Accessible Information

SCLD 2011

Accessibility Prior to the late 1980s the responsibility was very much placed on people with learning disabilities themselves to understand and interpret the information that was presented to them. Walmsley (2010) recognised a long history of attempts to “promote literacy amongst people whose intellectual and social functioning is limited, through special education, adult education and other initiatives” (p.23). In the intervening years the onus for ensuring access has shifted from the recipient to the producer of the information. There is still difficulty with defining exactly what accessible information is (Mitchell & Sloper, 2002) but Townsley et al (2003) pointed out that what makes a piece of information accessible is the ease with which it can be “obtained, understood and acted upon” (p.40).

In their 2008 study Baxter et al examined the importance of accessible information for informed service user choice in social care to be made. They highlighted the importance of this in an age where government is granting increased independence of individuals in choice and control over how their social care needs are met. They make the very important point that an increase in personal choice is meaningless unless accessible information exists to help inform choices (Baxter et al, 2008).

The Scottish government’s guidance on the Procurement of care and support services (2010a) recommended that information about local policies and procedures for the acquisition of care and support services should be available in “plain language” to meet the information needs of people with learning disabilities, their families and carers. They recommend consideration of developing easy-to-understand versions and providing information in alternative formats. The latest UK wide guidelines for producing accessible information were published by the Department of Health in November 2010. In the introduction to this guidance the Minster for Care Services and the Minister for Disabled People wrote that accessible information “helps people with learning disabilities to achieve a more equal role in society, to give us their views and help us shape government policies and services” (p.5), making the important link between accessibility and citizenship.

Hardcopy There are often difficulties encountered by people with learning disabilities when they use information, such as factsheets and leaflets, designed for the general public (Clapham, 2009). This can be due to a number of factors including the learning disability itself, the use of complex language and structure and because around 30% of people with learning disabilities have problems with their eyesight (Rodgers and Namaganda, 2005). People with learning disabilities may also require accessible information because they have lower than average rates of literacy or have never had the opportunity to learn to read (Levy, 2005; Harryson et al, 2004). A number of organisations and projects have drawn up guidelines and advice promoting the provision of accessible information to disabled people, including people with learning disabilities.

Guidelines In 2010 both the Scottish Accessible Information Forum (SAIF) and the Department for Health produced guidelines advising organisations and individuals on how to make information more accessible. In 2009 CHANGE published How to make information accessible: A guide to producing easy read document . In 2008 Mencap produced Making it clear, a directive for producing easy read material. In 2005 both the Social Care Institute for Excellence (SCIE) and the Royal National Institute for the Blind (RNIB) in conjunction with the Norah Fry Research Institute at Bristol University produced documentation on how to make information more accessible. The main points from these various guidelines and the literature include:

Words and content Rodgers and Townsley (2005) reiterate the importance of planning when producing accessible information for people with learning disabilities and this is confirmed by the Department of Health (2010), Mencap (2008) and RNIB (2005). This process should include clearly identifying what the aim of your information is and who the intended audience are.

All of the guidelines agree that words and sentences should be easy to understand and that the use of jargon and acronyms should be avoided unless the writers are confident the terms are well known by the audience. The Plain English Campaign produced The A to Z of alternative words which suggests easier language for more complicated words and phrases. The Department of Health (2010) recommend that if the information provider has no option other than to use a difficult word, it should be highlighted and explained the first time it is used. They advocate that an explanation of the term should be provided immediately after the sentence has finished, perhaps in a box to draw the reader’s attention. The guidance produced by both the SCIE (2005) and the RNIB (2005) suggest that difficult words should be explained in a “what the words mean” section at the end of the document.

The literature is in agreement that a sans serif font should be adopted when producing accessible information, such as Arial or Verdana. The Department of Health (2010) and the Mencap (2008) guidelines both advise a minimum of 16 point font as a standard text size, with larger points used for headings. The CHANGE (2009), SCIE (2005) and RNIB (2005) guidelines all recommend a minimum font size of 14 point. Text should be left-aligned (SAIF, 2010; CHANGE, 2009; SCIE, 2005) rather than justified and italics and underline functions should be avoided with the bold function used to highlight important words (SAIF, 2010).

Grammar, punctuation and numbers Punctuation should be as simple as possible and the use of hyphens and semi-colons avoided (Department of Health, 2010; SCIE, 2005). Mencap (2008) purport that unless absolutely necessary, the only punctuation an easy read should contain is full stops. The information itself should be placed in a logical sequence and headings and bullet points can be used to avoid large chunks of text (Department of Health, 2010; CHANGE, 2009; Mencap, 2008; SCIE, 2005). However, Walmsley (2010) warns that this can end up creating a long list which can be off-putting for people who only read a little (p.35).

All of the guidelines agree that numbers should always be written in figures rather than words and avoidance of the 24 hour clock is also promoted heavily (Department of Health, 2010; Mencap, 2008; RNIB, 2005).

The research of Mitchell and Sloper (2002) found that using a reassuring tone in the text, such as collective terms like “we” and “you”, makes the information more personal. They are supported in this proposition by the Department of Health (2010) and the RNIB (2005). Mitchell and Sloper also found that including quotes from parents and clearly defining services and acronyms was very useful (Mitchell and Sloper, 2002).

Length and layout It is recommended that a new chapter or a change in topic should begin on a fresh page. On average, each sentence should only contain between 15-20 words (Department of Health, 2010; CHANGE, 2009; SCIE, 2005; RNIB, 2005) and each individual document should generally not exceed 20 pages in length (Department of Health, 2010). Both the Department of Health (2010) and Mencap (2008) suggest the inclusion of a contents page as useful when producing accessible information. Mitchell and Sloper (2002) found that the parents of children with learning disabilities wanted information to come with a well designed front cover, a good index and up-to-date contact details for organisations and professionals.

Images It is widely accepted that each main idea in an accessible document or easy read needs both words and pictures (Department of Health, 2010; CHANGE, 2009; RNIB, 2005). The pictures should support and help explain the message the text is attempting to convey and be chosen with care and thought. It is important to promote consistency when choosing images so that the same picture means the same thing throughout a document or set of documents (Mencap, 2008). The RNIB (2005) guidelines suggest that using a mixture of drawings, photographs and symbols is acceptable whereas others promote the use of only one style throughout a document (Department of Health, 2010; SCIE, 2005). Codling and Macdonald (2008) found that the use of pictures to convey meaning led to participants in all of their focus groups having a different understanding from the one intended. They also found the use of too many images or too much text over complicates information leaflets and booklets. Thurman et al (2005) drew similar findings, concluding that too much information “beyond the person’s capacity to understand is ineffective”.

The Department of Health (2010), Mencap (2008) and SCIE (2005) recommend careful consideration when using pictures that are cartoon like as they can be confusing or age inappropriate. It is also recommended that images reflect the diversity of their audience (Department of Health, 2010; SCIE, 2005).

Inconsistencies in the guidelines include the recommendation of the Department of Health (2010), Codling and Macdonald (2008) and Poncelas and Murphy (2007) to avoid pictures with a negative symbol, such as a cross or tick, as they can be confusing to the user. However, the CHANGE (2009) guidelines promote the use of arrows, ticks, crosses and so on. All of the guidance suggests information providers put pictures to the left of the text apart from the SCIE (2005) who recommend putting images to the right.

Colour schemes The Department of Health (2010) recommend setting a black text against a white or light cream background, or alternatively placing white text on a very dark background. However, the Mencap guidelines state that words in white, or reversed out text, can be hard to read. Colours can be used as borders on hardcopy material to show where information on different topics can be found in the document to assist users with navigation (Department of Health, 2010; CHANGE, 2009; Mencap, 2008). It is advisable to not use the traffic light colours of red, orange and green when doing this as these colours can also demonstrate good, average and bad and could lead to confusion or user misinformation. Hardcopy accessible documents should be printed to a matt finish to avoid glare (SAIF, 2010; Mencap, 2008; Rodgers and Namaganda, 2005).

Co-production There is much agreement in the literature that people with learning disabilities should be involved in the production of accessible information (Townsley et al, 2003; Rodgers & Namaganda 2005; Ward & Townsley, 2005, 59; Holman, 2010, 25). Ideally this should include consultation during initial planning, a testing period where the information is still in a draft stage, input for ideas for pictures and evaluation once it is in use (Ward & Townsley, 2005, 62). This is important to test if the information is doing what it is meant to do in the way that was intended. Evaluation can be made through interviewing or talking to people face to face but written questionnaires are generally not thought to be the best medium for review as it is possible some participants may have difficulties with reading.

Formats Codling and Macdonald (2008) suggest that information sources for people with learning disabilities should be considered in a range of formats, including video, DVD and audio which may be more accessible. Rodgers and Townsley (2005) reiterate this, proposing that people may benefit from having access to more than one format. Accessibility in hard copy information can include offering the following formats:

Audio recording Printed information is often also produced on an audio storage device, such as a cassette tape or compact disc (CD). The latter has superseded the former as the most popular media for audio recording, the big advantage being that CDs are far easier for the user to navigate than tapes. Audio recordings are popular among people with learning disabilities as they often allow unsupported access to information (Department of Health, 2010).

Easy read Easy read is one type of accessible information. It is mostly used by people with learning disabilities but other groups may find this format useful, such as people who have dementia, have had a stroke, have low levels of literacy and speakers of other languages (Mariger, 2006; Holman, 2010). Easy read does not have a set of standards that must be adhered to, although there is general agreement on what it is and how it should look (Holman, 2010, 24). Easy read information is not just a simple translation of existing documents into easier to understand language. Instead, the main points of the original should be projected so that the user can understand the major issues and make informed decisions if required (Department of Health, 2010). Ideally each of these main points should be illustrated with an appropriate image. Recent major policy initiatives and decisions in the UK have usually produced easy read versions of full reports or what Walmsley terms “parallel texts” (Walmsley, 2010, 30). Despite the obvious need for people with learning disabilities to understand and comprehend policy that affects their lives, Walmsely warns that there “is a danger in the drive to be accessible, full meaning is lost” (p.31). Walmsley’s research suggests that there is a balance that has to be struck between providing information in an accessible format and losing the meaning and context of the document.

Multimedia The Rix Centre is a research and development organisation working towards exploring new media opportunities that can benefit people with learning disabilities. They ascertain that multimedia can help “organise thoughts, remember, learn and communicate more effectively” (Rix Centre, 2010). The Rix Center coined the term “multimedia advocacy” to demonstrate the different ways in which new media and multimedia can positively affect the lives of people with learning disabilities and can include the use of video, audio, computers and digital photography. Multimedia can encourage more effective communication and inclusion in people with learning disabilities and help them express their choices and preferences in a number of ways, including how they are supported (Rix Center, 2010).

Video/DVD Putting information on to a video or DVD can be extremely useful as a lot of people with learning disabilities are familiar with the medium and it removes the barrier of the written word.

Web The Web Accessibility Initiative (WAI) works to develop strategies, guidelines, and resources to help make the Web accessible to people with disabilities. They define Web accessibility as:

“Web accessibility means that people with disabilities can use the Web. More specifically, Web accessibility means that people with disabilities can perceive, understand, navigate, and interact with the Web, and that they can contribute to the Web” (WAI, 2010).

Examples of measures that enhance Web accessibility include close captioning any video on the site and making clickable areas, such as links, large enough so that users who cannot precisely control a mouse can still gain access to the functionality of the Website. Peters and Bradbard (2010) suggest that a lack of web accessibility is more a result of “faulty design than inadequate technologies” (p.211). They put forward the idea that web visual aesthetics is usually the primary design aim of web designers, rather than equal access.

Friedman and Bryen (2007) highlighted the fact that improving Web accessibility for people with cognitive disabilities is way behind that for the general population, those with physical disabilities and visual disabilities. This was in agreement with the earlier research of Harryson et al (2004) and Sevilla et al (2007).

Friedman and Bryen (2007) identified a number of factors that can act as barriers to web accessibility for people with cognitive disabilities including:

 Limited reading comprehension;

 Limited fine motor control;

 Reduced spatial perception;  Lower visual acuity;

 Less hand/eye coordination; and

 Lowered information overload thresholds (p.205)

As a result there are a number of common barriers to Web accessibility for people with learning disabilities such as:

 Images without alternative text (If ALT text is not provided in the code a barrier to graphic images is erected);

 Misleading use of structural elements on a web page;

 Uncaptioned audio or undescribed video;

 Tables that are difficult to decipher; and

 Pop-ups (Peters and Bradbard, 2010)

Guidelines Friedman and Bryen (2007) examined twenty different sets of Web design guidelines, the criteria for inclusion in the sample was that each guideline addressed some type of cognitive disability and included specific design recommendations. Over 70% of guidelines included recommendations to use pictures, icons or symbols along with text and to make sure the text itself is clear and simple. However, the researchers also found that only 30% of guidelines urge the use of larger fonts (12pt or 14pt) or the adoption of a simple screen layout.

The World Wide Web Consortium (W3C) is the main international standards organisation for the World Wide Web. In 1999 they published the Web Content Accessibility Guidelines (WCAG) 1.0, which included guidance on accessibility in relation to cognitive disabilities. The majority of the advice that would specifically assist accessibility to those with cognitive disabilities was given a low priority rating.

When the guidelines were updated in 2008, the W3C recognised that they were unable to address the needs of people with “all types, degrees and combinations of disability” (W3C, 2008, 3). The W3C guidelines are widely accepted as the definitive source on how to create an accessible website, but this does not mean they are not without their critics. They are seen by some as difficult to understand and navigate, partly because of their long length, but also because of the jargon heavy language the guidelines are written in. A formal objection was made prior to the publication of WCAG 2.0 by a number of individuals and learning disability organisations. They disagreed with the W3C’s claim that the new guidelines defined and addressed the requirements for making Web content accessible to those with learning and/or cognitive disabilities. They recommended removing “learning disabilities” and “cognitive limitations” from the list of WCAG 2.0 supported disabilities and instead adding the phrase "these guidelines may also provide some benefits for people with learning difficulties and cognitive limitations" (Seeman, 2006). Other guidelines for Web accessibility focus more on increasing functionality specifically for people with learning disabilities include those written by the Royal National Institute for the Blind (RNIB) and the Norah Fry Institute in 2005.

As already acknowledged, people with learning disabilities are a heterogeneous group so it is impossible to find a design that suits everybody (Harryson et al, 2004). Mariger (2006) also pointed out the diversity of needs within people with cognitive disabilities recognising that “there is no rubric that covers even the basics”. Wallis (2005) suggests that a “universal design” should be adopted to produce sites that are accessible to the widest possible range of users and technologies (Wallis, 2005). There are general design features that can be adopted to increase the overall accessibility of a Website for people with learning disabilities:

Design and content For textual elements of the Website much of the guidance for hardcopy accessible information is relevant. The principles of using plain and clear language and including images in the information still hold true, but online information can be extended to also include audio and film formats. The RNIB (2005) accessibility guidelines encourage the use of a mixture of sounds, words and pictures on each Web page.

The RNIB also suggest that online accessibility can be improved by including a site map. This can ease navigation and allow users to assess the overall content of the Website quickly for relevance. The navigation bars and menus should be located in the same place on each page and every page should have the following buttons:

 Exit

 Home

 Help

 Next page

 Last page (RNIB, 2005).

The design of the Website should be flexible so users can change colours, font style and size according to their own needs (SAIF, 2010). The text used for hyperlinks should specify exactly where it is sending the user rather than simply informing the person to “click here” (SAIF, 2010). If possible more than one way should be adopted to make the link standout from the rest of the page, such as changing the colour or underlining the link (RNIB, 2005). Alternative text should be provided for non-textual elements of a website, including a text transcript of embedded audio or visual files to assist those using screen readers. Both SAIF and the RNIB advise against the use of animated or flashing text and pop-ups.

Large amounts of information can be made available on-line as a Portable Document Format (PDF), with an accessible Microsoft Word document as the source. Adobe Acrobat Professional 8 (or above) or the built-in facility in Word 2007 can be used to create the PDFs, making sure the “enable accessibility and reflow with tagged PDF” function is ticked in the document settings (RNIB, 2005). PDF’s are useful files for accessibility purposes as the user can read them off-line and they help keep the size of the website a manageable size.

Computer and browser accessibility Sevilla et al (2007) noted that Web accessibility in terms of the content and structure of Web pages is only one dimension to overall accessibility, with other considerations including computer and browser accessibility. However, use of the Internet and other information and communications technology (ICT) by people with learning disabilities is not an area that has been extensively researched (Williams, 2006, 173; Williams et al, 2006, 338).

Williams (2006) aimed to explore the ways in which people with learning disabilities use and interact with computers. He found that many of the participants required assistive devices such as joysticks or squeezable mice while others needed large text or slow curser speed. In his research in to the use of information and communication technology by students with special educational needs, a number of constraints and barrier to using computers were identified:

 A lack of experience using various applications;

 Mistrust of the accuracy of information found on the internet;

 Material accessed is too advanced or otherwise inappropriate;

 Loss of privacy; and

 Lack of technical support

Harryson et al (2004) conducted a small-scale usability study designed to investigate computer use by people with cognitive disabilities. Their results suggested that the group, seven subjects aged between 15 to 44 years, were skilful at web navigation involving use of the forward/back buttons and clicking on hyperlinks. They concluded that “the processing of text can impede accessibility to the internet for people with cognitive disabilities” (Harryson et al, 2004, 141) and therefore proposed that text-scanning technology and screen-readers could be beneficial to this group. On asking the group to run a search of Google’s image search function, problems were caused by incorrectly spelling the search terms and also from selecting a relevant link from the large number of returns. This suggests that an important part of the support people with learning disabilities may need when using an online service is help finding and understanding information.

Accessible Information Bibliography

Baxter, K., et al. (2008). Making informed choices in social care: the importance of accessible information, Health and Social Care in the Community, 16 (2) pp.197-207.

Caffrey, B. and Maclean, S. (2009). A jargon busting dictionary for social care, Staffs: Kirwin Maclean Associates.

Care Quality Commission. (2008). Commissioner assessment guide.

Carnaby, S. (ed.) (2002). Learning disability today, Brighton: Pavilion.

CHANGE. (2009). How to make information accessible: A guide to producing easy read documents, Leeds: CHANGE.

Changing Lives User and Carer Forum. (2008). Citizen leadership happens when citizens have power, influence and responsibility to make decisions, Edinburgh: The Scottish Government.

Clapham, A. (2009). Effective information on out-of-hours health care, Learning Disability Practice, 12 (2) pp. 38-39.

Codling, M and Macdonald, N. (2008). User-friendly information: does it convey what it intends? Learning Disability Practice, 11 (1) pp.12-17.

Curtice, L (2006). How is it Going? A Survey of what Matters Most to People with Learning Disabilities in Scotland Today, Glasgow: Scottish Consortium for Learning Disability.

Department of Health. (2010). Making written information easier to understand for people with learning disabilities, London: Department of Health.

Department of Health. (2008). Department of Health glossary [Online] Available at: http://www.dh.gov.uk/en/Help/DHglossary/DH_076176 (Accessed 11th November 2010).

Devadason, F. and Lingam, P. (1996). A methodology for the identification of information needs of users, August 25-31, 62nd IFLA General Conference. Friendman, M. and Bryen, D. (2007). Web accessibility design recommendations for people with cognitive disabilities, Technology and Disability, (19) pp.205-212.

Gates, B. (ed). (2002). Learning disabilities: toward inclusion, 4th ed, Churchill Livingstone Elsevier.

Grant, G., Goward, P., Richardson, M. and Ramcharan, P. (Eds). (2005). Learning disability: A life cycle approach to valuing people, Maidenhead: Open University Press.

Harrysson, A., et al. (2004). How people with developmental disabilities navigate the Internet, British Journal of Special Education 31 (3) pp. 138-142.

Holman, A. (2010). Easy does it, Learning Disability Today, July 2010, pp.24-25.

Le Grys, P. (2009). A way out of the information ghetto, Learning Disability Practice, 7 (8) pp.36-38.

Levy, G. (2005). Seeing for ourselves: producing accessible information for people with learning difficulties and visual impairments, British Journal of Learning Disabilities, 33, pp.77-82.

McConkey, R. and Smyth, M. (2001). Reflections of parents and students with severe learning disabilities on their special schooling and the transition to post-school provision, Journal of Research in Special Educational needs, 1 (3) pp.117- 25.

McConkey, R. (2003). Information needs of parents about learning disabilities, Journal of Learning Disabilities 7 (3) pp.211-219.

Mariger, H. (2006). Cognitive disabilities and the web: Where accessibility and usability meet? [Online] Available at: www.ncdae.org/tools/cognitive (Accessed 11th November 2010).

Mencap. (2008). Make it clear [Online] Available at: http://www.mencap.org.uk/page.asp? id=1538 (Accessed 11th November 2010).

Mitchell, W. and Sloper, P. (2000). User-friendly information for families with disabled children: A guide to good practice, York: York publishing services for the Joseph Rowntree Foundation.

National Information Forum. (2002). How to provide information well: a good practice guide, London: The National Information Forum. Newman, S. (ed). (2009). Personalisation: Practical thoughts and ideas from people making it happen, Brighton: Pavilion.

NHS Education for Scotland Knowledge Services (NES) and the Institute for Research and Innovation in Social Services (IRISS). (2010). Sharing knowledge, improving practice, changing lives: A knowledge management strategy and action plan for social services in Scotland 2010-2012.

NHS Education for Scotland. (2009). Information support roles: Enabling partnerships to find, use and share information for health and healthcare decisions, Glasgow: NHS Education for Scotland.

Nind, M. and Seale, J. (2009). Concepts of access for people with learning difficulties: towards a shared understanding, Disability & Society 24 (3) pp.273-287.

Pain, H. (1998). Coping with a child with disabilities from the parents’ perspective: the function of information, Child: Care, Health and Development 25 (4) pp.299-312.

Peters, C. and Bradbard, D. (2010). Web accessibility: an introduction and ethical implications, Journal of Information, Communication and Ethics in Society 8 (2) pp.206-232.

Poncelas, A. and Murphy, G. (2007). Accessible information for people with intellectual disabilities: do symbols really help? Journal of Applied Research in Intellectual Disabilities, 20, pp.466-474.

The Rix Center. (2010). New media [Online] Available at: http://www.rixcentre.org/new- media.html (Accessed 24th November 2010).

Rodgers, J. and Townsley, R. (2005). Commissioning information for people with learning difficulties, Journal of Integrated Care, 13 (2) pp.44-48.

Rodgers, J. and Namaganda, S. (2005). Making information easier for people with learning disabilities, British Journal of Learning Disabilities (33) pp.52-58.

Royal College of Nursing. (2006). Meeting the health needs of people with learning disabilities, London: Royal College of Nursing.

Royal National Institute for the Blind. (2005). Information for all: guidance about making easy information, Royal National Institute for the Blind and the Norah Fry Institute.

SCIE. (2005). How to make information accessible. Scottish Accessible Information Forum. (2010). Making information accessible: Guidelines for producing accessible printed and electronic information, Glasgow: Scottish Accessible Information Forum.

Scottish Consortium for Learning Disability. (2010). eSAY Statistics Release, Glasgow: Scottish Consortium for Learning Disability, [Online] Available at: http://www.scld.org.uk/scld-projects/esay/esay-statistics-releases.

Scottish Executive. (2006). Changing lives: the report of the 21st century social work review, Edinburgh: Scottish Executive.

Scottish Executive (2000). The same as you? A Review of Services for People with Learning Disabilities, Edinburgh: Scottish Executive.

Scottish Government. (2010a). Procurement of care and support services, Edinburgh: Scottish Government.

Scottish Government. (2010b). Scottish Local Government Financial Statistics 2008-2009, Edinburgh: The Scottish Government, [Online] Available at: www.scotland.gov.uk/Resource/Doc/307376/0096646.pdf (Accessed 11th November 2010).

Scottish Government. (2007). Better health, better care: Action plan, Edinburgh: Scottish Government [Online] Available at: http://www.scotland.gov.uk/Resource/Doc/206458/0054871.pdf (Accessed 11th November 2010).