Cognitive
Impairment,
Mental Healthand Transport
Design with Everyone in MindINTERNATIONAL TRANSPORT FORUM
The International Transport Forum is an inter-governmental body within the OECD family.
The Forum is a global platform for transport policy makers and stakeholders. Its objective is
to serve political leaders and a larger public in developing a better understanding of the roleof transport in economic growth and the role of transport policy in addressing the social andenvironmental dimensions of sustainable development. The Forum organises a Conference for
Ministers and leading figures from civil society each May in Leipzig, Germany.
The International Transport Forum was created under a Declaration issued by the Council of
Ministers of the ECMT (European Conference of Ministers of Transport) at its Ministerial Sessionin May 2006 under the legal authority of the Protocol of the ECMT, signed in Brussels on
17 October 1953, and legal instruments of the OECD. The Forum’s Secretariat is located in Paris.
The Members of the Forum are: Albania, Armenia, Australia, Austria, Azerbaijan, Belarus, Belgium,
Bosnia-Herzegovina, Bulgaria, Canada, Croatia, the Czech Republic, Denmark, Estonia, Finland,
France, FYROM, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Italy, Japan, Korea, Latvia,
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The OECD and the International Transport Forum established a Joint Transport Research Centre
in 2004. The Centre conducts co-operative research programmes addressing all modes oftransport to support policy making in Member countries and contribute to the Ministerial sessions of
the International Transport Forum.
Also available in French under the title:
Déficience cognitive, santé mentale et transports : Vers une accessibilité pour tous
Further information about the International Transport Forum is available on Internet at:

www.internationaltransportforum.org© OECD/ITF 2009
No reproduction, copy, transmission or translation of this publication may be made without written permission.
Applications should be sent to OECD Publishing rights@oecd.org or by fax 33 1 45 24 99 30.

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CONTENTS . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Acknowledgements. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 4Foreword . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 5Introduction. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 7Transport accessibility: context and progress. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 7Cognitive impairment and mental health:A gap in policy and transport service provision. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 9Objectives of this report . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 9How many people? Who are they? . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 11
Cognitive impairment. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 11
Mental health problems. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 13
What are the transport issues?. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 14
What can be done?. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 16
Universal design. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 16
Education . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 17
Practical steps . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 17
Before the journey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
During the journey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Conclusions and recommendations. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 27
Before the journey. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 28
During the journey. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 28

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ACKNOWLEDGEMENTS. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
The International Transport Forum gratefully acknowledges:ò	The important research work in this field carried out by Professors Agneta
Ståhl and Susanne Iwarsson of Lund University in Sweden and the European
Commission funded MAPLE project.
ò	The contribution to the report made by Inclusion Europe, Mental Health Europe
and the European Disability Forum.
ò	Mrs. Ann Frye, expert consultant in the field of accessibility, for the preparationof this report.
The International Transport Forum is also grateful to Merseytravel in the UK for
use of the images taken from the MAPLE project brochure.

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FOREWORD. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Cognitive impairment affects a large and growing number of people andencompasses a wide range of conditions from autism to age-related dementia
and stroke. Mental health problems also impact large numbers of people, with
one in four individuals affected at some point in their lives.
For people both with cognitive impairment and those with mental healthproblems, using public transport can be a traumatic and challenging experience,and for many, simply impossible.
While much is being done to improve vehicles and infrastructure to meet theneeds of people with physical or sensory impairments, the issues of cognitive
impairment and mental health are largely neglected. There is a significant
untapped transport market for people who currently lack the confidence orunderstanding to make journeys.
A limited amount of research has been conducted in recent years to enhance
understanding of these issues and to suggest ways of overcoming the transport
problems that people with cognitive impairment and mental health problems face.
Many of the solutions are simple and low-cost, and by following the principles ofuniversal design, can also produce benefits for the wider travelling public.
The practical steps that can improve people’s ability to use public transport
include training of transport staff and familiarisation of people with cognitive
impairment or mental health problems with the transport system to help build or
restore their confidence.
Information is also key, and traditional ways of presenting timetable and othertransport information need to be re-considered. Other key factors include
the use of both audible and visual information and simple and clear signage.
Physical design features and the presence of staff can also help to build
confidence.
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This report is intended to help those who plan, design and run transportsystems and transport infrastructure to understand the issues that affect thissignificant proportion of the population and, in so doing, to find practical ways toimprove their services and facilities for the travelling public as a whole.

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INTRODUCTION . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Transport accessibility: context and progress
It is now widely recognised that accessibility is an important factor in ensuring
a high quality, efficient, sustainable transport system. It is no longer generally
regarded as an issue of concern only to a minority of people ‑ in particulardisabled people whose travel needs are seen as different from those of thegeneral population.
The demographic changes which affect all of us indicate very clearly that the
number of older people in the population will increase significantly. For example,
in Europe, the proportion of the population over 65 will increase by 40% in thenext 30 years and the share of all people over 80 will double. It is also wellunderstood that there is a strong correlation between age and disability: twothirds of disabled people are older, and over half the population aged over 75
has some form of disability.
Older people are the fastest-growing segment of the population in mostdeveloped countries.
The growing imbalance between working age people and older people will haveprofound social and economic implications. There will not be enough younger
people to support an older population that is not self-sufficient. Personal mobility
and access to public transport are essential components of independent living.
These trends must also be seen alongside the already significant population
who have mobility problems. Between 20% and 30% of people travelling havea mobility difficulty at any given time. In the countries of the European Union
currently upwards of 45 million people (roughly one in six) have a disability.
. www.internationaltransportforum.org/europe/ecmt/accessibility/pdf/CM200607Fe.pdf

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The European Conference of Ministers of Transport (ECMT), now theInternational Transport Forum, has been active for over 20 years in improving
understanding of the transport needs of disabled and older people at politicallevel and in putting forward practical solutions to them, in both policy andtechnical terms.(See website www.internationaltransportforum.org/europe/
Archives.html).
Transport Ministers have endorsed and supported these initiatives and haverecognised that:•All policy initiatives or developments in transport and land use planning should include
an evaluation of their potential impact on safety and accessibility of older and disabled
people.

•All links in the transport chain need to be improved so that an accessible environmentis created door to door, and increased efforts must be made to connect the different
means of transport and thereby create an integrated, safe and accessible transportsystem.

•

In particular, all new investments in transport must take account of and plan for
the needs of older and disabled people in accordance with the Charter adopted by
Ministers in Warsaw in 1999.

•

Close co-operation between governments, public authorities, manufacturers, operatorsand the people concerned is essential.
Many countries have taken strong initiatives based on these principles and haveintroduced legislation, regulation or other forms of support or incentive to ensurethat accessibility is integral to transport policy and development.

2. www.internationaltransportforum.org/europe/acquis/dis20013e.pdf
3. www.internationaltransportforum.org/europe/acquis/tphCharter.pdf

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Cognitive impairment and mental health:A gap in transport policy and service provision
There are, however, two groups of people whose mobility needs are little
understood by both governments and transport service providers: people withcognitive impairment and those with mental health problems.
The ECMT has highlighted this gap in accessible transport policy. A paper
outlining key policy messages on improving transport accessibility for all,presented at the Council of Ministers in Dublin in 2006, noted that:“these disabilities continue to be under-represented in accessible transport policy.
Disability comes in many forms: it is not enough to pay attention only to the needs of thosein wheelchairs or with walking difficulty. People with a loss of vision or hearing (both very
commonly associated with the ageing process) and those with intellectual disabilities
or mental health problems also have particular needs that can be addressed without
significant cost.”
A joint initiative between the ECMT and the UITP (The International Associationof Public Transport) on improving access to public transport has included the
publication of Guidelines for Transport Personnel. These guidelines specificallyaddress the need for transport staff to be trained in recognising and understanding
the needs of people with cognitive impairment and mental health problems.

Objectives of this report
The purpose of this report is to highlight the difficulties that public transport cancreate for people with mental health problems or with cognitive impairments;
examine how these difficulties affect people’s ability to use public transport and
4. www.internationaltransportforum.org/europe/ecmt/accessibility/pdf/CM200607Fe.pdf
. “Improving Access to Public Transport: Guidelines for Transport Personnel.” (75 2006 09 1 P), May 2006, 27 pages +CD-ROM, ISBN 92-821-0357-9.

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travel independently; and suggest what can be done to address the difficulties
both in practical and policy terms.
Accessibility for people with cognitive impairment or mental health problems,
as for people with other kinds of disability, is not only a social issue. There arealso strong economic arguments for enabling people to attain, retain or regain
independent mobility. The cost to society of providing support for people who
are unable to live independently is very high.
There is also a significant – largely off-peak – market for the transport industries
in providing for the needs of people who are predominantly non-drivers and forwhom public transport is the only option.
There has been relatively little quantitative research in this field but there issome significant qualitative research involving studies of groups of people
with a range of cognitive impairments and mental health problems. This reportdraws heavily on the work carried out for the ECMT by Professors Agneta Ståhl
and Susanne Iwarsson of Lund University in Sweden. Their work has, in turn,drawn on the European Commission-funded MAPLE project  and on Swedish
research at Lund University.
The recommendations in this report also include the input of organisations andindividuals who live with these issues or represent those who do.

. Persons with Cognitive Impairments and Public Transport CEMT/CS/AI(2005)5/REV2.
. Improving Mobility and Accessibility for People with Learning Disabilities in Europe (MAPLE).
. “Accessibility in Public Transport for Persons with Cognitive Impairments – Survey, Methodological Development andInnovative IT solutions.” (REKO)
. Mental Health Europe, Inclusion Europe, MENCAP (UK), Centre Rencontres pour personnes traumatisées cérébrales,
Switzerland.

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HOW MANY PEOPLE? WHO ARE THEY?. .  .  .  .  .  .  .  .  .  .  .  .  .
Taken together, cognitive impairment and mental health problems affect a large
number of people across countries.
This report will refer to cognitive impairment and mental health problems
largely in functional rather than medical terms. The issue here is to discuss
what aspects of public transport people find difficult or impossible and how thebarriers and problems which our public transport systems currently impose canbe tackled and alleviated.
Although there are very different issues affecting people with cognitive
impairment and mental health problems, there are also some common
difficulties. Individuals with cognitive impairment may also have mental healthproblems and people with mental health problems may, similarly, have somedegree of cognitive impairment. In functional terms and in a transport context
many of the problems that arise and the solutions to them are common to both– and indeed will often benefit a much wider population too.

Cognitive impairment
The term “cognitive impairment” encompasses a wide range of conditions fromlearning disability, autism or traumatic brain injury to age-related dementia or stroke.
In functional terms it can be taken to mean anyone whose ability to “perceive,organize and integrate information has been affected by their condition”10.
The term “learning disability” refers to a lifelong condition, usually present
from birth or that develops before the age of 18. It is a permanent condition,and people with learning disabilities may have impaired skills in areas such as
cognition, language, motor and social abilities.
10. Abreu BC & Toglia JP(1987) “Cognitive rehabilitation: a model for occupational therapy”.

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However, they also have a wide range of abilities. Some people can live
independent lives and will need help only in some very specific areas (forexample some people can read but have difficulties with numbers; some people
can count and calculate but have difficulties telling the time, etc).
Because of the close link between cognitive impairment and predominantly agerelated conditions such as stroke and dementia, the number of people in the
population with these impairments is increasing with the growing proportion ofolder people.
Dementia and related neurological conditions affect 10% of people aged
65 plus. In people aged over 85, around 50% have some form of cognitive
impairment ranging from mild to severe dementia.
Stroke is one of the most common causes of cognitive impairment. To takejust two examples, in Sweden 25 000 to 30 000 people every year have a
stroke while in Britain the annual figure is 150 000. Increasingly people aresurviving strokes (there are almost 1 million people in Britain today who have
had strokes) but many are left with residual physical and cognitive impairments.
Common side effects of stroke include tiredness and loss of concentration.
Many people give up or greatly reduce their use of public transport following astroke and many also give up driving.
Cognitive impairment is not, however, solely age-related. Many children andyounger people will also be affected. For example, traumatic brain injury
is another common cause of cognitive impairment. Incidence of traumaticbrain injury is in the order of 235 per 100 000 across Europe with road traffic
accidents representing a major cause.

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Mental health problems
While cognitive impairment will predominantly affect a person’s concentration,
memory and communication, people with mental health problems are likely tohave difficulty with their emotions, behaviour and generally with coping in achallenging environment.
One in four individuals will experience mental health problems at some point intheir lives11.
A great deal of stigma and prejudice is still attached to mental illness, andthere is much emphasis now on enabling people with mental health problems
to reintegrate into society rather than being shut away from it. Independent
mobility is not only a vital part of the rehabilitation process, helping people torebuild confidence in social interaction, it is also an essential means for people
to reach treatment and support networks.

11. World Health Organisation, www.euro.who.int/mentalhealth13© ITF, 2009

WHAT ARE THE TRANSPORT ISSUES?. .  .  .  .  .  .  .  .  .  .  .  .  .  .
The problems experienced by people with cognitive impairment or withmental health problems are not physical, although many people with cognitive
impairment (for example those who have had strokes) may also have somemobility difficulties.

Source: © Iconotec.

The main problem can becharacterised as difficulty incoping with a fast-moving
and constantly-changing
environment. Using public
transport involves processing
information quickly andtaking decisions based onthat information.
In practical terms people with cognitive impairment can also have difficulties
communicating with other people, or with finding their way around. This isbecause their capacity to concentrate, reason and remember may be affected.
Mental health problems may also cause social skills limitations which,combined, may reduce functional capacity and the ability to perform everyday
tasks associated with travelling.

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Particular problems in the day-to-day transport environment for both groups ofpeople can include:•

Getting one’s bearings.

•

Tiring easily.

•

Being unable to concentrate or remain vigilant.

•

Being anxious.

•

Becoming stressed as a result of hurrying/coping with deadlines.

•

Struggling to cope with information in small print, poor acoustics, fast speech etc.

•

Remembering information.

•

Dealing with unexpected or stressful situations.

•

Lack of information during the journey.

•

Fear of falling.

•	Lack of understanding/empathy from transport staff (cognitive impairment and mental
health problems may not be visible).

•

Stigma, discrimination, abuse.
Most of these are problems that we have all experienced to some degree at one
time or another while travelling, for example, in an unfamiliar environment, in acountry with whose language or customs we are not familiar, when we are tired
or when the expected route or timetable is disrupted for any reason.
The impact on someone with a cognitive impairment or with a mental healthproblem will, however, be much greater and may deter them from attempting touse public transport again.
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WHAT CAN BE DONE?. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Universal design
The key, as is often the case, lies in solutions that will enable everyone to travelwith less stress and greater confidence. The concept of universal design is very
important here. Following the principles set out below and, above all, focussing
on making transport “simple and intuitive” to use will result in transport systems
that people can use more easily.
The table below sets out the seven principles of universal design12.
Principle

Definition

1 Equitable use

Useable and marketable to people with diverse abilities

2 Flexibility in use

Accommodates a wide range of individual preferences
and abilities

3 Simple and intuitive use Easy to understand, regardless of experience,
knowledge, language skills or current concentration level
4 Perceptible information

Communicates necessary information effectively
regardless of ambient conditions or sensory abilities

5 Tolerance for error

Minimises hazards and adverse consequences ofaccidental or unintended actions

6 Low physical effort

Can be used efficiently and comfortably with a minimumof fatigue

7	Size and space forapproach and use

Appropriate size and space for approach, reach,manipulation, and use regardless of body size, postureor mobility

12. Center for Universal Design, North Carolina State University, NC, US (Folette Story 2001).

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Education
There is very little awareness of the issues facing people with cognitive
impairment or mental health problems among those responsible for the planningand delivery of public transport services and infrastructure.
A survey undertaken as part of a recent European Commission-funded project13
revealed a high level of ignorance or misunderstanding about the nature of these
conditions and their implications for the way in which public transport is run.
Some basic information and tuition on these issues as an integral part ofprofessional training and qualification in all transport-related disciplines would
be helpful alongside the growing body of material that is available on physicaland sensory impairments.

Practical steps
In parallel, some of the simple, often low-cost initiatives that can be very helpful
include:Before the journey
Travel awareness training
This is a technique to help an individual with a learning disability, for example,
build up the confidence necessary to make a routine journey unaccompanied,perhaps a daily trip to school or college.
It involves making the journey accompanied by a trainer, who will find the mosteasily manageable options for the journey and explain each step as the journey
progresses, including strategies for coping if the unexpected happens – for example
the bus does not arrive or the route is changed. This can be a very successful way
to help someone with a cognitive impairment or mental health problem to break theirdependence on door-to-door transport or to attempt to travel for the first time.
13. Improving Mobility and Accessibility for People with Learning Disabilities in Europe (MAPLE).

17© ITF, 2009

In a number of areas, “buddies” or travel companions areprovided by the operators of the local transport or doorto-door service provider. There are also examples ofschemes that provide a structured programme of support
with the aim of enabling the individual to gain both theskills and the confidence necessary to make the journeyalone. Schemes of this kind have been carried out inFrance, Ireland, the Czech Republic and in England.
In some areas, travel training/support schemes arebacked up by information material produced specificallyfor people with cognitive impairments. Merseytravel in
the UK has produced “Here to There with Merseytravel”
which includes illustrated fact sheets showing how to make a journey by bus,
train or ferry.
Similar initiatives aimed specifically at children can also be successful.
A scheme in Athens is run by a training centre which fosters the socialand vocational integration of young people aged 14 to 21 with cognitive
impairments. This involves practice-based learning, which leads to thedevelopment of a “cognitive” map for each individual student to understand andcope with their journey.
The use of games to help younger children with cognitive impairments is alsovaluable. In Sweden, help is available on the internet for parents of children
with cognitive impairments who want to teach their children to travel safely andindependently.
A similar approach, using a game as part of an “Independent Travel Package”,
has been produced by the local authority in Warrington in the UK.
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Source: University College London.

University College London has also
produced “Going Places”(illustrated), an interactive travel
training game aimed at young
people with cognitive
impairments14. The game uses
photographs of landmarks andplaces of interest along a chosen
bus route. It has been found to bevery helpful in assisting students tomemorise bus routes and soenable them to travel with greater
independence.
Pre-journey information
Travel information produced by transport operators often pre-supposes thatpeople are familiar with using public transport and therefore does not provide
sufficient basic information for those who may never have done so – whether
because of physical, sensory or cognitive impairment.
Attention to the way in which information about using a route or system is bothproduced and disseminated can also benefit the growing number of older people
who have had to give up driving and may seldom have used public transport.

During the journey
Training of front line transport staff
Training can be a valuable tool in helping staff to recognise and assist people
with cognitive impairment or mental health problems. This does not mean
expecting staff to be experts in diagnosis, simply to show empathy.
14. www.cts.ucl.ac.uk/arg/Research/Projects/Trumpet/index.asp

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One of the key persistent problems is discrimination born out of ignorance.
There is still too often perceived stigma attached to cognitive impairment andmental health problems, and there are many examples of insensitive and evencruel treatment by drivers, station staff and fellow passengers.
Effective training is generally best delivered by people with personal experienceof living with cognitive impairment or a mental health problem.
Audible and visual information in parallel
It is already a legal requirement under disability discrimination laws in somecountries to provide all information in both audible and visual forms, but thenorm in many places is still to give either visual information (for example
regarding train departures) or audible information (for example, announcing
from which platform a train will depart).
Providing all information as a matter of routine in both audible and visual form
provides additional assurance to the whole of the travelling public. It is vitalto those people whose sight or hearing is impaired and provides essential
reassurance to people with cognitive impairment or mental health problems.
Simple, clear information and signage
Too much information can be as distracting and confusing as too little.
Information (both audible and visual) should be restricted to what is essential toenable people to find the right platform/departure gate/vehicle, and to be awareof any changes to that information. Again, this can benefit the travelling public
as a whole.

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Many people struggle tounderstand maps when they
travel by public transport, andthe simplified “spider maps” ofLondon’s bus and undergroundnetwork, developed with thehelp of people with cognitive
impairments, have proved
to be very popular with thetravelling public as a whole.
(See illustration)
Similarly, too many signs in, forexample, a rail or bus interchange,
will add to confusion and anxiety. Signs
need to be kept to a minimum in order to be clear and unambiguous.
Pictograms or icons can be helpful, provided that they are immediately
recognisable. The city of Pisa, Italy has made use of coloured icons to aid route
guidance (shown at left).Thesecan be particularly helpful topeople who cannot read or
who do not know the languageof the country. However, it isessential that the range ofcolours used, for example todistinguish between lines in asystem, should be kept to theminimum necessary for clarity.

21© ITF, 2009

The local transit authority in Umeå,Sweden, uses pictograms specificallyintended to help people with cognitive
impairments. Signs on the side of thebus provide a simple illustration of awell-known landmark associated witha particular destination.

Another example of an intuitive anduncomplicated sign which has proved successful
comes from Liverpool, where a large footprint
with the word “Bus” written inside it has been
painted on the pavement to indicate the direction
to the bus stop.

22© ITF, 2009

Presence of staff on vehicles and at interchanges
The presence of staff on vehicles and atinterchanges is reassuring to all travellers bothin terms of information and assistance andpersonal security. This does not necessarilymean having staff available on all vehicles at
all times (although this is greatly valued bypassengers). The LUAS system in Dublin,for example, includes a button on all ticket
machines which can be pushed to activate
audio assistance and, if need be, personal
assistance.
Travelling companions can also be important
for those people who would not otherwise
be able to make a journey alone - even withtraining. In Paris, transport providers combine to offer a service known as “lescompagnons du voyage”. This scheme provides a trained escort for anyone
who feels the need to be accompanied on public transport. The pool of escorts
includes people trained to meet specific needs, for example using sign language
or guiding a blind person.
Real-time audio/visual information at stops
In a growing number of cities, real-time information is now available at bus
stops indicating how many minutes before the arrival of the next bus and whichbuses use that stop. Again, this can be particularly reassuring for anyone with acognitive impairment, but is also greatly valued by anyone anxious about how
long they may have to wait, or unsure if they are at the right stop.

23© ITF, 2009

Physical design features
The design and layout of transport interchanges can have a significant impact
on the confidence that people feel in using that facility. One key feature is clear
sight lines at rail or bus stations so that passengers can see immediately where
different facilities are located and how to reach them.
A good example is in Malmö, Sweden,
where the station facilities havebeen reorganised in a much morecoordinated and uncomplicated way.
For example, the new layout draws
travellers’ attention to the station clock
more easily. This kind of universal
good design is helpful in addressing
concerns about personal security as
well as for information and orientation.

Malmö station - Before

Malmö station - After24© ITF, 2009

Tactile surfaces, intended primarily to
guide people who are blind or partiallysighted, can also give helpful visual or
physical directional cues to people withcognitive impairments.
Such systems in use in Athens andWashington, DC., for example, use
flashing lights built into the platform toindicate that a train is entering the station,and thereby help to alert people with acognitive impairment as well as those with
impaired sight or hearing.

Technology
Several types of technical aids can be useful as well. For example, a Swedishcompany has developed a “quarter-hour clock”, which shows the number ofquarter-hours remaining before a predetermined activity. A “palmtop” computerwith tailored programmes for people who have problems finding their way has
also been developed.
In Warrington, UK,
the “Independent Travel Pack”
produced by the local authority
includes a key fob to activate
real-time audio information
at stops.

25© ITF, 2009CONCLUSIONS AND RECOMMENDATIONS. .  .  .  .  .  .  .  .  .  .  .
It is clear that the transport challenges faced by people with cognitive
impairment or mental health problems are not yet well recognised or understoodeither at political or executive levels in the transport field. It is also clear that,
although there are examples of good practice around Europe, they are by nomeans universal, nor are they routinely or systematically evaluated to measure
their effectiveness.
This is an area in which major information gaps persist, and efforts should bemade in government to commission the necessary research to fill those gaps.
There is, however, a great deal that can already be done. This report has set
out to illustrate that it is possible for transport providers and planners to makea significant difference to the lives of a large and growing number of people
simply by the application of principles of universal design and by addressing thefunctional needs of public transport users as a whole rather than the specificand therefore “special” or “minority” needs of particular disability or impairment
groups.
The diagnosis or medical history of an individual is irrelevant in transportterms. What is important is not whether a person has Alzheimer’s disease or
schizophrenia, but that they share a common difficulty with perception andmemory. That difficulty – and many others highlighted in this report – is also
shared to a greater or lesser extent by the vast majority of the travelling public
at some time and in some conditions.
To reiterate, the steps that can be taken to alleviate the difficulties specific topeople with cognitive impairment and mental health problems are generally
simple, low-cost and will benefit the travelling public as a whole.

27© ITF, 2009

In summary, they include:

Before the journeyò	Travel awareness training to help people build confidence and develop coping
strategies.
ò	Timetable and other pre-journey information which recognises that people are
not familiar with public transport and provides clear basic information.

During the journeyò	Training front-line staff to recognise, assist people and to show empathy.
ò	Providing journey information in both audible and visual formats.
ò	Keeping information and signage simple, clear.
ò	Having staff available on vehicles and at interchanges.
ò	Real-time information at stops in audio and visual formats.
ò	Station/interchange design and layout that is simple and uncluttered.
ò	Technical aids, for example to help those who cannot remember a route.
Underlying the practical recommendations and good practice examples given inthis report is the clear principle that empathy and understanding of people andtheir needs are at the heart of good transport planning and delivery.
Whether people have a cognitive impairment, a mental health problem or are
simply tired and distracted after a busy day, the same design features andprinciples of service delivery will benefit them and encourage them to continue
to be public transport users.
28© ITF, 2009

For more information on cognitive impairment
and mental health problems
INCLUSION EUROPE IASBL
The European Association of Societies of Persons
with Intellectual Disabilities and their Families
Galeries de la Toison d’Or - 29 Chaussée d’Ixelles #393/32
B-1050 Brussels - Belgium
Inclusion Europe is a non-profit organisation that campaigns for the rights and interests of people
with intellectual disabilities and their families throughout Europe, promoting Respect, Solidarity
and Inclusion and against discrimination. Inclusion Europe co-ordinates activities in many
European countries, including conferences, working groups and exchange meetings. It responds toEuropean policy proposals and advises the European Commission and members of the European
Parliament on disability issues.
For further information about Inclusion Europe IASBL, please visit: www.inclusion-europe.
org or contact: secretariat@inclusion-europe.org, tel. : +32-2-502 28 15, fax : +32-2-502 80 10

MENTAL HEALTH EUROPE
SANTE MENTALE EUROPE aisbl
Boulevard Clovis 7, B-1000 Brussels - Belgium
Mental Health Europe is a European level non-governmental organisation (NGO) and network
committed to the promotion of positive mental health and well-being, the prevention of mental
disorders, the improvement of care, advocacy for social inclusion and the protection of the humanrights of people with mental health problems and their families and carers. MHE represents thecommon interest of its members and lobbies and advocates for it at the European level.
For further information about Mental Health Europe, please visit:www.mhe-sme.org, or contact: info@mhe-sme.org, tel: +32 2 280 04 68, fax: +32 2 280 16 04.

Both are member organisations of the European Disability Forum.
29© ITF, 2009

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