1 Introduction
1.1 Background
1.2 Aim, objectives, and research questions
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What measures to make electronic communication accessible to people with cognitive disabilities are evaluated and reported in the scientific literature?
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What documented effects do these measures have?
2 Methods
2.1 Search strategy
Database | Hits |
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ACM digital library | 0 |
AMED, CINAHL, and ERIC | 1,367 |
BioMed central | 219 |
Compendex | 1,331 |
DiVA | 438 |
IEEE Xplore | 967 |
Inspec | 873 |
PubMed | 3,618 |
ScienceDirect | 96 |
Scopus | 341 |
Web of science | 956 |
Total (13 databases) | 10,206 |
2.2 Quality assessment
2.3 Data extraction
3 Results
3.1 Description of included articles
Countries | No. of articles |
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USA | 9 |
UK | 6 |
Spain | 3 |
France | 2 |
Belgium, Finland, Germany, Israel, Italy, Japan, Netherlands, Norway, Taiwan | 1 |
Reported diagnoses | |||||||||||||
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Types of communication or interaction | Intellectual disability | Dyslexia | Cognitive disability | Aphasia | Dementia | Acquired brain injury | ADHD | Autism | Depression | Schizophrenia | Learning disability | Other (cancer, physical and speech) | No. of articles |
Internet | [20] [21] [22] [24] | [23] | 5 | ||||||||||
Texts | [37] [38] [39] [40] | [36] | 5 | ||||||||||
E-mail | [27] | [25] | [26] [28] | 4 | |||||||||
Multimedia interfaces | [42] | [43] | [45] | [45] | [44] | [45] | 4 | ||||||
Telephone | [30] [31] | [27] [29] | 4 | ||||||||||
Chat | [34] | [35] | [33] | [34] | 3 | ||||||||
Operating computer | [30] [48] | [47] | [47] | 3 | |||||||||
Entering information | [46] | [46] | 1 | ||||||||||
Interactive TV | [32] | 1 | |||||||||||
Pictures | [41] | 1 | |||||||||||
No. of articles | 8 | 6 | 4 | 4 | 3 | 2 | 1 | 1 | 1 | 1 | 1 | 2 |
Reference and country | Design and participants | Types of communication | Intervention and main findings | Quality rating and strengthsa
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[20] USA | Quantitative controlled trial. 12 participants with intellectual disability (mental retardation), 20–45 years, 33 % females | Using Internet on computer | Compared with Internet Explorer, participants performed better (p < 0.03) in terms of independence, accuracy and task completion when using a web browser which utilizes multimedia | A. 1, 2, 3, 4, 6, 7, 8, 9 |
[21] Taiwan | Quantitative controlled trial. 10 participants with intellectual disability (mental retardation), grades 7–9, 30 % females | Reading web-based information on computer and interacting with browser interface | Compared with Internet Explorer, reading comprehension was higher (p < 0.05) when participants used an adaptive web browser with voice and picture assistance. The simplified interface was easy to learn | B. 1, 2, 4, 6, 8, 9 |
[22] Spain | Quantitative controlled trial. 20 participants with intellectual disability (mental retardation), 24–46 years, 40 % females | Interacting with website on computer | Participants tested a commercial website and an adapted version of it. Usability measures in terms of web understanding, number of visits, autonomy and success minus mistake trials were all higher (p < 0.024) for the adapted website. Satisfaction in terms of motivation and interest was higher (p = 0.29) for the adapted version. Correlation between web understanding and IQ was found for the commercial website (p < 0.05) while not for the adapted website (p > 0.05) | B. 2, 3, 4, 5, 6, 8, 9 |
[23] UK | Mixed methods trial. 5 participants with dementia, 57–72 years, 0 % females | Using Internet on computer | Participants were satisfied with both a standard format website and a website developed for people with early-stage dementia. Some specific areas were favored in both sites | A. 1, 2, 4, 6, 7, 8, 10 |
[24] USA | Mixed methods, cross-sectional. 27 participants with mild-to-moderate intellectual disability (developmental cognitive disability), 48 % or 52 % females | Interacting with website on computer | Being asked to carry out tasks on one of two different WCAG 1.0 compliant web sites, a majority of the participants were unable to successfully use them. The ability to navigate the web sites was impacted by unclear navigational confirmation, inconsistent navigation, non-standard interaction techniques, lack of perceived click-ability, user willingness to scroll pages, and user ability/willingness to read instructions | B. 1, 2, 6. 8 |
[25] Netherlands | Quantitative, cross-sectional. 26 participants with aphasia, 50–76 years, 38 % females | E-mail using computer | 60 % of the participants found an assistive e-mail program for people with aphasia easy to use. 50 % use the program once or more a week. 40 % receive e-mails with attachments more than once a day. 20 % send mails with attachments. Almost all use the ready-made sentences/phrases provided with the program. 80 % compose new sentences | B. 1, 2, 6, 7, 8 |
[26] USA | Qualitative trial (participatory action research). 8 participants with acquired cognitive-linguistic impairment, 26–78 years, 50 % females | E-mail using computer | Participants reading and replied to e-mails across four writing prompts conditions (no prompt, Idea prompt, fill-in-the-blank, multiple choice). There was no clear preference for a particular prompt condition. E-mail partner preferences varied between the prompt conditions. Three categories of interface-related usability problems were identified: lack of knowledge about the functionality of keys for basic word processing operations; poor conceptual understanding for the mouse/cursor operation; and poor use of interface prompts. Four types of task- and message-related usability problems were identified: difficulty remembering the task; difficulty generating ideas for a message; lack of greeting and closure; and reduced error monitoring | A. 1, 2, 3, 4, 6, 7, 8, 10 |
[27] Italy | Quantitative trial. 13 Participants with cognitive disability | E-mail and telephone using computer | Participants were trained in using a multimodal communication application for e-mail and telephone. Among 21 set communication goals, 17 were reached or exceeded, 1 goal was not reached, and 3 goals were given up | C. 6, 8 |
[28] USA | Mixed methods, longitudinal. 4 participants with acquired brain injury, 37–65 years, 25 % female | E-mail using computer | Participants used an adapted e-mail interface and were followed for 9 months. All participants learned to become independent e-mailers. All participants reported increased feelings of social connectedness. Little to no change in cognitive processing was measured. Extensive training to learn keyboarding and editing was required. Occasionally, hands-on technical support was required. Each participant engaged in a unique set of e-mail topics | A. 1, 2, 3, 6, 7, 8, 10 |
[29] USA | Quantitative controlled trial. 16 participants with moderate to severe cognitive impairment, 28–81 years, 62 % females | Calling using mobile phone | Participants tested to call using three different mobile phone interfaces (standard, flip and picture modes) before and after being distracted. Before distraction: 100 % success for flip and picture mode, and 12.5 % success for standard mode. After distraction: 100 % success for flip mode, 81.3 % success for picture mode, and 6.3 % success for standard mode | A. 1, 2, 3, 4, 6, 7, 8 |
[30] USA | Quantitative controlled trial. 32 participants with intellectual disabilities, 18–54 years, 47 % females | Using a palmtop computer and its address book | Compared with using Windows CE operating system to navigate between and use functions, participants required less (p < 0.001) number of prompts, made less (p < 0.001) number of errors and identified more phone numbers when they used a specially designed palmtop computer interface | A. 1, 2, 3, 4, 6, 7, 8, 9 |
[31] USA | Quantitative controlled trial. 22 participants with intellectual disabilities, 18–49 years, 41 % females | Calling using mobile phone | Compared with using a standard mobile phone to attempt making and receiving phone calls, participants required fewer (p = 0.001) prompts and made fewer (p < 0.001) errors when using a specially designed multimedia software | A. 1, 2, 3, 4, 6, 7, 8, 9 |
[32] Spain | Mixed methods, cross-sectional. 21 participants with mild-to-moderate Alzheimer’s disease | Responding to questions and follow instructions on TV | Using a remote control with Yes/No buttons, all participants were able to follow instructions and respond to Yes/No questions by an avatar on a TV. The time to respond increased during a session. No fear, misunderstanding or inconvenience in relation to the avatar was noticed. 80 % of the sample responded verbally to the avatar | B. 2, 3, 5, 6, 7, 8 |
[33] Japan | Quantitative controlled trial. 3 participants with aphasia, 51–71 years, 0 % females | Responding to questions in computer-based conversations | As compared with using video chat system and screen sharing, when participants used video chat system, screen sharing and conversation support tools (Yes–No, scale, choice, map, calendar, clock, number) the numbers of questions and questions per minute increased and the numbers of uncertain answers and repeated questions decreased. All participants used all conversation support tools. The Yes–No and choice tools were used most frequently | C. 3, 4, 6, 8 |
[34] Finland | Mixed methods trial. 9 participants of whom 8 had intellectual disability and 1 had physical and speech disability, 14–37 years, 0 % females | Chatting using symbols on computer | Participants found a picture-based communication interface fast, fun and not hard to use and would be happy to use it again. Experiences were mostly equal to or exceeded expectations. Among 8 participants, the median time to create a message ranged from 1 to 7 min and the median number of symbols ranged from 2 to 6 | A. 1, 2, 3, 5, 6, 7, 8 |
[35] Spain | Qualitative, observational. 11 participants with cognitive impairments | Instant messaging on computer | Participants were able to communicate using a pictogram-enabled instant messaging service. They found it interesting and entertaining. Those presented with a post-office metaphor (message, envelop, postman) found it less frustrating to communicate. Elaborate messages negatively impacted on communication interactivity, causing frustration among recipients who got to wait longer | C. |
[36] Israel | Quantitative controlled trial. 20 participants with ADHD and 20 without ADHD, 15–18 years, 72 % females | Reading on computer | Participants carried out a reading comprehension task with two texts each in four conditions: printed with regular space, printed with extra space, computer screen with regular space, and computer screen with extra space. Participants with ADHD scored lower on correct answers (p < 0.007) and higher on percentage of errors (p > 0.007) and reading duration (p < 0.007) (Bonferroni-corrected p-values). Participants from the ADHD group were classified as having poorer (p < 0.009) sustained attention. Participants with poor or medium level of sustained attention obtained the highest number of correct answers when texts were displayed on a computer screen with extra space. No significant effects of type of presentation or text’s spacing on reading duration were found. There was no interaction between level of sustained attention, type of text presentation and text’s spacing | A. 1, 2, 3, 4, 6, 7, 8, 9 |
[37] UK | Quantitative controlled trial. 6 participants with dyslexia, 14–16 years, 0 % females | Reading on computer | Compared with default MS Word settings, 5 out of 6 participants made fewer errors (p = 0.32) when using a word processing environment which allowed for personalized font, color and space settings. Performance between default MS Word settings and personalized settings improved (p < 0.05) | B. 2, 3, 4, 6, 8, 10 |
[38] UK | Qualitative, cross-sectional. Experiment 1: 12 participants with dyslexia, 18–30 years. Experiment 2: 7 participants with dyslexia, 14–30 years | Reading on computer | Manipulating the appearance of the word processing environment and text presented within it, all participants in experiment 1 found a color scheme which was subjectively superior for them to black text on white background with Times Roman 10 or 12 point text. Each participant had his/her own favourite color combination, although brown text on murky green background was liked by all even if no one felt it was best. Sans-serif Arial was rated the best typeface by almost all. Applying bold to a text had a negative effect for most participants. All seemed to think that increasing the spacing between characters, words and lines was beneficial. Experiment 2: Changing color scheme appeared to be most helpful. Developed schemes varied between participants. Larger text size than default was preferred. Some appreciated spacing between characters and words. Altering the column width worked well for those with fixation problems. Coloring reversal characters (e.g., b and d) greatly improved the display of the document for all but the participant with the least difficulties | B. 2, 6, 8 |
[39] Belgium | Qualitative trial. 32 participants with dyslexia, 18–37 years, 78 % females | Reading on computer | Following campus wide introduction of two different dyslexia software, 21 out of 32 participants continued using the software, mainly for text-to-speech assistance with reading | B. 2, 5, 6, 8 |
[40] UK | Mixed methods, cross-sectional. 455 Participants with dyslexia, post-secondary school age, 51 % females | Reading and writing on computer | 91 % of participants who had been provided equipment for dyslexia were satisfied or very satisfied with the hardware and software they had received. 95 % used their hardware and 82 % used their software often or always. 84 % were positive about the ease of use of hardware and 75 % about the ease of use of software. Participants commented very positively about the effect of the equipment on their studies | B. 1, 2, 3, 5, 6, 7, 8 |
[41] USA | Quantitative controlled trial. 50 participants with aphasia, average age 60 years, 30 % females | Picture-based communication using computer | When participants tested web images and icons, the error rate of icons was higher in 13 out of 25 nouns. Images slightly outperformed icons although not significantly. Most of the time participants got a concept faster from an icon than from a web image (non-significant difference). Participants with high and medium cognitive levels were faster with images, while those with low cognitive level were faster with icons. Images and icons worked equally well for participants with high cognitive level, while for the others, icons did a better job (non-significant differences) | A. 1, 2, 3, 4, 5, 6, 7, 8 |
[42] UK | Quantitative controlled trial. 30 Participants with dyslexia, 18–36 years | Learning statistics from computer-based teaching materials | Participants using “text only” to learn statistics improved more (p < 0.04) than those who used “text and diagrams” or “sound and diagrams” | A. 2, 3, 4, 5, 6, 7, 8 |
[43] France | Quantitative controlled trial. 10 participants with autism, average age 13 years, 0 % females. 10 controls without autism, average age 9.5 years, 20 % females | Understanding facial expressions and finding errors in dialogs on computer | While controls performed higher (p < 0.04) with both a simple (text only) and a rich (text, synthetic voice, image) interface, participants with autism performed better (p = 0.058) with a simple interface but not with a rich interface. Controls performed better (p < 0.05) than participants with autism when facial expressions were used in dialogs. Participants with autism recognized both human and cartoon pictorial style facial expressions to similar degrees | A. 1, 2, 3, 4, 5, 6, 7, 8 |
[44] Germany | Quantitative controlled trial. Experiment 1: 20 participants with learning disabilities, 14–22 years, 45 % females. Experiment 2: 47 participants with learning disabilities, 14–21 years, 36 % females | Learning about computers and Internet (experiment 1), and the human body (experiment 2) | Participants tested one out of four different representational formats. None of the participants had specifically learnt with symbols before. Experiment 1: Results for both recognition and understanding were highest for text + spoken text + symbols, followed closely by text + spoken text. Results for text + symbols were lower and for text only lowest. Although not statistically significant, the mean scores for formats with spoken text resulted in higher scores than those without. No such difference was found between formats with and without symbols. Experiment 2: compared with text + spoken text + symbols, knowledge gain in verbal test were lower for text (p > 0.1), text + spoken text (p < 0.05) and text + symbols (p < 0.01). Compared with text + spoken text + symbols, knowledge gain in pictorial test was lower for text + symbols (p > 0.05), text + spoken text (p < 0.05) and text only (p < 0.05) | A. 1, 2, 3, 4, 6, 7, 8 |
[45] USA | Qualitative, focus groups and interviews. 21 participants of whom 5 had schizophrenia, 7 had cancer and 9 had depression | Providing information to potential research subjects using computer | Participants generally felt that a multimedia tool was useful and could replace a paper document for informed consent. It would be less stressful. They liked that information was provided in a hierarchic and modular approach, and felt that video use made information more understandable | B. 1, 2, 3, 6, 8 |
[46] Norway | Qualitative trial. 2 participants of whom 1 had aphasia and 1 had dyslexia, 0 % females | Entering information in mobile terminal | Participants could employ a speech-centric multimodal interface to use a map-based information service, while they could neither use text only nor speech only | B. 4, 6, 8 |
[47] France | Quantitative controlled trial. 15 participants of whom 4 had mild cognitive impairment, 7 had Alzheimer’s disease and 1 had dementia, 65–89 years, 53 % females | Mouse interaction with computer | Participants selected a piece of sugar and put it in a cup of coffee with the help of a mouse with three different interaction techniques: clicking, dragging, and clicking and magnetization. Identified difficulties with mouse: keeping the mouse steady when moving; losing the cursor out of the exercise map; bad control in moving in the adequate direction; running out of the room on the mouse cursor; the mouse cursor getting stuck. Dragging was rejected by participants with cognitive impairments. Dragging takes longer time than clicking or clicking and magnetization. Clicking and magnetization generated short times also for those with low Mini Mental Score | B. 2, 6, 8 |
[48] UK | Quantitative trial. 5 participants with profound and multiple intellectual disability, 15–28 years, 40 % females | Activating video file on computer | 2 out of 5 participants learnt to use functional action to trigger a video file by symbols on cards shown to cameras and recognized by open source software | A. 1, 2, 3, 5, 6, 7, 8, 10 |
3.2 Narrative synthesis
3.2.1 Internet
3.2.2 E-mail
3.2.3 Telephone
3.2.4 Interactive TV
3.2.5 Chat
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Yes–No tool: Window containing “Yes”, “No” and “Not understood” buttons.
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Scale tool: A scale bar is shown.
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Choice tool: Text areas for a conversation partner to type in.
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Map tool: Web-based map system.
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Calendar tool: A blank calendar.
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Clock tool: Clock without hands.
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Number tool: A group of numbers.