing their menstruation.

This study sought to: 1) better understand the lived experiences of menstrual management or MHM among people experiencing homelessness in NYC with respect to public toilets; 2) describe general and MHM-related characteristics of public toilets in high need areas of Manhattan and analyze their interrelationships; and 3) examine the associations among neighborhood-level demographics and the public toilet characteristics in those areas.

We conducted a mixed-methods study that sought to capture, at individual, institutional, and ecological levels, the nature of menstrual management on the part of those experiencing homelessness, and how the local context may shape those experiences. This included: 1) key informant interviews with staff of government agencies and homeless service organizations; 2) in-depth interviews with people experiencing homelessness who menstruate; and 3) audits of public toilet facilities in a select number of sites across the borough of Manhattan in NYC. This paper will focus on select findings from the qualitative data, and quantitative insights gained from public toilet audit data. The qualitative information served to enhance and guide our understanding and interpretation of the toilet audit data.

Qualitative methods

Our sample for the key informant interviews (n = 15) included staff of government agencies and organizations providing services to people experiencing homelessness, including shelters. Our sample for the in-depth interviews (n = 22) included street and sheltered individuals experiencing homelessness who were ages 18 years and older and who menstruate. We sought to identify 4–5 individuals in each of the following age groups: 18–25; 26–35; 36–45; and 46 and above in order to capture a range of menstruation-related experiences (more in-depth methods described in Sommer et.al. 2020 [ 23 ]). The participants all presented as female, although we did not ask for gender identification. Similarly, we did not probe on exact age beyond confirming they were above 18 years of age, given the sensitivity of the population. However, a number of participants offered their age during the interviews, and the researchers estimated the age of the others based on appearance and life story. Based on these methods, we can approximate that the participants ranged from ages 18–62, including 8 in the 18–25 category, 5 in the 26–35 category, 4 in the 36–45 category, and 5 in the 46 and above category. All participants provided oral consent prior to participating.

Participants were recruited during the months of June–August 2019, with recruitment ending when we reached data saturation. Key Informants were recruited through electronic outreach to organizations known to be relevant to homeless services and/or public toilets provision in NYC. The majority of key informant interviews were conducted online using free conference call, with a small number conducted in the offices of those being interviewed, depending on the preference of the key informant. Recruitment for those experiencing homelessness occurred through the Coalition for the Homeless as well as from an organization specifically serving homeless youth. Both organizations placed a flier in their lobby and made announcements about the study including an incentive ($10 or $15 metro card) to the population who they serve. Clients who expressed interest in participating in the study were introduced to the research team by the Coalition or service provider. All of the interviews conducted with the homeless population occurred in private rooms (e.g. empty offices) at the Coalition or other service provider.

Our decision to focus on Manhattan was both pragmatic and strategic. Although the shelter system is scattered throughout NYC’s five boroughs, annual street counts routinely find many more street-dwelling homeless in Manhattan than in the other boroughs of NYC (excluding subways) [ 46 ].

The study received Internal Review Board (IRB) approval from the Columbia University Medical Center (CUMC) Institutional Review Board. A waiver of written consent was requested and approved by the CUMC IRB on the basis that the only record linking the subject and the research would be the consent document and the principal risk of the study was the potential harm resulting from a breach of confidentiality. In consultation with the Coalition for the Homeless, we concluded that a written consent form may also be an issue due to varying literacy of those experiencing homelessness. A consent tracking sheet was maintained to ensure all participants’ consenting was documented.

Public restroom audit

In order to quantify differences in public toilets, an audit instrument was created by combining and adapting existing instruments used to assess the accessibility and acceptability of toilets in global development programs in both humanitarian and development contexts [ 47 ]. These tools assess multiple elements of the toilet design including structure and hardware, availability of basic supplies, and safety and privacy features. Data collected by our customized audit instrument included basic information (e.g., location, number of toilets), cleanliness (e.g., floors, toilets, sinks), data on availability of general resources (e.g., soap, toilet paper, trash cans, hooks on the back of stall doors for hanging clothing or bags, locks on stall doors), permission and economic-based accessibility (e.g., permission needed to use toilets, purchase required, codes or keys needed, access to the establishment needed), other accessibility characteristics (e.g., hours of operation, signage, gender neutral restrooms), and availability of MHM-specific resources. The latter included availability of menstrual products such as freely accessible or vending machine-provided menstrual pads or tampons, and disposal bins, which are refuse receptacles near the toilet (e.g. trash can) or within the toilet stall (e.g. small unit on the stall wall). Such internal stall bins eliminate the need to carry a used product to a garbage receptacle situated in a public space (e.g., the shared larger restroom). It is important to note that all of the variables collected, such as hooks on doors and privacy assured by locks on stall doors, are relevant to enabling comfortable, safe and dignified MHM, even if they are not MHM-specific. The majority of variables are binary (yes/no), simply indicating the presence, or lack, of a certain feature or characteristic (e.g., a disposal bin). However, the cleanliness variables were coded on a 5-class Likert scale.

Prior to data collection, the full research team met to discuss the tool and reach consensus about the categories included. After the tool was developed, it was field tested, and upgrades were made to improve usability and functionality. This involved discussing the general process for auditing a public toilet facility, including minimizing disruption of usual practice, making careful observations, and performing functionality tests on the hardware (e.g., locks, sinks, hand dryers). In addition, researchers discussed the definition of each variable to ensure common understanding and consistency in utilizing the audit tool. Particular emphasis was placed on the cleanliness variables (Likert scales) as they are the most open to subjectivity. Between July 12 and September 3, 2019, researchers performed the audits in teams of two or more, with one of the researchers participating in every audit to ensure consistency in coding.

Spatial methods—Identifying high-needs areas of people experiencing street homelessness.

Various data sources were reviewed to identify places within Manhattan which may have a higher need for public toilet facilities. These included various homelessness counts and censuses, shelter locations and capacity, and others. Ultimately, locations of “hot spots,” identified with the assistance of the Manhattan Outreach Consortium (MOC) as of April 2019, were used as they proved to be more stable and spatially discrete than other options explored ( Fig 1 ). These are not geographic statistical hot spots (e.g., as calculated by spatial distribution statistics), but rather places where people are known to congregate or “bed down.” They are identified mainly through ongoing outreach efforts and updated monthly. It is important to note that locations may change over time due to relocation of the individuals (e.g., some people may get sheltered, accept outreach offers, be asked to disperse by the police, or move to another neighborhood). Gender breakdowns, although important, were more difficult to estimate due to a lack of reliable or complete data and thus are not included in the analysis. This “hot spot” information is used to identify potentially high-needs locations (i.e. locations with greater numbers of people experiencing homelessness) to perform the public toilet audits (see below).

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Locations are displayed with intentional locational error for privacy and safety concerns.

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Public toilet audit areas were defined by creating ½ mile (~ 805 meters) radius buffers from selected hot spot / encampment locations. As many of these locations are spatially clustered, some audit areas included multiple encampments of individuals who are living on the street or “sleeping rough.” The team walked all streets and accessible park and open spaces intersecting the buffer areas and identified all publicly accessible toilets (e.g., within parks, subways, libraries, commuter train stations, public museums). It is important to note that the researchers only audited public restrooms, and did not assess private businesses (e.g., coffee shops, restaurants, bars) or those found in shelters or other facilities. This was because shelter facilities may be unavailable during the daytime for those staying there, and because those sleeping on the street tend not to access shelter facilities if they are not sleeping there. The data collection resulted in the identification of 31 publicly accessible toilet facilities. However, six were out of order, closed, or otherwise inaccessible resulting in 25 fully audited facilities ( Fig 2 ).

https://doi.org/10.1371/journal.pone.0252946.g002

Qualitative analysis.

All of the qualitative data (KIIs and IDIs) was transcribed and analyzed by two of the researchers using Malterud’s ‘systematic text condensation’ for thematic cross-case analysis [ 23 ]. This included the following steps: (1) identification of preliminary themes; (2) creative development of qualitative codes; (3) condensation of coded text; (4) synthesis and reconceptualization. The PI reviewed and helped to revise the final codebook, and the analysis team used Dedoose analytic software to code the data. The key themes were shared with the full research team for discussion, refinement and validation. The section below presents the key analytical themes and supporting textual passages of relevance to the public toilet audit data insights.

Quantitative (audit data) analysis.

Statistical analyses were performed in SPSS (IBM Corp., Armonk, NY) and spatial analyses in ArcMap 10.7 (ESRI, Redlands, CA). Collected data from the audits were explored in a number of ways. First, simple indices were created to capture broad domains of public toilet-level characteristics. Second, descriptive statistics of the indices were calculated to show the overall characteristics of the public toilets in these high-needs areas. Third, the indices were compared to one another using Spearman’s correlations. And finally, bivariate associations among public toilet characteristics and contextual neighborhood-level socioeconomic data were explored.

Simple indices were created to represent major domains of public toilet facility characteristics. These include (1) cleanliness, (2) general resource availability (availability 1—general), (3) MHM-specific resource availability (availability 2—MHM), (4) accessibility with respect to permissions or purchases (access 1—permissions), and (5) accessibility with respect to hours of operation, visibility, and inclusiveness (access 2—other). Raw data were converted into index values by summing the individual variables and then using linear transformations, so that all the resulting index scores were between 0–1. For the cleanliness index, scores were not impacted by missing features (e.g., if there was no trash can or disposal bin present the cleanliness score was not affected; however, it would be reflected in the availability score). A simple additive index was then created (full index) which represents the sum of the individual domain indices, resulting in possible values ranging from zero to five.

In order to compare public toilet facility characteristics to the broader social contexts in which they are situated, “neighborhoods” had to be defined and operationalized. Locations of audited public toilets were geocoded using ArcGIS World Geocoding Service and manually checked for accuracy. American Community Survey (ACS) 5-year estimates (2014–18) at the Census Block Group (CBG) level were acquired via IPUMS / National Historical GIS [ 48 ] and mapped to represent sociodemographic characteristics of the residential population. ACS data include total population, poverty status, per capita income, median rent, non-Hispanic (NH) White residents, NH Black residents, Latinx/Hispanic residents, and adult population who did not graduate from high school ( Fig 3 ).

Top row (from left to right): per capita income, percent of the population below the federal poverty level, median rent, percent of the adult population without a high school diploma. Bottom row (from left to right): percent NH White, percent NH Black, and percent Latinx/Hispanic.

https://doi.org/10.1371/journal.pone.0252946.g003

As the public toilet point locations served as the unit of analysis, pedestrian-accessible network distance buffers of 0.25 miles (~ 0.40 km) were created ( Fig 4 ). These network buffers differ from fixed-distance (“as-the-crow-flies”) buffers as they reflect areas within a walkable distance along the network (pedestrian-accessible streets and paths). Because the buffer boundaries do not conflate with CBG boundaries, the ACS data were attributed to each public toilet by using areal weighting. This method of data disaggregation is a type of dasymetric approach, where a second dataset (in this case area), is used to reapportion the variable of interest (in this case ACS data). Areal weighting assumes a homogeneously distributed population, which although committing ecological fallacy, has been shown to provide more meaningful estimates than other, non-dasymetric, neighborhood estimation techniques (e.g., centroid containment, intersection) [ 49 – 52 ]. In the case of this study, CBGs intersected by the network buffer are split, creating “child” polygons. The area of each child polygon is calculated and the variable of interest (e.g., total population) is disaggregated to the new polygons by multiplying the CBG value by the ratio of the child polygon area divided by the original CBG area. For instance, if there were 1000 residents in a CBG, and the network buffer included 50% of the CBG area, it would be assumed that 500 residents (50%) lived in within the buffer area. Public toilet-specific demographic and socioeconomic contexts (“neighborhoods”) were then calculated by summing count variables in all child polygons within the public toilet’s network buffer. Non-count variables (e.g., median rent) were calculated using population-weighted means.

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Qualitative

The qualitative findings served to reveal the human experience behind the toilet audit findings, enriching and guiding our interpretation of the audit data. As reported elsewhere [ 23 ], the most prevalent challenges that emerged from the interviews pertained to accessibility, resource, cleanliness, and safety issues. This proved to be the case both for those living on the street and those living in shelters, the latter of whom also need facilities as they move around the city when seeking out services or employment.

Inadequate maintenance of public toilets.

Specific challenges included significant concerns around the cleanliness of many public toilets; a common refrain was wondering whether public toilets were ever used, particularly in the subway system, combined with comments about the challenges their lack of upkeep posed:

I think I’ve used the subway bathroom like twice in my life…And it was disgusting…The smell. Mostly the smell…you notice little things in there, like the sink might be a little dirty, the tissue might be all over the floor, so, mm, it’s just nasty. I wouldn’t, if I could avoid it, I would… –IDI017

Many informants also expressed concerns about their lack of maintenance, with recommendations emerging from the respondents that corresponded to the types of cleanliness challenges observed during the toilet audits:

Clean the bathrooms enough to where someone can go in and make sure we have the necessities, soap, napkins, the dryer, even if there’s no dryer…Maintain [them] that way.–IDI14

For their part, key informants based in service organizations or local government, described challenges related to the provision and maintenance of public toilets, such as resource limitations that constrain hours of operation. Parks department informants, for example, bemoaned the lack of staff needed to ensure that public toilets could be adequately cleaned in order to open on time at 8am (especially if they had been “trashed” the night before). Given the centrality of park-based toilet facilities (referred to as “comfort stations”) as a daytime resource for those needing a public toilet, uncertainty with respect to hours of operation, cleanliness and adequate supplies is a routine worry. When special effort is made to address MHM, other city employees report, vandalism can make short work of, say, menstrual product vending machines in public facilities:

We did try sanitary napkins and tampons [in dispensers] at one point , but , people broke in and just…This was quite a while ago , but , people would , you know , try and either take the products , light ’em on fire , have fun with them , whatever it is that they do , because that is the reality .–KII 03

The latter example highlights the challenge facing city government in the provision of more accessible and MHM-friendly public toilet facilities, particularly if there are insufficient resources for monitoring their usage and/or maintenance. However as with the maintenance issue, the homeless respondents had suggestions in relation to improving the accessibility and MHM-friendliness of facilities:

If, you know, it were up to me, I would have bathrooms, just, a lot of bathrooms…bathrooms with locks, one stall, privacy, um. I honestly wouldn’t even mind if the, I don’t know what it’s called but there were machines, you paid a quarter, I wouldn’t mind if we went back to the twenty-five cent tampons, just I wish there were access, cause I don’t carry pads if I don’t expect my period….but I feel like just the event of getting your period is such a mission, to like put on a pad, it’s like, there should be a bathroom 5, 10 minutes away, with access to stuff like that for free, hopefully one day.–IDI13

Inadequate hours of operation.

Informants also complained about the limited numbers of public toilets throughout the city, and their restricted hours of operation, such as those located in the city’s parks. As one respondent shared:

So, you have to, like, go to the subway to use the bathroom, and those are closed from midnight to 5am. They’re, um, they don’t even always open them at 5am.–IP2

As many noted, periods do not stop flowing at nighttime, yet public toilets become almost inaccessible. As another informant suggested, the restriction of hours–similarly found in the toilet audit data–was potentially purposeful:

They just don’t want people in it, because they know that that’s the place where homeless people go…like, you know, um, so they know that at a certain time at night, if they close it, that this is only when homeless people are going to be in there. _IDI003

Toilet audits

Such cautionary statements provide a sound prelude to our own inspections. In reviewing the basic descriptive information about the audited public toilets (n = 25) and their respective neighborhoods, there emerged a fair amount of variation in most of the variables ( Table 1 ). For instance, although all of the audited public toilets had running water and adequate lighting available, not all had functioning stall doors and locks (96% and 92%, respectively). Additionally, only 60% (n = 15) provided hooks or shelves for bags, clothing or belongings (a component of the general resource availability index, and useful for those carrying menstrual products with them). Cleanliness scores also demonstrated a wide range of values with all variables ranging between 1 (least clean) to 5 (most clean).

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With respect to MHM-specific resources, only 24% of restrooms (n = 6) had disposal bins within stalls, 12% (n = 3) had menstrual product vending machines, and none provided free products. Overall, 17 of the 25 (68%) restrooms had no MHM-specific resources at all. Of the three MHM-specific resources (disposal bins, free products, vending machines), only one public toilet had both disposal bins and a vending machine. Of the eight which had any sort of resource, two were in parks (vending machines), two in transit stations, and the remainder were housed within various institutions (e.g., museum, department of motor vehicles, NYC job center).

Access data shows that most of the public toilets themselves did not require specific permissions or purchases, with 92% not requiring permission to use the toilet (e.g., asking an officer in the police station to use the restroom) and 96% did not require a purchase to access the toilets (e.g., needing special access to enter the establishment such as a subway station where the fare must first be paid to get to the area where the toilet is located). None required a key or electronic access code, in contrast to what individuals may encounter in some commercial establishments. However, over 75% of the restrooms required researchers to first enter or gain access to the establishment (e.g. museum, library, some park facilities or transit stations—which may not require payment but may be experienced differently based on one’s ability to “pass”). Additionally, only four (16%) were open continuously (24 hours per day, 7 days per week), all of which were either inside a police station or major transit hub. Note that even continuously open restrooms may not, in practice, be continuously available (e.g., long periods of closure for cleaning or maintenance).

Characteristics of the residential populations living around the audited public toilets (“neighborhood” variables) showed wide variation. There were large differences in all measured indicators for income (e.g., population-weighted mean per capita income ranged from approximately $17,500 to over $182,000; poverty rates from 6% to 41%), educational attainment (e.g., rates of adults without a high school degree from less than 1% to nearly 45%), and race/ethnicity (e.g., proportion of NH white populations from under 5% to over 80%).

Bivariate two-tailed Spearman’s correlations show the associations among restroom indices ( Table 2 ). These data suggest that permissions and purchase-related accessibility (Access-1) is inversely related to the availability of MHM-specific resources (Availability-2; -0.588, p = 0.002)– meaning the more accessible a restroom is , the less likely it is to have these resources . Other associations show that cleanliness is positively associated with the availability of general resources (0.685, p < .001). This suggests that cleaner restrooms tend to have more general resources, which may be a function of more frequent maintenance and upkeep.

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Two-tailed Spearman’s correlations were also calculated to assess the associations among restroom index values and neighborhood demographics ( Table 3 ). Higher indicators for income and wealth tended to correspond with more availability of resources as well as overall public toilet facility quality. For instance, higher median rents were positively correlated with more availability of general resources (0.372, p = .067), MHM resources (0.506, p = 0.010), “other” access (0.367, p = 0.071), and the full index (0.445, p = 0.026). Per capita income showed a similar trend; however, only availability of MHM resources had a meaningfully low p-value (0.408, p = .043). The proportion of the population below the federal poverty level and adults without high school degrees both showed negative correlations with MHM resource availability (-0.408, p = .043 and 0.397, p = 0.050, respectively) and the full index (-0.432, p = 0.031 and -0.381, p = 0.061, respectively). With respect to race and ethnicity, higher proportions of NH White populations were associated with greater general availability (0.349, p = 0.087) and NH Black populations with fewer permission or purchase-related access obstacles (0.360, p = .077). However, higher proportions of NH Black populations were also negatively associated with restroom cleanliness (-0.396, p = .050), general resource availability (-0.596, p = .002), and the full index (-0.538, p = .006). The only racial/ethnic variable which showed an association with MHM resource availability was a negative correlation with proportion of the population who are Latinx (-0.362, p = 0.075).

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This study offers independent support of MHM difficulties previously reported for New Yorkers experiencing homelessness. Specifically, it shows that likely high need areas of Manhattan, those hosting concentrations of people experiencing homelessness, are also wanting in resources for adequate MHM. Qualitative interviews suggest that public toilet-based access to MHM products and resources (e.g. products, disposal bins) is a pressing concern for people experiencing homelessness. Our quantitative results support such worries; none of the toilets audited in our sample provided free products, and nearly 70% had no MHM-specific resources at all. Given the likely higher reliance on public toilet facilities by people experiencing homelessness, this paucity of resources, described as basic and fundamental needs for people who menstruate, almost certainly has a differential effect based on socio-economic status and unequal access to non-public alternatives.

The above inequity is further exacerbated by the quantitative findings which suggest that public toilets with more MHM-related resource availability tended to be more difficult to access with respect to needed permissions or purchases, which is in turn compounded by the fact that the vast majority (84%) of audited public toilets are not open overnight. The qualitative interviews revealed the latter to be an important barrier to menstrual management.

Pointedly, too, access to public toilets may include hidden costs or location-specific permissions–whether economic (e.g., pay for subway access) or social (e.g., ask an attendant at a museum). Negotiating these is often further complicated for people experiencing homelessness by the need to present themselves convincingly as otherwise: to “pass” as not homeless. Elsewhere, we have shown how access to private toilets, those located within private sector or commercial entities, is encumbered by this symbolic requirement [ 23 ]; public toilets, too, often come laden with their own de facto gatekeepers.

There were also detectable differences in neighborhood-level characteristics based on public toilet qualities. For instance, the public toilet facilities which provided any sort of MHM resources were positively associated with higher income and higher rent areas—and negatively associated with higher proportions of Latinx residents, lower educational attainment, and people living in poverty. Put simply, MHM resources in public toilet facilities were more prevalent in areas characterized by high socioeconomic status, as opposed to areas which may already be under-resourced or marginalized, and as such benefit more from their availability and accessibility. Overall public toilet quality followed the same trend, indicating that neighborhoods which have higher shares of vulnerable residents tend to have lower quality public toilet facilities with fewer MHM resources. This is particularly true for neighborhoods with high proportions of NH Black residents, where the toilets tended to be less clean, have less availability of general resources, and have lower overall quality. These issues may be associated with maintenance and upkeep and were revealed as important aspects of MHM based on qualitative interviews.

It is important to be reminded that the overall quality of the public toilet facilities (which included variables describing cleanliness, privacy, safety, and accessibility), are essential for , even if not specific to, MHM. This suggests an environmental injustice, where neighborhoods have differential access to “environmental goods” based on the sociodemographic nature of the residents. As the public toilet facilities that were audited were associated with clusters of people experiencing homelessness who may be menstruating, this has significant implications for their access to private, hygienic spaces for managing their menstruation safely and comfortably as needed. Although a preferential solution would be housing for all, and so reduce the unmet need that public toilet facilities in urban areas are expected to address, the exigency of menstrual management is one that lasts day and all night during a given menstrual period. Hence, safe access to clean public toilets is essential for anyone, housed or otherwise, moving about the streets of Manhattan. If anything, the COVID-19 pandemic has intensified such concerns, and made contagion the metric of solidarity.

It is important to note the limitations of this study. First, there were a small number of samples (25 audited public toilets, only audited once each) which may result in unstable statistical findings and would benefit from a more complete (e.g., 100%) sample of the borough. Second, the areas of Manhattan selected for auditing were based on data which are not necessarily representative of the true distribution of people experiencing homelessness, but rather rely on locations identified by homelessness outreach workers as “hot spots” at a specific point in time. Nor were we able to identify any potential bias in the spatial distribution of women or other people who menstruate who would benefit most from MHM resources. Third, this data uncertainty is linked to the inability to perform a true supply-and-demand type of analysis. As such, this study does not examine a central aspect of accessibility or availability in terms of “amount per person,” but rather just the qualities of the amenities that exist. It may be argued that any public toilet is better than no public toilets; however, based on the interviews, many women that are experiencing homelessness avoid public toilets specifically because they are not seen as clean, safe, or hygienic. Although the study design and data did not allow for a supply-demand analysis, there was large variability in the number of public toilets, and more so in the number of individual toilets/stalls within those facilities, in any given audited area. For instance, some downtown locations (e.g., near Stuyvesant Town and parts of the East Village) had no nearby public toilet facilities. Conversely, audited locations near major transit hubs or regional attractions often had over 20 individual toilets/stalls in nearby public toilet facilities.

Overall, interviews suggest that public toilet facilities in Manhattan simply do not meet the menstrual hygiene management needs of women experiencing homelessness in terms of accessibility, cleanliness, privacy, or resource provision. The spatial distribution of higher and lower quality public toilet facilities, reinforced by, and interpreted through, the findings from qualitative interviews, may be an example of an environmental or spatial injustice in neighborhoods proximal to “hot spots” of people experiencing homelessness in Manhattan. Such mixed-methodological approaches are a useful way to identify and highlight such inequities; insights that may have been incomplete without the convergence of findings. The overall lack of menstrual hygiene resources in all public toilets is further exacerbated by the findings that these resources tend to be found more often in public toilet facilities which are difficult to access. Ultimately, we believe that if these spatial biases, accessibility and resource issues, and overall paucity and poor quality of supply are addressed in Manhattan, it would not only contribute to meeting the needs of the most marginalized or vulnerable populations (e.g., people experiencing homelessness), but provide substantial benefits for the public good. That such needs are exacerbated during the global COVID-19 pandemic adds ever more urgency.

• View Article
• Google Scholar
• PubMed/NCBI
• 7. Street P. Public Toilets: Determinant of the Progress of Civilization and Consciousness of Societies or a Necessary Evil? Advances in Human Factors in Architecture, Sustainable Urban Planning and Infrastructure: Proceedings of the AHFE 2019 International Conference on Human Factors in Architecture, Sustainable Urban Planning and Infrastructure. 966. Washington DC: Springer; 2019. p. 87.
• 16. UNICEF. FAST FACTS: Nine things you didn’t know about menstruation UNICEF: UNICEF; 2018 [Available from: https://www.unicef.org/press-releases/fast-facts-nine-things-you-didnt-know-about-menstruation .
• 46. NYC Department of Homeless Services. HOPE 2020 2020 [Available from: https://www1.nyc.gov/site/dhs/outreach/hope.page .
• 48. Manson S, Schroeder J, Van Riper D, Ruggles S. IPUMS National Historical Geographic Information System: Version 14.0 [Database]. Minneapolis, MN: IPUMS2019.

Adapting to Misspecification

Empirical research typically involves a robustness-efficiency tradeoff. A researcher seeking to estimate a scalar parameter can invoke strong assumptions to motivate a restricted estimator that is precise but may be heavily biased, or they can relax some of these assumptions to motivate a more robust, but variable, unrestricted estimator. When a bound on the bias of the restricted estimator is available, it is optimal to shrink the unrestricted estimator towards the restricted estimator. For settings where a bound on the bias of the restricted estimator is unknown, we propose adaptive estimators that minimize the percentage increase in worst case risk relative to an oracle that knows the bound. We show that adaptive estimators solve a weighted convex minimax problem and provide lookup tables facilitating their rapid computation. Revisiting some well known empirical studies where questions of model specification arise, we examine the advantages of adapting to—rather than testing for—misspecification.

Timothy Armstrong gratefully acknowledges support from National Science Foundation Grant SES-2049765. Liyang Sun gratefully acknowledges support from the Institute of Education Sciences, U.S. Department of Education, through Grant R305D200010, and Ayudas Juan de la Cierva Formacion. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

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Accessible Home Environments for People with Functional Limitations: A Systematic Review

Hea young cho.

1 Centre for Global Health, Trinity College Dublin, 7-9 Leinster Street South, Dublin 2, Ireland; ei.dct@hohc

2 School of Psychology, Trinity College Dublin, College Green, Dublin 2, Ireland

Malcolm MacLachlan

3 Centre for Rehabilitation Studies, Stellenbosch University, Private Bag X1, Matieland, Stellenbosch 7602, South Africa

4 Olomouc University Social Health Institute, Palacky University Olomouc, Olomouc 77111, Czech Republic

Michael Clarke

5 Northern Ireland Network for Trials Methodology Research, Centre for Public Health, Queen’s University Belfast, Belfast BT126BA, UK; [email protected]

Hasheem Mannan

6 School of Nursing, Midwifery & Health Systems, University College Dublin, Belfield, Dublin 4, Ireland; [email protected]

The aim of this review is to evaluate the health and social effects of accessible home environments for people with functional limitations, in order to provide evidence to promote well-informed decision making for policy guideline development and choices about public health interventions. MEDLINE and nine other electronic databases were searched between December 2014 and January 2015, for articles published since 2004. All study types were included in this review. Two reviewers independently screened 12,544 record titles or titles and abstracts based on our pre-defined eligibility criteria. We identified 94 articles as potentially eligible; and assessed their full text. Included studies were critically appraised using the Mixed Method Appraisal Tool, version 2011. Fourteen studies were included in the review. We did not identify any meta-analysis or systematic review directly relevant to the question for this systematic review. A narrative approach was used to synthesise the findings of the included studies due to methodological and statistical heterogeneity. Results suggest that certain interventions to enhance the accessibility of homes can have positive health and social effects. Home environments that lack accessibility modifications appropriate to the needs of their users are likely to result in people with physical impairments becoming disabled at home.

1. Introduction

The United Nations Convention on the Rights of Persons with Disabilities, Article 9 safeguards the rights of persons with disabilities to live in an accessible physical environment, as well as the right to equal access to information and communications [ 1 ]. Among physical environments, there is little doubt that the accessible domestic home is fundamental to enabling independent living for persons with disabilities. Home environments without the basic accessibility components can negatively impact on the daily activities of persons with functional limitations. For instance, those dependent on mobility devices may be confined indoors, or even to very limited spaces within the dwelling; consequently violating their human rights and diminishing their quality of life. It is often assumed that persons with disabilities are a small proportion of the total population, but the World Report on Disability has estimated that more than a billion people, or 15% of the world’s population, have some form of disability [ 2 ].

The relationship between ageing and associated functional limitations is becoming increasingly important [ 3 ]. The increase in life expectancy over recent decades has resulted in an ageing population especially in high-income countries [ 4 ]. More than 20% of the world population is predicted to be aged 60 years or over by the year 2050, with the European region having the highest proportion at an estimated 37% [ 4 ]. However, some of the fastest rates of population ageing are now found in low- and middle-income countries [ 4 ]. Due to ageing related functional limitations, many older adults face the prospect of living with poor access to their own home environments; threatening their safety and undermining their quality of life. The majority of older adults wish to continue independent living in their own home [ 5 ]. However, they are often forced to move into institutional settings due to lack of accessibility to their home environments. Such institutional settings are associated with higher economic costs to both the individual and society in general [ 6 ].

According to the International Classification of Functioning (ICF), disability and health, disability is an umbrella term to indicate impairments in body functions and structures, limitations in activities or participation restrictions [ 7 ]. Environmental factors (physical, social and attitudinal) can be facilitators or barriers and will determine the level of disability experienced by a person [ 7 ]. Disability is not an attribute: it is the outcome of the interaction between bodily impairments and health conditions, and contextual factors (environmental and internal personal factors) [ 7 ]. How society is organised, for instance in terms of architectural accessibility, affects whether someone with impairments is “disabled”, or not.

Although the concept of functioning is broad and encompasses impairments, it is often operationalised in terms of whether a person can accomplish Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) [ 8 ]. The term ADL applies to the basic tasks of everyday life, such as bathing, dressing, transferring, toileting and feeding [ 9 , 10 ]. While ADL are more related to personal self-care, IADL refer to a range of activities that are required for independent living in the community, such as preparing meals, housekeeping, taking medications, shopping, managing own finances, travelling and using the telephone [ 9 , 10 ].

It has been estimated that 60% of new houses in the USA are, at some point, likely to be resided in by a person with physical impairment [ 6 ]. According to the environmental docility hypothesis, persons with low functional capacity are more likely to be vulnerable concerning environmental demands than are those with higher functional capacity [ 11 ]. Therefore, a home without accessibility features creates further strain for persons with functional limitations, increasing their risk of falls and injuries as well as restricting their social participation [ 12 ]. Such environments also increase the burden on caregivers and external social services [ 12 , 13 ]. Whereas the built environment and its effects on health and wellbeing have been widely studied [ 14 , 15 , 16 ], there has been relatively little specific attention to the accessible home environment in the domestic context for persons with functional limitations.

There are various labels that are used for access or accessibility in relation to home environments [ 17 ]. For example, Universal Design is defined as the design, construction and adaptation of standard housing that can be used by all people regardless of their age, size or ability [ 17 ]. Life Span Housing refers to housing that can accommodate changing capabilities of a person over his/her lifetime, and is also known as Lifetime Homes in the UK and Adaptable Housing in Australia [ 17 ]. Enabling technologies for independent living by the elderly has become a new and essential approach, as known as Ambient Assisted Living [ 18 ]. For the purpose of this review, we defined the accessible home environment as one which allows a person with functional limitations to get into, out of, and circulate within the home, and to function independently.

Accessible homes can be purposely built or achieved through modifications, from which various groups of people can benefit: persons with ageing related functional limitations, those with other disabilities, as well as their caregivers and visitors. Furthermore, the importance of an accessible home environment is most likely to increase in coming years and decades because of the increasing prevalence of functional limitations in an ageing population. It is therefore important to evaluate the effects of homes that have accessibility features. This is the objective of the present systematic review. This systematic review is part of a programme of work conducted to support the development of the World Health Organization’s (WHO) Guidelines on Housing.

2.1. Eligibility Criteria

We addressed the research question using the following structure, which influenced the search strategies used in this review:

• Context: Domestic home in the community setting regardless of household tenure. Indoor and immediate outside of house, and public spaces and mutual corridors in the case of blocks of flats or buildings. Assisted living facilities, group homes and institutional settings were excluded.
• Participants: People of all ages who have functional limitations whether physical or cognitive. Frail older adults were included, given that “frail” indicates some forms of impairments. Older adults were excluded if no functional limitations were specified.
• Interventions: Those implemented in the physical environment of home building that were intended to enhance accessibility: modification of specific furniture and fixture, structural changes, affixed assistive device. Multicomponent interventions and other interventions, e.g., occupational programmes, were included if an accessibility component was incorporated.
• Comparisons: Groups living in accessible and conventional/unmodified home environments. Comparisons that assessed outcomes before and after an eligible intervention were included.
• Outcomes: Health or social related changes. Outcomes that were measured jointly regarding home accessibility features and participants’ health/social changes were excluded if they could not be disaggregated.

Searches were conducted in English but there was no language restriction for studies to be eligible. There was no restriction by study type in searching. We planned to limit ourselves to studies with a high level of evidence only if the number of such studies were sufficient for this review. The aim of searching was to identify individual studies and reviews of studies, published as journal articles, technical reports and accessible dissertations. Theoretical papers, commentaries, editorials and abstracts with no full paper were excluded. Book chapters, book reviews and conference proceedings were closely scrutinised as sources for potentially eligible studies.

2.2. Data Sources and Search Strategy

Tailored and sensitive search strategies were developed by the expert searcher in liaison with the research team. The search strategy for MEDLINE ( Appendix A ) was used as the basis for search strategies in the other databases: Cumulative Index of Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database, Embase, OT Seeker, PsycINFO and National Health Service Economic Evaluation Database. Searches were performed from December 2014 to January 2015.

2.3. Study Selection

We originally carried out our electronic database searches without any restriction by publication year. However, due to the high number of retrieved records, the WHO Guideline Development Group later set the eligibility to publications to the last 10 years (since 2004), which was more feasible for our review in terms of time frame and budget. Duplicates of records were identified and removed within each database first. After the results from each database had been added to EndNote library, another round of de-duplication was carried out.

Two reviewers independently screened record titles or titles and abstracts based on the pre-defined eligibility criteria, using the EndNote library software programme. Where there was any disagreement or ambiguity, a third reviewer assessed the relevant records and consensus was reached between the three researchers. If it was unclear whether to include or exclude a study on the basis of its abstract, we retrieved its full text. Authors of papers were contacted when more information was required. We checked the reference lists of the included studies, and of systematic reviews that were excluded at the full text screening stage if they concerned home environmental interventions or home interventions on older adult populations.

2.4. Data Extraction and Critical Appraisal

After the full text screening process, necessary information was extracted by one reviewer from potentially eligible studies. This included study type, number of participants and their functional limitations, study inclusion and exclusion criteria, interventions and any comparators, outcome measures and results reported. A second reviewer checked data extracted, with any discrepancies resolved by a third reviewer. Potentially eligible studies were then discussed among all the researchers to agree on their relevance to the review.

One of the special characteristics of this review is that such a wide range of study designs were included: studies with no comparison group, correlation studies looking at the association between home accessibility features and outcomes, and mixed-method studies for which results are presented as qualitative themes. Therefore, we used the Mixed Method Appraisal Tool (MMAT), version 2011 to have coherence when assessing the quality of all included studies. The MMAT has been designed to appraise the methodological quality of studies included in complex systematic reviews that incorporate qualitative, quantitative and mixed-method studies [ 19 , 20 ]. The MMAT checklist has two initial screening questions and 19 components corresponding to qualitative research, randomised controlled trial (RCT), non-randomised studies, quantitative descriptive studies and mixed methods studies. It has a scoring metric whereby each study is scored between 1 as the lowest and 4 as the highest quality.

The Evidence Profile was completed using all the information extracted and data from the quality assessment. The summary of findings table was also prepared to identify the effects of interventions for each outcome. All the researchers reviewed and discussed the quality assessment results, the evidence table and summary of findings, easily reaching consensus.

Initially, 26,782 records were identified without any time restriction. After removing records that were published before 2004 and de-duplications, 12,544 records were identified. After titles or titles and abstracts screening, we identified 99 records eligible for the full text screening. Snowballing was also performed and as a result we identified 4 more citations by checking reference lists. Of 103 studies, 5 studies were found to be duplications and 4 with no full articles or unable to obtain full copies. A total of 94 articles were judged to be potentially eligible and therefore we assessed their full text, leading to the exclusion of 80 articles. We did not identify any meta-analysis or systematic review directly relevant to the research question. All researchers agreed on the eligibility of the remaining 14 papers. Figure 1 shows the flow diagram for the identification of studies for this review.

Flow diagram for the identification of eligible studies. (Only one reason is given per excluded study although in many cases reasons for exclusion were more than singular.)

We included all study types in this review as a small number of studies were identified. Table 1 provides a brief presentation of included studies. Full details of characteristics of included studies and their quality assessments are in Appendix B .

Studies included in the review.

The MMAT score is presented using descriptors: * as the lowest and **** as the highest quality. This score is the number of criteria met divided by four for qualitative and quantitative studies, and the lowest score of the study components for mixed-method studies.

3.1. Participants

The majority of study participants were elderly population over 70-year old, although inclusion criteria for age groups varied with one study including children [ 29 ]. In terms of functional limitations, all study participants had physical impairments except one cross-sectional study that had participants with cognitive impairments [ 28 ]. While some studies reported participants with specific functional limitations (such as paraplegia and visual impairments), the majority used diverse terms for and definitions of functional limitations (see Table 2 ).

Descriptions of functional limitations in studies included.

3.2. Interventions and Home Accessibility Features

Interventions implemented to enhance home accessibility features were home modifications, described as housing adaptations or home safety programmes in some studies. Home modifications were carried out either as a sole intervention [ 21 , 22 , 24 , 29 , 30 , 31 , 32 ] or part of a multicomponent programme [ 25 , 26 , 27 , 34 ]. Furthermore, the safety component of these, such as hazard reduction, tended to be integrated with the accessibility interventions. Home modifications were mainly focused on architectural changes or fitted devices such as grab bars, targeting mobility issues; a few focused on lighting improvements or adjustments targeting vision. One cohort study had a distinctive intervention which consisted of the installation of a light path near the bed, coupled with tele-assistance: this aimed to reduce falls at night among frail older adults [ 34 ]. One randomised trial used a factorial design to evaluate the effect of each intervention, and possible interactions between interventions: home safety programmes; exercise programme; and social visits [ 23 ]. Two cross-sectional studies reported the association between accessible home environments and ADL or quality of life [ 28 , 33 ]. Table 3 provides descriptions of accessibility features identified from each included study.

Descriptions of accessibility features in each study included.

3.3. Effects of Interventions on Outcomes

Six different outcomes of home accessibility interventions were identified. The most common outcomes measured were those related to changes in ADL/IADL. Some outcomes were directly related to physical health, such as falls and mortality, and some were related to quality of life and psychological health. Occupational performance was also reported as an outcome of home modifications [ 32 ]. All the outcomes were collected via self-report, except mortality that was sourced from the National Death Index [ 26 , 27 ], and fall induced serious injuries which were collected from hospital and general practice records [ 23 ]. As will be discussed, Figure 2 schematically illustrates associations between functional limitations categorised into groups (mobility, vision and cognition related) and effects of home accessibility features or interventions on ADL/IADL, occupational performance, falls, mortality, quality of life and psychological health.

Associations between functional limitations, home accessibility features and outcomes (…. represents no significant or inconsistent associations/effects).

3.4. Activities of Daily Living

Five studies reported the effects on ADL/IADL related outcomes [ 22 , 24 , 30 , 31 ]. In addition, one population-based survey study identified a strong association (odds ratio 3.7, 95% confidence interval, 2.9–4.6) between self-recognised difficulty managing ADL and perceived unmet needs for home accessibility features among people with activity limitations, after adjusting for severity of their limitations [ 33 ]. Large decreases in perceived difficulties performing ADL/IADL were identified after home modifications and the multicomponent programme [ 25 , 30 , 31 ], whereas difficulty with mobility/transfer did not significantly change [ 25 ]. Several other aspects in performing ADL/IADL were also reported: safety, dependence, self-efficacy and certainty. Self-efficacy, which was defined as confidence in managing difficulty, was improved in the intervention group after the multicomponent programme among older adults with functional limitations [ 25 ]. Increased safety with ADL/IADL was also identified two months after home modifications among adults with functional limitations [ 30 ]. In particular, the greatest benefits were in relation to difficulty and safety in bathroom use and entry access [ 30 ]. Gitlin 2006a also found that the greatest benefit was in bathing and toileting [ 25 ].

On the other hand, two studies found no significant change in dependence with ADL/IADL at 2 months and up to 8–9 months after home modifications [ 24 , 30 ]. However, it was noted that dependence in bathing was significantly decreased between 2–3 months and 8–9 months after home modifications [ 24 ]. Furthermore, one randomised trial did not identify a significant improvement overall in self-rated certainty in performing specific activities 6 months after lighting adjustments [ 22 ]. Certainty in performing activities of “pour drink“ and “slice bread“ on the working surface of the kitchen were the only ones that improved significantly 6 months after the intervention.

3.5. Falls/Injuries and Mortality

Two studies reported on reductions in the likelihood of falls and injuries [ 23 , 34 ]. One randomised trial reported 41% fewer falls by one year follow-up in the home safety programme with a group of older adults with severe visual impairments, compared with those who did not receive this programme [ 23 ]. Also, Tchalla 2012 identified a significant reduction in falls at home and post-fall hospitalisations among frail older adults after the use of a light path coupled with tele-assistance [ 34 ]. Two studies reported a significantly lower mortality rate at up to 2 years in the intervention group over the control group, after the implementation of the multicomponent programme, which included home modifications as well as training control-oriented strategies to promote healthy behaviours [ 26 , 27 ]. However, there was no statistically significant effect on survival at 3 years post intervention.

3.6. Quality of Life

Two randomised trials found a positive effect of interventions on quality of life [ 21 , 22 ]. Ahmed 2013 found that quality of life was significantly enhanced in the intervention group, compared to the control group, 2 months after home modifications among paraplegic wheelchair users [ 21 ]. Also, additional lighting adjustments in the living room increased quality of life and wellbeing among adults with low vision [ 22 ]. Conversely, a cross-sectional study found no associations between quality of life, and home safety and accessibility factors such as hazards, grab bars and visual cues among adults with dementia [ 28 ].

3.7. Psychological Effects

Psychological effects of home accessibility interventions were identified. For instance, older adults with functional difficulties reported less fear of falling following multicomponent home intervention [ 25 ]. One mixed-method study, which presented findings as themes from the qualitative part of the study, also identified a reduced fear of accidents: 62% of the recipients of minor adaptations (mainly handrails and grab-rails) reported “feeling safer from accidents”, and recipients of major adaptations also expressed the relief of feeling safer [ 29 ]. In addition, “ending depression” was identified in the theme of health gains from good quality adaptations for people with physical impairments.

3.8. Occupational Performance

A significant increase in self-perceived occupational performance up to 6 months after home modifications among low-income adults with functional limitations was reported [ 32 ]. The outcome measurement included self-care (personal care, functional mobility and community management), productivity in work, household and play/school, and leisure (quiet recreation, active recreation and socialisation) [ 35 ].

4. Discussion

Studies included in this review differ greatly in terms of study designs, participants, interventions and outcomes. Although the majority of the studies’ participants were from the elderly population over 70-year old, the type, definition and level of functional limitations varied. Elements of interventions were remarkably diverse. Despite the fact that mobility related modifications were the most common, some home modifications also included heating or lighting. In addition, it is not clear if the effect of the multicomponent intervention was directly from the accessibility component, and which part of the intervention was more effective. Numerous psychometric instruments were used to measure the same outcomes, such as quality of life and changes in ADL/IADL. This methodological and statistical heterogeneity meant that we adopted a narrative approach to synthesise the findings, rather than performing a meta-analysis.

We found evidence for the positive effect of accessible home environments among people with functional limitations either ageing related or from other causes in this systematic review. Although it contains studies with a low level of quality of evidence, gathering and synthesising the existing evidence will help to guide further research and develop guidelines based on the best evidence available. Overall findings of this review suggest that, in general, people with functional limitations living in accessible home environments have better health, wellbeing and ADL/IADL than those living in conventional or inaccessible home environments. Physical health benefits were identified, such as reductions in falls and injuries. Lower mortality rates were also identified among older adults with functional limitations up to two years after a multicomponent home intervention. Self-perceptions of increased quality of life and general wellbeing were found, along with psychological effects such as reduced fear of falling/accidents and feeling of depression. As fear of falling is known to be a strong risk factor for functional decline and falls [ 25 ] this reduction in fear is also an important finding. Furthermore, home modifications decreased difficulties and increased safety and self-efficacy in ADL/IADL outcome measures [ 25 , 30 , 31 ]. This suggests that people who already have difficulties functioning in everyday life can benefit from home accessibility features, possibly delaying deterioration of their already limited functions.

We did not identify any study reporting the effects of the interventions on dependency on external social care services. Instead, most outcomes were elements in performing ADL/IADL. It seems that longitudinally, improvements in managing ADL/IADL, such as safety, may delay people with impairments being reliant on caregivers or social services. Also, social participation was not directly measured as an outcome in any study. Nevertheless, some psychometric instruments used in the included studies contain rather broad components. For example, occupational performance was reported in one study [ 32 ] in terms of performance, and satisfaction with performance in work and leisure. Also, the Client-Clinician Assessment Protocol Part 1, which was used in two studies [ 30 , 31 ], contains a leisure and social activities component, although the remainder is related to ADL, IADL and mobility.

It is noticeable that two studies found no significant change in perceived dependence with ADL/IADL after home modifications [ 24 , 30 ]. This is important because one reason for providing interventions that enhance home accessibility features is to increase the functional independence of people with impairments. However, the participants in both of these studies were aging populations thus their functions may rapidly decline, which means specific home modifications might have an effect for a short period of time only [ 36 ]. Furthermore, the primary goal of home modifications for older adults with impairments may be to enable them to live in their own home, rather than increasing their independence per se [ 30 ].

Several studies indicated that people with functional limitations received the greatest benefits from interventions in terms of bathroom use, such as bathing, showering and toileting [ 24 , 25 , 30 ]. This may be because half of ADL tasks focus on the bathroom; and a large number of home adaptations have targeted hygiene facilities [ 24 ]. Nonetheless, this is an important finding because it can inform planning for home modifications for people with impairments. Furthermore, Heywood 2004 identified that home modifications that were inadequately implemented due to bad planning or administrative errors, actually had a negative impact on physical and mental health of persons with functional limitations [ 29 ]. This indicates that home modification planning should consult with service users as well as health and architectural professionals.

Our search strategy was not restricted to any type of functional limitations but all included studies, except one, were with participants who had physical impairments. During our screening process, it was clear that studies on home environments for people with cognitive impairments were concerned with other environmental matters, such as ‘the creation of safe and secure, simple and well-structured, and familiar environments’ for older adults with dementia [ 37 ]. Nevertheless, some of those environmental factors may not necessarily be related to their quality of life: no association was found between patient-perceived quality of life and home accessibility and safety factors among adults with dementia [ 28 ]. Instead, having more unmet assistive device/navigation needs and health conditions were associated with lower quality of life [ 28 ].

We conducted this systematic review to gather evidence on the effects of the accessible home environment for people with functional limitations, but the findings reach beyond this group. Benefits of accessibility features in the home environments were also apparent for caregivers and family members, who gained positive health impacts, such as greater safety, and prevention of falls and injuries [ 29 ]. Furthermore, it is clear that a second person—usually also an older adult—in the household would also use the accessibility features, such as rails or shower [ 29 ]. From a population health perspective, this indicates that providing home accessibility interventions may have additional benefits for others; preventing the development of more severe functional limitations, enhancing quality of life and lowering the costs of healthcare. The results of our review are clearly relevant to the ICF framework, given the emphases on the interaction between personal, technological and environmental factors. Furthermore, the results are applicable to the WHO World report on ageing and health, providing evidence that environmental accessibility and safety enable greater functioning in older people [ 38 ].

Study Limitations

There are methodological limitations in the studies included in this review. First, this systematic review included a relatively small number of papers with relatively small sample sizes; making it unfeasible to draw generalised conclusions. Furthermore, the quality of the evidence compiled in this review is quite uneven. Non-randomised studies were included and only four randomised trials of good quality were identified. However, there might be ethical challenges in randomising persons to not receive an intervention or to delay its implementation if there is insufficient uncertainty about the potential benefits of the intervention. It is also important to note that most of the studies included in this review were conducted in the USA and Sweden. While there is no comprehensive national programme and only a few local programmes for home modifications in the USA [ 17 ], every local authority in Sweden has to provide home modifications for people with impairments by law [ 30 ]. Therefore, the country and systems context in which interventions are evaluated may be quite different, making it impossible to have a control group of people if they have been scheduled for home modifications.

A further limitation is that most of the outcomes in the included studies were subjective self-reports (e.g., ADL/IADL), not objective performance-based measures. However, self-rated function has been found to be useful in clinical assessment as it is predictive of broader health outcomes [ 39 ]. In addition, although outcomes are grouped in categories for the reason of convenience, it is important to acknowledge that ADL/IADL related outcomes—such as safety and self-efficacy—are not completely distinct from the psychological effects identified. There are also reliability and validity concerns with some of the psychometric instruments used for ADL/IADL related outcomes, as noted in several papers [ 22 , 30 , 31 ]. Finally, while the technology used to allow home improvements clearly has some psychologically beneficial effects, related areas have found that the use of assistive technologies, for instance, can present challenging issues concerning user’s self-identity—as being “disabled”—both in terms of how people think about themselves and their own bodily self-image [ 40 , 41 ]. Further exploration of these issues in the context of home improvements may also be worthwhile.

5. Conclusions

Home environments that lack accessibility modifications appropriate to the needs of their users are likely to result in people with functional limitations becoming disabled at home. The increasingly aging population means that this is a major concern and also related to the fundamental rights of persons with disabilities. Our systematic review indicates that, in general, interventions to enhance the accessibility of homes can have positive effects. However, currently available research is not robust as a body of evidence and should be considered as providing some support for this finding, albeit with some exceptions. Future research may need to be more specific about type of functional limitations, because different accessibility features may apply to mobility or cognitive impairments for instance. As researchers cannot entirely control the home modification process, it is problematic to conduct controlled studies in the home environment. However, high-quality research is needed, especially longitudinal studies, using standardised outcome measurements, to obtain a stronger evidence base for the benefits of home accessibility interventions. As it is unlikely that improvements to accessibility in the home will be instigated one modification at a time, researchers need to develop more sophisticated designs and analyses in order to partial out the effects of multiple interventions in different types of settings, and health and welfare systems.

Acknowledgments

We thank Kath Wright, expert searcher, from the Centre for Reviews & Dissemination, University of York, UK, who designed and refined the search strategies. We also thank the World Health Organization for funding this research, Susan Stark from Washington University, USA for her advice; and reviewers of this paper for helpful comments.

Appendix A. Search Strategy for Ovid MEDLINE

In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) <1946 to Present>, Search date: 22 December 2014, Records identified: 6829 (5635 after de-duplication)

• exp Disabled Persons/ (48958)
• exp housing/ (26214)
• 1 and 2 (426)
• (home or homes or house or houses or housing or residen$ or built environment or living environment).ti. (111898)
• 1 and 4 (1382)
• architectural accessibility/or “Facility Design and Construction”/or residence characteristics/or environment design/ (34524)
• 1 and 6 (1156)
• ((home or homes or house$ or housing or residen$) adj2 (adapt$ or modif$ or access$ or usability)).ti,ab. (2117)
• (smart home$ or smart home technolog$).ti,ab. (193)
• (assistive technolog$ and (home or homes or house or houses or housing or residence$ or built environment$ or living situation)).ti,ab. (163)
• environmental barrier$.ti,ab. (430)
• universal design.ti,ab. (148)
• (disability or disabled or handicap$).ti,ab. (129312)
• 2 and 13 (410)
• ((disability or disabled or handicap$ or frail$) adj2 (home or homes or house or houses or housing or residen$ or environment)).ti,ab. (592)
• (home environment$ adj2 intervention$).ti,ab. (15)
• (environment$ intervention$ adj2 home$).ti,ab. (26)
• person environment$ fit.ti,ab. (139)
• person-environment$ fit.ti,ab. (139)
• person environment$-fit.ti,ab. (139)
• person-environment$-fit.ti,ab. (139)
• (home or homes or house or houses or housing or residen$ or built environment or living environment).ti,ab. (378471)
• (functional$ adj (handicap$ or impair$ or limit$ or decline$ or deficit$ or disable$ or disability)).ti,ab. (28806)
• (cognitive$ adj (handicap$ or impair$ or limit$ or decline$ or deficit$ or disable$ or disability)).ti,ab. (57923)
• (mental$ adj (handicap$ or impair$ or limit$ or decline$ or deficit$ or disable$ or disability)).ti,ab. (5162)
• (physical$ adj (handicap$ or impair$ or limit$ or decline$ or deficit$ or disable$ or disability)).ti,ab. (8385)
• (motor adj (handicap$ or impair$ or limit$ or decline$ or deficit$ or disable$ or disability)).ti,ab. (11157)
• (hearing adj (reduc$ or loss or handicap$ or impair$ or limit$ or decline$ or deficit$ or disable$ or disability)).ti,ab. (39532)
• ((vision or visual or sight) adj (reduc$ or loss or handicap$ or impair$ or limit$ or decline$ or deficit$ or disable$ or disability)).ti,ab. (21276)
• (blind or deaf or frail$).ti,ab. (173515)
• wheelchair user$.ti,ab. (856)
• amputee$.ti,ab. (4124)
• 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 (338691)
• 2 and 33 (331)
• (((functional$ adj (handicap$ or impair$ or limit$ or decline$ or deficit$ or disable$ or disability)) or (cognitive$ adj (handicap$ or impair$ or limit$ or decline$ or deficit$ or disable$ or disability)) or (mental$ adj (handicap$ or impair$ or limit$ or decline$ or deficit$ or disable$ or disability)) or (physical$ adj (handicap$ or impair$ or limit$ or decline$ or deficit$ or disable$ or disability)) or (motor adj (handicap$ or impair$ or limit$ or decline$ or deficit$ or disable$ or disability)) or (hearing adj (reduc$ or loss or handicap$ or impair$ or limit$ or decline$ or deficit$ or disable$ or disability)) or ((vision or visual or sight) adj (reduc$ or loss or handicap$ or impair$ or limit$ or decline$ or deficit$ or disable$ or disability)) or (blind or deaf) or wheelchair user$ or amputee$) adj (home or homes or house or houses or housing or residen$ or built environment)).ti,ab. (170)
• wheelchairs/ (3833)
• 2 and 36 (27)
• 22 and 36 (246)
• communication aids for disabled/ (2187)
• 2 and 39 (6)
• 22 and 39 (82)
• (mobility adj (impair$ or device$ or aid$)).ti,ab. (934)
• 2 and 42 (6)
• 22 and 42 (171)
• 3 or 5 or 7 or 8 or 9 or 10 or 11 or 12 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 34 or 35 or 37 or 38 or 40 or 41 or 43 or 44 (6931)
• (rat or rats or mouse or mice or poultry or pig or pigs or cat or cats or sheep or cow or cows).ti. (1370530)
• 45 not 46 (6829)

Appendix B. Characteristics of Included Studies

RCT: randomised controlled trial; N/A: not applicable; MMAT: mixed method appraisal tool; MMAT *: * the lowest and **** the highest score; SD: standard deviation; CI: confidence interval; OR: odds ratio; ADL: activities of daily living; IADL: instrumental activities of daily living; CES-D: center for epidemiologic studies depression scale; NHIS-D: national health interview survey on disability; ISO-SMAF: functional autonomy measurement system.

Author Contributions

All authors contributed to designing the research. Hea Young Cho conducted the article screening, study appraisal, data extraction and preparation of the manuscript, which was supervised and finalized by Malcolm MacLachlan. Michael Clarke contributed as the method expert and independently screened the records. Hasheem Mannan reviewed the data extracted and quality assessments of the studies. All authors edited and approved the final manuscript.

Conflicts of Interest

The authors declare no conflict of interest.