Abstract
Importance:
Accessible home modifications (HMs) can positively influence the lives of people with disabilities (PwDs). Occupational therapists may recommend HMs, but implementation often falls to clients. Research on the experiences of PwD related to implementing accessible HMs in a North American context is lacking.
Objective:
To describe the process and impacts of implementing accessible HMs from PwDs’ perspective.
Design:
Qualitative descriptive design with semistructured interviews with codebook thematic analysis to identify themes.
Participants:
Community-dwelling adults with musculoskeletal and sensory disabilities (n = 31) and 2 cohabiting caregivers from Ontario, Canada, who had either made HMs or required accessible housing. Fourteen of these participants also had professional expertise related to accessible housing.
Outcomes and Measures:
The primary outcome was participant perspectives and experiences related to HMs. No standardized measures or hypotheses were used, consistent with the exploratory qualitative design.
Results:
Four themes emerged that depict the process and impacts of implementing HMs: (1) impacts of an unmet need for HMs, (2) barriers to and (3) facilitators of effective HMs, and (4) outcomes and benefits of having HMs. Issues related to independence, safety, and dignity, as well as how structural, financial, and attitudinal barriers intersect in decision-making. Participants also described a lack of guidance on how to approach the HM process.
Conclusions and Relevance:
Findings highlight the importance of HMs to achieve person–environment fit. Given the complexities of the HM process, occupational therapists are well positioned to support individuals in navigating this process and to contribute to broader advocacy efforts.
Plain-Language Summary
This study looked at how people with disabilities make their homes more accessible or how they assist others with this process and the challenges they run into. People who took part said they had to find information on their own and speak up for themselves. They described their independence, individual needs, and finances as being important. The results highlight the importance of helping people make their homes more accessible and ways that occupational therapists can help.
This study looked at how people with disabilities make their homes more accessible or how they assist others with this process and the challenges they run into.
Accessible housing is designed, built, or modified to improve function, facilitate independence, and ease care (Canada Mortgage and Housing Corporation, 2018). There is a substantial need for accessible housing; one in four Canadians lives with disabilities that limit occupational participation (Statistics Canada, 2023), and 45% of people with physical disabilities require at least one assistive device or accessibility feature at home (Choi, 2021). Although access to appropriate and affordable housing is generally recognized as a human right, many people with disabilities (PwDs) experience unmet needs for accessibility because of the costs of renovations and a lack of resources (Giesbrecht et al., 2017).
Systemic, institutional, and societal factors shape environments and systems that hinder full engagement in life for PwDs (Reber et al., 2022). Existing housing policies in Canada frequently mandate only minimal accessibility standards, leaving many PwDs in low-quality and unaffordable homes that fail to meet their needs (Randle & Thurston, 2022). Barriers include limited information and guidance on home adaptation, structural constraints, and homeownership status (Fawkes et al., 2024; Roy et al., 2008). In addition, underfunded disability support services (McCuaig & Cowie, 2017) exacerbate challenges given that PwDs are twice as likely to live below the poverty line (Crawford, 2013).
Occupational therapists undergo extensive training in adapting the environment to promote health, safety, and occupational engagement (Canadian Association of Occupational Therapists, 2024). They regularly perform home safety assessments and prescribe accessibility-related home modifications (HMs; Young et al., 2019). Although occupational therapists may assist clients with navigating funding sources, there can be a disconnect between the recommendations they make and the ultimate implementation of those recommendations (Fawkes et al., 2024). North Americans are often responsible for obtaining financial support, if eligible, from a patchwork of government and nonprofit programs, and for hiring professionals to carry out the modifications. For example, in Ontario, Canada, a not-for-profit organization administers a government-funded financial aid program for citizens in financial need to assist with HMs (Ministry for Seniors and Accessibility, 2022), and a federal tax credit is available to eligible individuals (Government of Canada, 2023). However, these credits are often insufficient to fully cover the extent of HMs required.
A number of qualitative studies have explored the process and impacts of HMs in countries that offer federally administered HM funding programs, such as Sweden (Pettersson et al., 2012), the United Kingdom (Whitehead & Golding-Day, 2019), and Australia (Aplin et al., 2015, Gillett et al., 2026). Participants in these studies, and in a smaller number of studies conducted in North America, have commonly described the importance of home accessibility or inaccessibility to feelings of personal safety, home usability, and quality of life through the impacts on activity participation, dignity, and independence (Goddard et al., 2025; Greiman et al., 2022). There is a lack of qualitative research, however, on the process HM from the context of North America, where HM funding programs are decentralized (Lindsay, Fuentes, et al., 2024). To begin to address this gap, in the current study we aimed to describe the process and occupational impacts of implementing HMs from the perspective of PwDs in Ontario, Canada. Insights into the HM process from the perspective of end users are important for occupational therapists because they can guide improved practices through facilitating better understanding and advocating for client needs.
Method
Design
We adopted a qualitative descriptive design (Vears & Gillam, 2022) to derive content categories directly from the data and ensure the applicability of the findings to occupational therapy practice. To recruit community-dwelling hard-to-reach participants who may seek anonymity, we used snowball sampling (Parker et al., 2020) and distributed flyers through partnering organizations, such as hospitals, advocacy groups, housing organizations, and social media. To ensure inclusion and accessibility for PwDs, data collection options included in person, online, or telephone interviews and surveys.
Participants
In this article, we present an analysis of a subset of data collected as part of a larger study on co-creating priorities to advance accessible housing practices, policy, and research in Canada (Hitzig et al., 2025). Inclusion criteria were self-identification as having made accessibility-related HMs or as requiring HMs. Both PwDs and cohabitating family caregivers of a PwD were eligible for inclusion. Participants were required to be English- or French-speaking community-dwelling adults (age ≥18 yr). Of the 33 participants interviewed, 14 self-identified as having professional expertise in accessible housing, which included formal paid or volunteer experience relevant to accessible housing and familiarity with housing in the context of Ontario, Canada. The exclusion criteria were living outside of Ontario, Canada; inability to provide informed consent; or diagnosis of a severe cognitive disability (e.g., dementia) or severe mental illness (e.g., psychotic disorder).
Data Collection
Study approval was obtained from research ethics boards at the University of Toronto (No. 00046200) and Sunnybrook Health Sciences Centre, Toronto (No. 5775). All individuals who self-referred, met inclusion criteria, and provided informed consent were accepted to participate in the study, which began in May 2023. After consent was received, interviews were scheduled, and participants completed a preinterview survey to collect sociodemographic, disability, and housing information. Study materials have been published in open-access form (Yuzwa, 2024). Participants with relevant professional expertise were asked additional questions to describe their professional role and experiences related to accessible housing. Participants with professional expertise are differentiated in this article text by an ID beginning with P. Survey data were collected online or via telephone and managed using REDCap electronic data capture tools hosted at Sunnybrook Research Institute in Toronto (Harris et al., 2009, 2019).
All participants completed a 45- to 60-min audio-recorded semistructured interview over Zoom video conferencing, telephone, or in person, with an interviewer trained in qualitative methodology (Eva Cohen or Kirstin E. Yuzwa). Broad open-ended questions asked participants to describe their disability or disabilities; housing suitability; and personal and professional experiences with HM services, information, and financial resources. Although none of the researchers who completed the data collection identified as having a physical disability, PwDs were involved in reviewing the research proposal, protocols, study materials, and providing of feedback on the qualitative findings.
Data Analysis
We analyzed the data using codebook thematic analysis (Braun et al., 2018; Braun & Clarke, 2022). After familiarizing themselves with the transcripts and generating initial codes from the data, four investigators (Farah Bacchus-Misir, Kirstin E. Yuzwa, Siobhan Galeazzi, and Sander L. Hitzig) iteratively identified themes by adding or combining initial codes. All data were coded by three investigators (Bacchus-Misir, Yuzwa, and Galeazzi) who used NVivo (Version 12) to organize the study data. Two of the investigators (Bacchus-Misir and Galeazzi) were occupational therapy students, one was a clinical occupational therapist and researcher (Yuzwa), and one was a research scientist with a background in psychology and rehabilitation (Hitzig). Reflexive notes were kept, and disagreements were tracked in an audit trail. A codebook was maintained that allowed us to trace themes back to the original data. Themes were finalized through consensus meetings with Bacchus-Misir, Yuzwa, Galeazzi, and Hitzig.
Results
Participants (N = 33) included 31 PwDs and 2 family caregivers (Table 1). Of the 33 participants, 42% had professional experience related to accessible housing, including, but not limited to, the roles of lawyer, realtor, architect, advocate, accessibility advisor, and social worker. Participants identified as having a variety of medical conditions, including, but not limited to, arthritis, Ehlers-Danlos syndrome, cerebral palsy, muscular dystrophy, spinal cord injury, amputation, multiple sclerosis, myalgic encephalomyelitis, poliomyelitis, glaucoma, retinitis pigmentosa, and deafness. Participants resided in a mix of housing types—condominiums, apartments, and single-family houses—and represented both homeowners and renters. Approximately half of participants reported a low income, defined as an annual combined household pretax income of less than C$60,000 (US$43,000).
Participant Characteristics
Note. HM = home modification.
a N = 30; 3 participants preferred not to report their information.
bReported secondary conditions included attention deficit hyperactivity disorder, autism, asthma, sarcoidosis, chronic fatigue syndrome, posttraumatic stress disorder, and diabetes mellitus.
c N = 26; 7 participants preferred not to report their information.
We identified four key themes that depict the process and impacts of implementing accessible HMs. Theme 1 describes the impact on participants’ lives of an unmet need for HMs, Themes 2 and 3 describe barriers to and facilitators of effective HMs, and Theme 4 focuses on outcomes and benefits of HMs.
Theme 1: Impact on Participants’ Lives of an Unmet Need for HMs
Participants consistently expressed decreased occupational participation because of challenges accessing their entire home, which was best described by Participant A012 (age 55–60, owner of a single-family house) as “limiting my potential.” In addition to the home’s overall structure being described as limiting, specific areas and features frequently mentioned as being inaccessible included stairs; points of entry and egress; internal doorways; bathrooms; kitchens; and technological features, such as lighting, elevators, appliances, and intercoms.
Inaccessible homes were associated with significant safety risks for some participants. This was exemplified by Participant A001 (age 45–50, apartment tenant), who described needing to move to a more accessible home after being a new wheelchair user in an inaccessible space that left her reliant on others for basic self-care activities: I could not get my wheelchair into the washroom. … I could not get into my kitchen because it was a galley kitchen; a wheelchair couldn’t fit in there. So, I couldn’t open my fridge; I couldn’t get water. … [My caregiver] used to bring me lunch every day, but they couldn’t get to me because of [a local marathon]; the city was closed. So, there was a whole day with no water, no food, no medication. … I was completely dependent on other people. … So, [my home] gave me no options and gave me no dignity, which became a huge mental health and physical health issue, because I couldn’t take my medication.
Safety was also affected for Participant A018 (age 70–75, owner of a single-family house), who described confinement after having two serious fall-related injuries at their home entryway and further challenges as a result of being recently widowed: If I’m going out, it’s a problem getting out and getting in, from those steps. If it’s raining, or if it’s winter, the walkway and driveway [are] slippery. Now, I can’t manage clearing up the driveway. My wife used to help me, but I can’t manage it on my own. Very often now … I have no choice but to stay at home.
Participants described the desire for independence and the importance of maintaining a sense of personal dignity by being able to independently complete intimate self-care activities, such as showering and toileting. For example, Participant P008 (age 65–70, apartment tenant) described wanting independence with showering and experiencing indignity in having to rely on unwanted help: Before my unit was modified, I went through six months [when] I had a bathtub, so I had to have sponge baths, and it was difficult getting my hair washed. Having that dignity taken away from you just because developers don’t want to build it or they don’t see that there’s a market for it, it’s truly discriminating.
Theme 2: Barriers to HMs and How Participants Navigated Them
Lack of Information
Participants without professional expertise in accessible housing reported that they lacked information and guidance regarding HMs. Many had encountered difficulties finding contractors knowledgeable about accessibility, finding financial support options and, for renters, information on legal rights to HMs. This resulted in participants actively seeking information on the internet, with one participant stating, “We turn to Google … ‘Let’s Google this to see if there’s something out there for us to help make this house accessible’” (Participant A023, age 30–35, owner of a single-family house).
Participants also described seeking information from readily available community health care professionals who did not specialize in home accessibility, such as a local pharmacist or family doctor. Participant A012 (age 55–60, owner of a single-family house) said, “I [was] really just relying on the guy at [pharmacy chain] to talk to me through what [HM] options there were. I’m pretty sure that’s all I had at that time. Maybe a little bit of internet.”
For some, navigating the steps required to implement HMs was described as overwhelming. Participant A001 (age 45–50, apartment tenant) attributed this overwhelm to living with limited energy as a result of having to navigate inaccessibility: I find navigating what [information] might be out there, or might not be out there, to be overwhelming. And, when you’re already in a space where just coping, so that you can go to work every day, that is the maximum capacity you have left. When you have no access in the world, it’s overwhelming to think about. … I think it’s hard to know where to go to get help and to get answers on what our options and our rights might be.
Negative Attitudes
Other participants described how negative attitudes toward accessibility or disability from landlords or property managers limited their ability to implement HMs. For example, Participant P023 (age 50–55, townhouse tenant) spoke of how a landlord viewed visible HMs (e.g., an entryway ramp) as being an “eyesore,” leaving them hesitant to ask for other needed HM out of fear of being evicted: Any conversation that includes accommodation or accessibility is [worrisome] … because I don’t want to use those words, because I feel they invoke some sort of, “Oh, she’s giving us [legal] terms.” And that seems to alter how people are going to respond. So, I try not to be. … It sounds really awful, but I try to appear to be more easygoing by saying “This would help me” rather than saying “This is an accommodation.” Because this is better than being on the street.
Structural Limitations and Costs
Participants expressed that HMs needed to fit within limitations of their budget and the building’s structure. Some described how some modifications, such as widening door frames or moving walls, can be cost prohibitive. For example, Participant A013 (age 40–45, apartment tenant) expressed, “I do have a bit of fear. … Depending on what I’m asking for, [the building management] may not be able to provide it since this building is old.” Similarly, participant P010 (age 80–85, condominium owner), described limiting their HMs because of structure and cost: “We’ve tried to make our place accessible, but you can’t. It’s a 50-year-old condo with cement and wire mesh walls, and to take out part of the wall is hugely expensive.”
Theme 3: Facilitators of Effective HMs
Hiring Knowledgeable Professionals
Some participants described how accessing professionals knowledgeable about home accessibility helped them navigate the HM process, as exemplified by Participant A009 (age 40–45, townhouse tenant), who had consulted an advisor through a local disability organization: “Once I had a better understanding … I then knew what was the best course of action and steps to take. I worked to make my home more accessible and make my life more independent and less challenging.”
Many participants who had professional experience in accessible housing themselves expressed confidence in independently navigating their own HM process. For example, Participant P024 (age 75–80, owner of a single-family house) described a positive HM experience by consciously choosing builders with accessibility experience: I realized what’s available. I’d spoken to a contractor who had done similar projects and understood the needs. He was able to get the plumbers to do the right things, the electricians to do the right things. … [Accessibility] was not a foreign language to him. …We had a great contractor. I did my homework.
Other participants who had professional experience in accessible housing described using their knowledge to purchase a home with a more adaptable design to best minimize the need for HMs and the associated costs (e.g., a single-level bungalow vs. multilevel home). For example, Participant P018 (age 40–45, owner of a single-family house) shared the following: We have the benefit of understanding the costs. … Something we thought was … we could eliminate those [less accessible] options right away and, over the long term, accrue the costs of paying for a bungalow versus putting in [an elevator or stair lifts] and having to live through a renovation.
Self-Advocacy
Participants with and without professional home renovation expertise described needing to self-advocate for their needs to achieve home accessibility. For example, Participant A002 (age 60–65, owner of a single-family house) described advocating to a builder to have her specific needs met: When we started, it was, we did it all on our own. I couldn’t find any architects who specialized in accessible home design. … I asked our handyman, “Can you redo the stairs for us?” And I said, “This is what I need.” And I came home from work one day, and he said, “Okay, this is what I’ve done,” and I said, “Well, you didn’t listen to what I said,” and he said, “But I had to build them to code,” and I said, “No, you didn’t; you needed to build them for me because I need shallower steps and longer.” So I said, “No, that’s not what I asked for.” So, he said, “Okay, no problem. I’ll do it.” And he did [rebuild the stairs]. That helped me to be more independent and mobile for another eight years.
This participant also described the benefit of hiring contractors who are “very open” and “flexible” such that they enter into the HM process “with a sense of adventure.” This emphasizes how hiring professionals who have a positive attitude and growth mindset toward accessibility and disability helps facilitate the HM process and achieve a positive outcome.
Balancing Form and Function
Another individual consideration frequently mentioned was the aesthetic qualities of HMs and, on occasion, the need to balance or prioritize aesthetics and functionality. For example, Participant P027 (age 55–60, condominium owner), who had sight loss, described accessibility challenges with respect to navigating around decorative items at home, stating “[My wife] keeps a beautiful home, but sometimes keeping a beautiful home and making it functional are two separate things.” Similarly, Participant A017 (age 60–65, condominium owner) described frustration with inaccessibility after completion of a recent renovation to common-space (gym/pool) bathrooms: “[The designers] think if they make something pretty that’s good enough. … And I like pretty as much as the next guy … but taste is very personal, and structure is what you need to function.” Some participants who were pleased with the end result of their HMs described the importance of accessibility blending into their home’s aesthetic. For example, Participant A004 (age 50–55, owner of a single-family house) stated, “Even the grab bars in my bathroom are decorative. … Why should I have to look different just because I have a disability?”
Theme 4: Benefits of Having HMs
Participants described improved health, safety, social participation, and an overall improved quality of life because of HMs. For example, Participant A011 (age 45–50, apartment tenant) reported feeling safer and more energized throughout the day after a door with a wider entryway and an automated opener were installed. They described experiencing fewer collisions between their wheelchair and the walls: Yes, that was a whole lot better than trying to muscle the door open, and push the door open, and squeeze in. That was a big positive change for me. … I don’t want to think about what would it be like without the automated feature; those things definitely helped.
Others described how existing accessibility features improved their ability to socialize and helped them avoid further HMs. For example, Participant P032 (age 65–70, condominium owner) stated, [In] my building, it was a pleasant surprise that they had Braille on the elevator. … I could identify the main lobby and the floor I need to go to in Braille. If I’m visiting somebody in another floor, the Braille helps me a lot.
Participant A015 (age ≥60, condominium owner), shared, We chose a building that had no internal steps or elevations, which is really important to me, because I have disabled friends who are [using] scooters or wheelchairs or who just have mobility issues. So that was already here, and the flooring could remain intact.
Participants frequently described the importance of bathroom HMs as essential for supporting intimate personal care tasks, such as toileting, perineal care, and bathing or showering. As Participant P018 (age 40–45, owner of a single-family house) explained, “I think [the bathroom] is one of those spaces. It’s your personal hygiene. It’s where you’re most vulnerable. You don’t necessarily want help in that area, unless you require it.” Similarly, Participant A012 (age 50–55, owner of a single-family house) explained that replacing an internal swinging door with a sliding pocket door increased the available bathroom floor space, allowing both them and their paid caregiver to move more easily. This change led to “a big quality-of-life change” for the better.
Discussion
In this study, we used a qualitative descriptive approach to explore the experiences of 33 PwDs and cohabiting caregivers of PwDs with respect to attaining accessibility-related HMs. The participants described personal experiences, impacts, outcomes, and complexities they had faced when undertaking the HM process. Four themes were identified. Theme 1 describes the impact of having unmet needs for HMs, including significant risks to personal safety, independence, dignity, and isolation. Theme 2 focuses on barriers to the HM process, including a lack of information, negative attitudes, structural and financial constraints, and overwhelm caused by inaccessibility and navigating fragmented systems. Theme 3 describes factors that facilitated effective HMs for participants, including access to knowledgeable and open-minded service providers, self-advocacy, and modification solutions that balance and align aesthetic preferences and functional needs. Theme 4 describes the benefits participants experienced with having effective accessibility features at home, including improvements to overall quality of life, social and leisure activity participation, and significant positive impacts on dignity thanks to bathroom modifications that support care and independence with intimate personal hygiene tasks.
Affordability was identified as a key consideration that broadly underlies the four themes, with many PwDs facing challenges in affording necessary HMs. This subject has been addressed in detail, alongside policy considerations, in publications based on the larger project of which this subset analysis is a part (Hitzig et al., 2025; Yuzwa et al., 2026). In brief, the piecemeal funding system for HMs that is common across North America has previously been identified as a major barrier (Fawkes et al., 2024; Giesbrecht et al., 2017), limiting HM choices for low-income individuals (Hounsell et al., 2021). This result highlights a key role for occupational therapists in advocating for more comprehensive HM support programs that expand access to evidence-based information sources and knowledgeable service providers, streamline the modification process, and ultimately promote health and occupational engagement.
Previous research has indicated that housing professionals often misunderstand the needs of PwDs, leading to insufficient services and modifications (Fawkes et al., 2024), and that limited availability of information on accessibility features and services can hinder the HM process (Roy et al., 2008). Research also has found that renters can face added barriers to HM because of landlord attitudes (Lindsay, Ragunathan, et al., 2024). The results of this study bolster these findings and add that hiring professionals who are knowledgeable about accessibility, and renovation service providers with positive and flexible professional attitudes, is an important facilitator of successful results. This result reinforces calls for more effective collaboration among HM professionals (Fawkes et al., 2024) and highlights service gaps for occupational therapy clients as they navigate information and support across the process of implementing HMs.
Implications for Occupational Therapy Practice
The results of this study have practice implications for occupational therapists, in particular those working in hospital and community settings. Previous reports of important dimensions for occupational therapists’ consideration when undertaking home assessments and HM recommendations include financial resources, health status, social support, physical space (Aplin et al., 2013), and functional needs (Cho et al., 2016). Our findings illustrate how a lack of accessibility in homes can influence basic needs, such as access to nutrition, medication, emergency egress, personal hygiene, and social interaction. This result supports the need for critical consideration of client safety when assessing home accessibility and making HM recommendations, such that it remains at the forefront of clinical analysis and decision-making.
Conclusion
In line with prior research showing that disability can require adaptation to a new self-identity (Adler et al., 2021) and that medical-style home structural designs can carry stigma (Struckmeyer et al., 2021), our study adds new insight into how individuals weigh aesthetics against functionality. Participants emphasized the importance of maintaining their home’s appearance, yet some criticized modifications or home features that prioritized aesthetic value over usability. These findings bolster the literature suggesting that successful HMs must strike a balance between visual appeal and functional support (Heywood, 2005) and add the need to evaluate and respect client preferences for both form and function as they weigh in against practical constraints, such as financial, structural, social, or systemic limitations alongside risks to health and safety.
This study has some limitations. Participants in this study were concentrated in southern Ontario, and thus the views of PwDs living in other regions of the province are not represented. In addition, people with cognitive, intellectual, and severe mental health disabilities were not included, meaning that the described experiences of PwDs and caregivers are those of people going through life with sensory and mobility impairments.
This study also has notable strengths. It had a participatory design wherein a community partner and two representatives from local disability organizations, each of whom were wheelchair users with a mobility disability, were invited to participate in team meetings and to review and provide feedback on the research proposal, design, materials, and results. The study budget included provision for a stipend for these partners in appreciation for their contributions. Future studies should similarly use participatory approaches to support research and knowledge translation efforts that have been identified as meaningful and effective to knowledge users. Additional studies that include participants from diverse geographic regions, as well as those with cognitive, intellectual, and mental health disabilities, would help deepen the profession’s understanding of how location and disability type influence the experiences of PwDs undertaking HMs.
Overall, this study highlights the experiences of PwDs who have navigated the implementation of accessible HMs, revealing barriers that often required problem-solving and self-advocacy to secure modifications that supported their quality of life, dignity, and daily activity participation. Key considerations for occupational therapy practitioners include prioritizing resource navigation and advocacy support and evaluating client safety and choices in aesthetic preferences and functionality. Given their expertise, occupational therapy practitioners are well positioned to take the lead in prescribing HMs and to advocate in partnership with disability community organizations for improved government funding for both occupational therapy services and HM financial supports. They can also provide leadership in this practice area through research and development of resources related to HMs, supporting professional education, and developing best practice guidelines for HM.
Footnotes
Acknowledgments
This project was funded by Accessibility Standards Canada/the Government of Canada (Grant ASC-23/24-045-G). Sander Hitzig holds the John C. and Sally Horsfall Eaton Chair in Rehabilitation Research, a joint Hospital-University Chair between the University of Toronto, the Sunnybrook Health Sciences Centre, and the Sunnybrook Health Sciences Centre Foundation.