Strategies for Graphic Design aimed at the Multiple Sclerosis Community
The Development of the Inclusion Framework to
Assist in Design Thinking and Visual Communication Artifacts
A thesis submitted to the School of Visual Communication Design,
College of Communication and Information
of Kent State University in partial fulfillment of the
requirements for the degree of Master of Fine Arts
by
Andrew Fogle
august, 2016 Thesis written by
Andrew B. Fogle
A.A.S., Sinclair Community College, 2010
B.F.A., Kent State University, 2014
M.F.A., Kent State University, 2016
Approved by
Ken Visocky O’Grady, M.F.A., Advisor School of Visual Communication Design
Jamie Kennedy, M.F.A., Interim Director School of Visual Communication Design
Amy Reynolds, Ph.D., Dean, College of Communication and Information Table of Contents
LIST OF FIGURES...... vii
PREFACE ...... ix
Acknowledgments...... x
CHAPTER I: Introduction...... 1
Background...... 2
Thesis Intent...... 2
CHAPTER II: MS and Common Symptoms ...... 3
Multiple Sclerosis...... 3
Types of MS ...... 3
Relapsing-Remitting MS ...... 4
Secondary Progressive MS ...... 4
Primary Progressive MS...... 5
Progressive-Relapsing MS...... 5
Common Symptoms ...... 7
Fatigue...... 7
Cognition...... 8
Visual Impairment...... 9
CHAPTER III: Visual Communication and Design ...... 12
Issues with Access ...... 12
ADA, SEGD and Laws...... 12
Graphic Design...... 13
Problem Space and Solution Space ...... 14
III CHAPTER IV: The National Multiple Sclerosis Society ...... 16
Communication Materials Aimed at the Multiple Sclerosis Community...... 16
Unstructured Interview with Manager of Research at the National MS Society.....17
Unstructured Interview with Creative Director of the National MS Society ...... 19
CHAPTER V: Survey Development and Results ...... 21
Development...... 21
Survey Goals...... 22
Outcomes...... 22
CHAPTER VI: Personas ...... 23
Background ...... 23
Molly ...... 23
Gared...... 24
Bea ...... 24
Anthony ...... 25
Persona Use within the Framework...... 26
CHAPTER VII: The MS Inclusion Framework Guidelines ...... 27
Easy-to-Read...... 27
Legibility and Readability...... 28
Aspects of Legibility...... 29
X-Height’s Relationship to Legibility...... 29
Typographic Selections...... 32
IV Serif Versus Sans-Serif ...... 35
Typographic Sizes ...... 37
Type Weights...... 37
Expanded and Condensed...... 39
Spacing Issues with Typography...... 40
Typography Conclusions from IFS...... 40
Page Layout and Grid Structure...... 41
Line Length...... 42
Typographic Alignment...... 44
white Space is not Negative Space...... 45
The Golden Ratio...... 46
Grid and Layout Insights from Survey...... 47
“Gestalt” Principles...... 48
Similarity ...... 49
Figure-Ground Relationship...... 50
Closure...... 51
Continuation...... 51
Proximity...... 52
Conclusions...... 53
Color ...... 53
Color Contrast, Hue and Lightness ...... 55
Typography and Color...... 56
Color Insights from Survey...... 58
Photography & Representation...... 59
Poster-Children ...... 59
Disability as a Symbol—Visual and Metaphoric...... 60
V Photography Insights from Survey...... 62
Production...... 63
Binding Methods...... 64
Digital Files...... 64
Conclusion...... 65
CHAPTER VIII: Focus Groups ...... 66
Development...... 66
Focus Group 1...... 67
Focus Group 2...... 71
Focus Group 3...... 72
Conclusion...... 73
CHAPTER IX: Quantifying the Drawings...... 74
Background...... 74
MS as a part of ‘self’...... 74
Figures Addressing Symptoms...... 75
MS as a Metaphor or Abstraction...... 77
CHAPTER X: Barriers to the Outside World...... 79
Introduction...... 79
Language...... 80
CHAPTER XI: Conclusion and Final Thoughts...... 82
VI List of Figures and Appendices
Figure 3-1: Multiple Sclerosis Disease Courses Visually Rendered...... 6
Figure 4-3: Simulated Vision Problems...... 10
Figure 1-2: Survey recognized by the National MS Society...... 18
Figure 1-3: National Multiple Sclerosis Society Brand Guidelines...... 20
Figure 2-1: Typographic Anatomy Chart...... 29
Figure 2-2: X-Height Comparison Chart...... 30
FIgure 2-3: Typographic Form-Counter form Relationship...... 31
Figure 2-4: Americans with Disabilities Act (ADA) Stroke to Width Ratios ...... 32
Figure 3-1: Typographic Historic Classifications...... 33
Figure 3-2: “Jigsaw” and “APHont” Typographic Systems...... 35
Figure 3-3: Serif Typography versus Sans Serif Typography...... 36
Figure 3-4: Typographic Weight Comparison...... 38
Figure 3-5: Extended/Condensed Comparison...... 39
Figure 4-1: Various Grid Systems...... 42
Figure 4-2: Line Length Figure...... 43
Figure 4-3: The Golden Ratio...... 46
Figure 5-1: Principles of Visual Perception “Gestalt”...... 48
Figure 5-2: Principles of Similarity...... 49
Figure 5-3: Principles of Figure-Ground Relationship...... 50
Figure 5-4: Principles of Closure and Continuation...... 51
Figure 5-5: Principles of Proximity...... 52
Figure 6-1: Range of Color Contrast...... 54
VII List of Figures and Appendices
Figure 6-2: Color Wheel showing Effective/Ineffective Contrast...... 56
Figure 6-3: Typography and Color Diagram...... 57
Figure 7-1: Poster Children Example...... 60
Figure 7-2: National MS Society Photography Example...... 62
Figure 7-1: Focus Group Testing Document...... 68
Figure 7-2: Drawing Multiple Sclerosis Visually...... 69
Figure 8-1: Multiple Sclerosis as a Part of ‘Self’...... 74
Figure 8-2: Figures addressing Symptoms...... 75
Figure 8-3: Multiple Sclerosis as a Metaphor...... 76
Appendix A: Survey Appendix...... 84
Appendix B: Personas Appendix...... 93
Appendix C: Focus Group Appendix...... 98
Appendix D: Drawing Appendix...... 106
VIII Preface
A special thank you goes out to all the individuals with Multiple Sclerosis who aided in the research conducted. Thank you for sharing your personal stories, challenges, and struggles. Without the involvement of the MS community, this thesis would not have been possible. I was raised by a single mother with Multiple Sclerosis, and as such it touched my life at a very early age. It’s not an easy journey to take. As allies we must always continue to push for better rights, continuing research studies, and hopefully one day a cure for MS.
In determining a thesis topic, I knew I wanted to tackle a project that utilized visual communication as a framework to help designers better understand and design for people with MS. The project became a large interaction with several members of both the design community and the MS community. I want to reiterate how thankful I am for everyone involved in this project. I was interested in the topic matter that paid tribute to all the effort my mother put into raising me to be the person I am today. Thank you Stacy
Elizabeth Roten.
Thank you to my thesis committee: Sanda Katila, Jessica Barness and Ken Visocky
O’Grady for taking time out of their schedules to help me resolve issues, both personal and thesis related. Each one of these professors genuinely cared about my academic journey but also about me as a person. They helped shape and fine tune the final document and kept me on the right path. My eternal gratitude goes to these people. A special thanks to John Brett Buchanan who served as a spiritual fourth member of my committee. Your involvement in the thesis writing and the overall grammar structure of the document helped me stay focus and on track. I feel honored to consider each one of these people as mentor and as a friend. It is my hope this research document pushes the needle just a little bit further towards more accessible design overall.
IX Acknowledgments
Stacy Roten, my mother and a constant source of inspiration. This is for you. Nothing could ever take your spirit away and that is the most beautiful lesson a parent could ever teach.
An expression of my most sincere gratitude for the wisdom, encouragement and support during the work throughout graduate school. This thesis, as well as my personal and professional growth, is a result of the cumulative efforts of the following people:
• Judy and Russ McGuire
• Diane Fogle
• Ken Visocky O’Grady
• Sanda Katila
• John Brett Buchanan
• Jessica Barness
• Jillian Coorey
• Holly Dahl
• Aofie Mooney
• Shelby Muter
• Matthew Smith
• Blaire Fogle
• Laura Haines
• Leigh Hughes
• Rachel Helgreen
• The MS Warriors Support Group
• The National MS Society X 1
CHAPTER I
Background and Thesis Intent
1. Introduction
Access to information is a democratic right for all people. The American
Disabilities Act (ADA) passed July 1990, prohibits: “discrimination against people with
disabilities in employment, transportation, public accommodation, communications,
and governmental activities.” By law, everyone should have access to information. The
form that information takes varies greatly depending on the artifact, but is generally
understood to be a complex presentation of concepts, symbols, writings as well as oral
and visual language. The sum of these parts is that the user acquires meaning through
a holistic understanding of the intended message.
Visual communicators have a considerable amount of control over the way a
message is delivered, working to discover new ways to create exciting, compelling,
innovative and attractive design solutions. Communication solutions need to be
accessible to all individuals, which is where the influence of graphic designers becomes
very important. Typographic details like font selection, legibility, color, readability and
margins of a page become even more crucial elements for designers when the audience
includes a demographic that may have reading or cognitive disabilities.
Being able to read, understand and access materials gives a person a tremendous
amount of power by allowing them to expand their world view and take control of their
own lives (Nomura, 2010). Through communication, people are able to understand and
share ideas, culture, thoughts, and knowledge. Communication ultimately allows
people to grow and become a part of their society. With respect to increasing
accessibility of information, this thesis focuses specifically on crafting a framework to
assist graphic design teams working on visual communications targeted at individuals
living with Multiple Sclerosis (MS). 2
2. Thesis Intent
This thesis will address the challenges of living with MS by researching visual communication in a printed context to ensure that current “best practices” are creating accessible and comprehensible communications for this audience. The primary and secondary research will focus on three specific symptoms common in the community.
Visual impairment, cognitive changes and fatigue are key manifestations of the MS community and the symptoms that could be most affected by inaccessible design choices.
The following thesis research has four main purposes: 1.) to describe the nature of and the need for accessible print communications by addressing the challenges of living with MS; 2.) to access and identify issues related to the current system of print communications, if any; 3.) survey and interact with the MS community in reference to print communications and visual methods; and 4.) create a framework for design teams working on communications that serve people within the Multiple Sclerosis community. 3
CHAPTER II
Multiple Sclerosis and Common Symptoms
1. Multiple Sclerosis
MS in its broadest definition is “an unpredictable, often disabling disease of the
central nervous system that disrupts the flow of information within the brain, and
between the brain and body” (National Multiple Sclerosis Society, 2012). With long-
standing and intense scientific research, the manner of causation and origins for MS
remains only partially known. The disease generally shows up between the ages of 20
to 40 years and is more common in women, who are diagnosed at twice the rate of men
(National Multiple Sclerosis Society, 2012). What is known is that MS specifically involves
an immune-mediated process in which the body’s immune system is directed against and
attacks the central nervous system (Compston and Coles, 2008).
The central nervous system (CnS) includes the brain, spinal cord and optic
nerves. This leads to a variety of unpredictable and variable symptoms in MS. These
symptoms are individualistic and no two people share the exact same symptoms.
Though the disease’s origins are currently unknown, accumulating evidence from
genetic and epidemiological studies indicate a relationship between genetic susceptibility
and environmental triggers (Compston and Coles, 2008).
2. Types of Multiple Sclerosis
Despite its variable nature as a disease, it is well researched and documented that
people with MS typically will experience one of four disease courses (National Multiple
Sclerosis Society, 2012). To better understand the needs and demands of people with MS,
and how graphic designers can make more sound design choices, it’s imperative to
understand these disease courses. MS causes a variety of symptoms, breaking
down both the disease course and the most common symptoms that could potentially 4
cause disruption in access to printed communications and artifacts was a key component
of this research. From this disease course research along with primary surveys and focus
groups, personas were created from ethnographic research into MS. In the following
section an outline of the four MS disease courses will be presented to take better
advantage of opportunities for inclusion.
2-1. Relapsing-Remitting Multiple Sclerosis (RRMS)
This disease course is the most common within the community, and approximately
85% of people with MS are diagnosed with RRMS (National MS Society, 2014). This
type is identified by defined attacks where neurologic function is decreased or reduced.
These attacks, called “relapses,” are followed by partial or complete recovery periods
called “remissions” (Frohman, 2008). During these remissions part or nearly all of the
neurologic function is regained as can be seen in Figure 3-1. Damage done to the central
nervous system is individualistic which causes the variable nature of MS. This produces
two people with MS who may have entirely different symptoms. People with RRMS may
experience fatigue, numbness, vision problems, issues with memory or information
processing and digestive issues (National MS Society, 2014). Though RRMS is diagnosed
typically earlier than the other disease courses, within ten years most people will
transition into Secondary Progressive MS.
2-2. Secondary-Progressive Multiple Sclerosis (SPMS)
Following after the RRMS disease course, nearly all people who are initially
diagnosed as RRMS will transition to this type of MS. This time period of transition
is extremely individualistic with it being as little as five years or as long as twenty.
Around 90 percent of people with RRMS will transition to SPMS within twenty-five
years (MS Society of Canada, 2015). In Secondary Progressive MS (SPMS), the disease 5
begins to progress more steadily with or without relapses and periods of remission
(National MS Society, 2012). This disease course is marked with increasing levels of
disability as symptoms either maintain or worsen as time goes on. People with SPMS may
experience greater fatigue, numbness, vision problems, cognitive issues, digestive issues,
troubles with walking or legs, and occasional sensory impairment, among other more
individualized symptoms (MS Society of Canada, 2015).
2-3.Primary-Progressive Multiple Sclerosis (PPMS)
Most of the MS population will either have RRMS or SPMS, however, 10-15%
percent of people diagnosed with MS experience Primary-Progressive MS (PPMS).
According to the MS Society of Canada “Primary-progressive MS (PPMS) is characterized
by a slow accumulation of disability, without defined relapses. It may stabilize for
periods of time, and even offer minor temporary improvement but overall, there are no
periods of remission.” This specific disease course can be harder for health professionals
to diagnose. Typically most people experience issues with walking, balance, vision
problems, optic neuritis, fatigue, bowel problems as well as other symptoms related to
gait difficulties. Unlike other types of MS, there are no relapses or remissions, however,
this type is considered far more progressive than the other two.
2-4. Progressive-Relapsing Multiple Sclerosis (PRMS)
Progressive-Relapsing MS (PRMS) is the least common of the four disease
courses, and appears in about 5% of people with MS according to the National
MS Society. PRMS can be compared to a combined form of the other two disease courses.
People with PRMS experience a progressive decline in neurological function, similar to
people who have PPMS (National MS Society, 2012). However, like people with RRMS,
these individuals can potentially experience recovery following attacks but this is rare; 6 typically the symptoms do not get better as they do with RRMS remission periods.
Similar to the other MS disease courses, symptoms of PRMS include vision problems, weakness in the legs, cognitive impairments, to name a few.
figure 3-1. multiple sclerosis disease courses visually rendered
progressive relapsing ms (prms) steady decline since onset with super-imposed attacks.
secondary progressive ms (srms) relapsing remitting ms moves into spms where steady decline of disability occurs without periods of remissions. increasing disability
primary progressive ms (ppms) steady increase into disability without periods of relapse or remission seen in other courses.
relapsing-remitting ms (rrms) unpredictable periods of relapse and remission, which may or may not leave damage to the person.
time data collected from the national ms society and ms canada. 7
3. Common Symptoms of MS
Regardless of the type of MS a person is experiencing, most health
professionals and researchers agree that as a condition there are key symptoms
that run throughout all of the disease courses. In this section an outline of the three
most common symptoms occurring in MS will be presented. These three symptoms:
fatigue, cognition, and visual impairment play a great link guaranteeing that visual
communication in a print format is inclusive and accessible to this community of people.
3-1. Fatigue
Fatigue is one of the most common symptoms of MS, occurring in about 85–95%
of people. (MS Society of Canada, 2015). Describing MS-fatigue to someone who hasn’t
experienced this symptom is difficult. Fatigue in MS is not the same as normal fatigue,
which one can recuperate from with good rest. It is chronic fatigue, where everything
seems to be an effort. Simple things like reading or grabbing the paper become daunting
tasks. Fatigue is MS is not just tired muscles. It is the effect of the disease on the sensory
nerves that go to the muscles (Graham, 1984). These sensory nerves transmit touch,
taste, smell, hearing and sight. Thus fatigue in MS may cause blurry vision or slowed-
speech patterns.
The National Multiple Sclerosis Society of America (MSAA) found fatigue to be
one of the primary causes of early departure from the workforce. Fatigue may be the
most prominent symptom in a person who otherwise has minimal activity limitations.
What happens when a person with MS gets fatigue differs from person to person. Fatigue
is caused by a number of different environmental factors in MS (Graham, 1984). Some of
the most common causes of fatigue are a hot day, humid weather, stress, overexertion,
eye strain, and smoking.
The subject of MS-fatigue has been studied in-depth with several academic texts
and books existing on this subject alone. Fatigue and sensory perception has a lot to do 8 with how people interact with the world and the artifacts around them. Therefore, fatigue is an important link in understanding how the MS community interacts with print materials and artifacts.
3-2. Cognition
The mind and brain are complex systems and are still the topic of ongoing scientific research. Cognition shapes who we are and how we see the world. According to the National MS Society, half of the people with MS experience cognitive dissonance, which changes the way they perceive things. Cognition refers to a range of upper level brain functions. These functions include the ability to plan and problem-solve, focus, read, understand and use language, and accurately perceive the environment. Cognitive processing and issues associated with MS are only tangentially related to other disease characteristics. This means that a person with MS who may have no physical limits, could have significant issues with cognitive processing, while another individual with
MS, who is in a wheelchair, could be unaffected cognitively N( ational MS Society, 2012).
Among the MS population, five to ten percent of people with MS develop severe enough cognitive dissonance to significantly interfere with everyday activities
(National MS Society, 2012). Issues with cognitive functioning appears in all four MS disease courses, but is more common in the progressive stages. Cognitive changes tend to progress slowly but according to the MS Society of Canada, “are unlikely to improve dramatically once they have begun.” Issues with cognition can be one of the biggest factors in impeding a person with MS from printed communications. In a recent survey study conducted by MS in Focus, looking specifically at cognitive functioning, more than half of people with MS between 45 and 88 years old reported that cognitive difficulties interfered somewhat with their daily life (MS in Focus Magazine, 2015). These changes in upper brain functions can affect verbal fluency, word processing and reading 9 comprehension among other functions which can limit accessibility to the printed word
(Graham, 1984).
4-3. Visual Impairment
Disturbances of the visual system are among the most common manifestations of MS, affecting up to eighty percent of patients at some time in the disease course
(Frohman, 2008). It serves as the initial manifestation of MS in many people. MS can affect any portion of the visual sensory system which can sometimes lead to more specific conditions like acute blindness, optic neuritis or asymptomatic optic neuropathy.
However, visual disturbances are the initial symptom up to 50 % of the time
(Atkins, 2009). These visual disturbances may fluctuate in severity, come and go, or become permanent. One of the most common visual disturbances in MS is known as optic neuritis. The word neuritis means inflammation of a nerve (Frohman, 2008). In an attack of optic neuritis, the optic nerve is affected. Isolated acute optic neuritis is often the first sign of MS, and many individuals with MS develop optic neuritis during the course of their disease (Atkins, 2009). This is the presenting syndrome in 20% of
MS patients (National MS Society, 2012).
MS causes brain tissue injury through multiple inflammatory demyelinating lesions. There are several visual problems in MS that arise from multiple lesions that involve both the input and output sensory systems, resulting in disorders of both visual processing and eye movements (Frohman, 2008). Over the course of the disease, virtually
100% of those with MS will have some visual problem, including visual loss and/or various distortions of vision (Atkins, 2009). Many of these visual impairments cause abnormalities in color vision, inability to read small type, diminished color perception, contrast sensitivity, and double vision (Figure 4-3). 10 figure 4-3. simulated vision problems
simulated vision problems using “jigsaw bold”, the core type family of the national multiple sclerosis society.
simulated vision problems using “clarendon std bold.”
Simulated vision problems using “aphont”, specifically developed for people with vision problems by the american printing house for the blind. data collected from the professional association for design (aiga). 11
simulated vision problem showing the difference between normal focus and blurred vision, data collected from the professional association for design (aiga).
to a person with color-deficient partial sight, the left-hand panel might appear like the right-hand panel appears to a person with normal color vision (Lighthouse International). 12
CHAPTER III
Visual Communication and Design
1. Issues with Access
Issues with cognition, fatigue, walking and vision present an entirely new realm of issues when dealing with printed materials, the Internet and three-dimensional spaces. Design teams working with these communities must be cognizant of laws, existing guidelines, “best practices” and regulations so they can make inclusive design decisions that consider accessibility to an artifact above all else.
2. American Disabilities Act, Society for Experiential Graphic Design and Laws
Environmental graphic designers with projects in public spaces must obey the rules set forth by the Americans with Disability Act (ADA) and the Society for
Experiential Graphic Design (SEGD). Consequences for non-compliance are dire; if guidelines are not met, a civil lawsuit could force changes or removal of a project entirely
(Allan, 1992). Traditionally, graphic designers do not have to adhere to government regulations regarding disability in printed communications. At the present time there are no nationally or universally accepted guidelines for graphic designers working on printed communications targeted at people with disabilities.
Social models and frameworks have been developed to assist with designing for disability such as the 2006 SEGD White Paper which included graphic design guidelines and recommendations on “Typography for the Blind,” “Position of Text and Braille on
Signs,” and “Innovation,” a discussion of the wayfinding needs of the blind and visually impaired (Communication Arts, 2009). Accessibility improves understanding of the message, creates stronger design solutions and helps build a more inclusive society.
Ultimately, graphic design thinking that is aware of accessibility can play a key factor for the social inclusion of people with disabilities and beyond. 13
At an early age we learn to use movement to express ourselves visually. Drawings,
writing and mark-making of all kinds enable a connection with anyone who may see
them, thus, bringing our thoughts and ideas to life (NMSS Brand Guidelines, 2014). Our
bodies are in constant motion, moving information from the brain to the body, however,
with MS, movement is not always a guaranteed.
3. Graphic Design
Design is can be found anywhere by anyone from simple things like magazines,
books and products to more complex artifacts like computers, tablets and multimedia.
Design is present in wayfinding of three-dimensions spaces. Design is everywhere. While
the ideas behind design evolve with time, certain standards remain, as it expands into
interdisciplinary realms such a social roles, medical infographics, human experiences
and innovation. Recognizing the robust and varied nature of visual communication aids
in informing the choices teams can make when designing for accessibility and inclusion.
Relating the MS symptoms to accessible design showcases a large amount of
supporting evidence of how important accessible design thinking is in relation to
communications in regards to any disability. For instance, reading successfully is not
always a matter of decoding the words.
Reading, and in larger context, meaning, should also lead the user to being
able to acquire knowledge of the author’s intent. Cognitive difficulties and perception
disturbances often lead to reading, writing and understanding problems. The end
goal is that the user acquires understanding. To achieve such an end result with the
communication, the writing and design teams must take into consideration content,
language, color illustrations and grid structure.
Graphic designers create a message through a combination of typesetting letter
forms, color, and image. Ultimately though, the artifact will need to be read and reading 14
artifact will need to be read and reading is a stressful task. When people read, their eyes
need to make roughly four movements every second which is 15,000 eye movements
for every hour they spend reading (Sheedy, 2008). This eye strain can bring on fatigue in
MS (Graham, 1984). Graphic design teams must be cognizant of these facts when gearing
design solutions towards accessibility for the user.
Designers attempt to use high quality text when readers are expected to read
for any period of time, but using a comfortable text size is not always possible. In
print communications, there is often a trade-off between the size of typography and
the amount of text that can fit on a page. 9-point type may be chosen because it is cost-
effective, whereas 14-point would be easier and more accessible for people with MS.
Overall, in the creation of print artifacts, meaningful interactions within communities,
and social change for people with limited access, design becomes a powerful act of change
that can make existing conditions better.
4. Problem Space and Solution Space
There are many ways to define visual communication or graphic design; for the
purpose of this thesis, Newell and Simon’s definition of graphic“ design being connected
to the notions of problem and solution space” works as the best definition. Generally, the
problem space represents a set of requirements and the solution space represents a set of
artifacts that satisfy these requirements (Newell and Simon, 1972).
Using this view, graphic design problems are ill-defined problems, in the sense
that the ends are not given in the working environment but are a part of the design
process (Simon, 1973; Goel and Pirolli, 1992). There is outside research that references
the mutual influence between problem and solution in the design process, while others
conclude designers define the problem as they work towards the solution (Dorst and
Dijkhuis, 1995; Dorst and Cross, 2001). 15
These concepts incorporate the idea that design problems are open-ended and
thus no single, optimal solution exists. For this reason, design problems are often
characterized as ‘wicked’ problems (Buchanan, 1992), a notion that incorporates the idea
that such problems have many solutions. Due to the open-endedness of design problems,
visual communicators require subjective interpretation, critique and evaluation to
arrive at the best design solution possible. As the mediators who stand between sender
and receiver in the communication process, designers have a high degree of control in
the outcome of a design artifact or solution. This degree of control helps graphic design
teams make more accessible design choices when the set of requirements for the solution
involves any kind of disability. 16
CHAPTER IV
The National Multiple Sclerosis Society
1. Communication Materials Aimed at the Multiple Sclerosis Community
The largest producer of graphic design artifacts targeted at people with MS is,
without a doubt, the National Multiple Sclerosis Society (NMSS). The society mobilizes
people and resources to drive research for a cure and to address the challenges for
everyone affected by MS N( MSS Brand Guidelines, 2014). The U.S. society is one of 44
sister societies forming the Multiple Sclerosis International Federation (MSIF). These
societies serve as champions for the community but, ultimately, one of their driving
forces is accessible visual communication as they are a brand as same as any other with
guidelines and standards for their society’s best practices.
Primary research began with the U.S. society in the form of several unstructured
interviews via telephone and email to better understand what research had already
been done in the realm of creation, visual methods and design thinking in regards to this
community. This began by connecting locally with the Ohio Buckeye Chapter’s Executive
Vice-President of Marketing and Outreach, Jennifer Hammilton. This marketing vice-
president spoke at length about what the society does locally in terms of marketing,
outreach and getting as many individuals involved in the “movement” as possible.
All of the society’s research is driven by charitable contributions and private
donors and while they are nationally recognized, they are not a government entity. It
is because of that fact that nearly all of the society’s research goals are devoted to the
medical field and finding a cure or solutions for MS. Much of the “best practices” the
society uses for design solutions comes from secondary research sources, including 17
primary and ongoing research by the society. Ms. Hammilton suggested it would be
advantageous to speak with both Sara Bernstein, Manager of Research Information and
Research Programs for the society located in New York, and Mark Serratoni, Director
of Creative Services for the society located in Colorado for further secondary research
and input.
1-2. Unstructured Interview with Manager of Research at the National MS Society
The second unstructured conversation was with Sara Bernstein, Manager of
Research Information and Programs at the society in New York, who was extremely
helpful in the thesis process. Ms. Bernstein spoke of some of the current medical
research going on within the society which was followed up by access to this secondary
information. She relayed that the NMSS is interested in outside research being done at a
graduate level and outside organizations whose research trajectories are outside that of
the traditional medical research.
As Ms. Bernstein, Manager of Research Information and Programs stated:
“ Our ‘design’ research comes from secondary sources as the society is devoted
towards finding a cure and medical alternatives. However we are always open
review alternative non-medical research for posting on our website after approval of
our health and policy staff.”
with approval of the NMSS’s health and policy staff, the society agreed to assist
with recruitment by posting on their official website in a section entitled “Research
Surveys” (Figure 1-2) and through connections in the community found in various
local chapters. This thesis research was recognized by the society which assisted in
recruitment of individuals with MS. The participants interacted with an anonymous
online survey that served as a form of primary research for the thesis. 18
figure 1-2. inclusion framework survey recognized by the nmss.
inclusion framework survey recognized by the nmss and posted on the nmss website to assist in recruitment of participants in the survey. 19
1-3. Unstructured Interview with Creative Director of the National MS Society
To understand how value can be seen in accessible graphic design, and in order to
create a framework that artifacts can be built from, it was crucial to engage and interact
with the creatives at the NMSS. The goal of these interviews was to better understand
how the society has developed a sense of brand awareness and how design thinking is
being implemented to make accessible design choices. Design thinking helps individuals
ask questions, discover diverse solutions and work together to shape new outcomes that
change the world bit by bit (AIGA, 2013). It is a crucial element in the work that creative
industries do.
Mark Serratoni, Director of Creative Services for the society, provided just this
insight into the work that the society does in relation to design thinking and accessible
visual communication. He echoed earlier unstructured interview answers that much
of the information the design team uses comes from outside secondary research
focused on the larger disability community. This is because the NMSS’s main research
focus is on developing medicine and seeking a better understanding of the disease’s
origins with hopes of finding a cure. Mr. Serratoni also provided the society’s brand
guidelines (Figure 1-3) and the secondary research they have used to develop accessible
designs. These elements serve as part of the thesis’ primary research and aided in the
development of the final inclusion framework.
As Mr. Serratoni, Director of Creative Services explains:
“ Most of our research about accessibility of type comes from Lighthouse and the ADA,
which has done numerous research studies into typography for people with visual
disturbances Our best practice is to use serif type for body copy in printed documents
and communications and sans-serif for our website and tablet/smartphone applications.” 20
figure 1-3. national multiple sclerosis society brand guidelines
sample pages from the nmss brand guidelines provided by mr. serratoni, director of creative services for inclusion in the survey, secondary research and focus groups. 21
Chapter V
Survey Development and Results
1. Development
To better understand the challenges that face people with MS it was essential to
engage this community as part of the primary research. Development of an anonymous
online survey as a part of the primary research began as one of the initial phases in
the thesis development. This was an imperative step in understanding the challenges,
if any, facing current design artifacts. It was developed with input from both graphic
designers and three individuals with MS as a way of quantifying the communities’ views
regarding the nature of printed design communications.
The Multiple Sclerosis Inclusion Framework Survey (IFS) had a specific emphasis
on typography selection, legibility, understandability, size, and detail. Sections of
the survey examined several elements of typographic design. Of the design elements
presented, it was necessary to have survey participants look at the comprehensibility of
several typefaces (both serif and sans-serif) in body copy in order to understand and
determine optimal typeface selections for this community.
Other questions engaged participants’ knowledge of typographic grids, x-height
preferences in typefaces, color theory, and photography selections in current MS
communications. Each participant was anonymous and was asked to complete an
identical questionnaire. The total participants for the survey was 90.
The only requirement for the survey was that the person must have had a
positive diagnosis of MS. The 90 were gathered using various online methods, in
particular, the National MS Society, local support groups, Facebook and Blogger played
an integral role in assisting with collecting individuals within the MS community
willing to participate in the anonymous survey. All websites posted a link to the survey 22
in research sections with the attempt of gathering more individuals to the survey. The
data was collected and then processed using Qualtrics. Qualtrics is a research software
company which produces online tools, forms, and programs for online data collection
and analysis.
2. Survey Goals
Three fundamental goals drove the IFS survey questions and subsequent data
analysis. The goals were to 1.) quantify the communities’ views; 2.) establish a baseline
knowledge for serif vs. sans-serif font families; and 3.) better understand the scope of
challenges facing people with MS. These objectives were accomplished and the findings
presented in this section demonstrate the potential impact that accessible design
thinking can have on this community.
3. Outcomes
The outcomes and results of the survey aided in helping to gain an understanding
of the disease itself as well as understanding specific points about graphic design in
regards to this community. Overall one of the biggest outcomes of the survey was an
understanding in the type of artifacts people with MS interact with and whether or not
they relate to this types of communications. The survey results also gave insight into the
variable nature of MS and aided in the development of the personas. Individual survey
results are addressed in Chapter 6: Framework Research, and for selected results and data
please see the Appendix A: Survey Appendix. 23
Chapter VI
Personas
1. Development
The MS community is not a homogenous one as we saw earlier; there is much to
be said about the individualistic nature of the disease courses. Symptoms can sometimes
vary from individual to individual. However because all people with MS will follow
one of four symptom courses, four personas were developed to aid the research and
the framework to make sure it was fully accessible to the entire community. According
to Vijay Kumar in 101 Design Methods, personas are “the types of potential users and
organized according to sets of shared attributes. It is helpful to think of a persona as a
personality type.”
These personas are created and considered as representations of the target
users for the project. The knowledge and research used for these personas come from
in-depth secondary and primary research including the survey, focus groups and
drawing exercises. Crafting four personas based on the research was designed to work
in conjunction with the final framework, to allow greater opportunity for inclusion and
accessibility within the problem and solution space.
2. Molly, Relapsing-Remitting MS, “You look so Healthy”
Molly is in her mid-20s and has been newly diagnosed with MS. Molly is active,
healthy most days, and at times feels as if the disease has no hold on her. Molly has
relapsing-remitting MS (RRMS) and as such she has “relapses,” where her MS symptoms
flare up. Relapses are followed by a period of recovery time with little to no symptoms
often referred to as “remission.” During these times of remission Molly feels normal
and her MS is not progressing any further. Molly has slight eye pain and double vision
consistent with her RRMS. These symptoms were her first in diagnosing her MS. For 24
Molly, important design elements that could affect her access to print communications
are components like typography, substrate and color.
3. Gared, Secondary Progressive MS, “Managing Symptoms is Life”
Gared is in his 40s and has had MS for longer than 15 years. Gared has issues
walking and may use a cane or leg braces. His walking is noticeably affected from MS
and he leads a more sedentary lifestyle than Molly does. Gerald has transitioned from
RRMS to Secondary Progressive MS (SPMS). 80% of people with RRMS eventually
will transition into SPMS (National MS Society, 2013). With Gared, periods of
“remission” and “relapse” are less distinct and unpredictable. Instead, with SPMS,
relapses and remissions that used to come and go with Gared have changed into daily
symptoms he now manages as they become steadily worse.
Gared, like Molly, has eye pain and double vision, as well as two occurrences
of optic neuritis, which have cleared up. Like Molly, typography, substrate and color
are key points for Gared’s accessibility. In the last ten years Gared has struggled with
increasing fatigue and cognitive dissonance. Gared’s fatigue and cognitive struggles
causes him to become irritable and impatient doing things he once did with ease. For
Gared, access to communications is an important part of his life and elements like
accessible page layout/grid structure and avoiding the use of complex jargon may offer
greater opportunities for inclusion.
4. Bea, Primary-Progressive MS, “No Wheelchair Today!”
Bea is in her late 50s and has had MS for 30 years. Bea has been confined to
a wheelchair for the last ten years when her legs became too weak to support her
walking. Bea lives a sedentary lifestyle, very different from when she was first
diagnosed with PPMS. In general, Bea requires assistance in her daily life to complete
everyday activities. Bea, like Gared, has had several flare ups of optic neuritis which 25
have greatly hindered her vision over the course of her life. Bea is a part of many
online MS support groups and at times has had opportunities to impart wisdom about
her journey to other members of the MS community.
Bea has cancelled many subscriptions recently citing that mainstream magazines
and newspapers have gone to the practice of using smaller and lighter fonts to grab
attention of standard readers. During the evening Bea’s vision occasionally worsens and
she struggles with her cognitive abilities especially when it comes to the recognition of
simple words. During these times Bea might make use of “reader magazines” which can
be read to her from electronic means like computers or podcasts. Podcast alternatives
of printed design materials could be considered for this persona. Opportunities for
inclusion in print design for Bea are similar as to the other two personas, but greater
attention must be given in Bea’s scenario due to her advancing symptoms.
5. Anthony, Progressive-Relapsing MS, “I’m not a part of the MS Community”
Anthony is in his 30s and has the rarest form of MS of the four disease courses.
Progressive-Relapsing MS (PRMS) occurs in about 5% of the MS population (National
MS Society, 2012). with Anthony’s type of MS being so rare, he feels the majority of the
MS communications he receives are not necessarily aimed at him. Unlike the other
three personas, Anthony struggles with finding his place within the MS community
and doesn’t identify with members of the community. Anthony lives at home with his
parents because he simply cannot function independently. He is close with his mother
and father, providing much of the community feeling he does not find in the MS
community. Anthony doesn’t interact with print items really, he finds it too difficult to
read the typography even at 14- or 16-point and would much rather utilize an easy
reader like Bea or interact with a tablet.
For Anthony, opportunities for inclusion are vast from community engagement 26
to printed design materials that he has never taken the time to sign up for. The same
considerations for the other three personas are crucial but here a sense of social
inclusion and integration could be an option to make Anthony more aware of the cause
and perhaps change his stance on not being part of the MS community. In the same
regard, trying to reach Anthony may not be within the realm of a traditional marketing
campaign. However outside chances for social integration and inclusion may be an
opportunity for Anthony.
6. Persona Use within the Framework
It is important to understand that these four personas cited here reflect a
culmination of secondary and primary research into the MS community. No two
people are likely to have the same set of MS symptoms in exactly the same way. Some
problems may occur in some people that others will never experience. It is because of
this fact these personas are not a definitive “how-to” for design teams working
on communications for this community. Instead, these personas work within the
framework to allow a greater chance for inclusion and accessibility by taking into
account the variable nature of MS. These personas can be used in conjunction with the
framework to find where opportunities for inclusion are the highest. Though visual
communication or an advertisement campaign may not be able to reach every single
person with the MS community, it may provide areas for further study and research
into future inclusion strategies. For a full list of the personas including visuals please
see Appendix B: Persona Appendix. 27
Chapter VII
The MS Inclusion Framework Guidelines
1. Development
The “MS Inclusion Framework” is intended to help graphic design teams as well as copywriters, photographers, illustrators, health organizations and educational institutions among others by offering suggestions that hope to address any inclusion shortfalls present in the current system of communications. The first step in creating the framework was an intensive literature review of current disability guidelines. The secondary research was comprised of both MS-specific research and studies related to disabilities closely resembling or related to MS such as blindness, optic neuritis, and cognitive difficulties. The following sections comprise the secondary and primary research that went into creating the final framework.
All of the secondary, primary research findings and recommendations are filtered through a perspective of design thinking. The author is not a professional in the field of health, neuroscience or the medical field and makes no claims to provide people with
MS any form of medical guidance or care. If you have MS please see your physician or neurologist for treatment with your disease course. The author is a graphic designer, researcher and creative with an understanding of ethnographic research methods, typography and design. All research for the framework was filtered in its application to understand accessibility within the basic principles of visual communication and design.
1. Easy-to-Read
This concept is more dedicated to copywriters and authors, than design teams, however, it is important to make sure, first and foremost, that the actual copy of a document is accessible or “easy-to-read.” There are two different definitions for the 28 term “easy-to-read” (Nomura, 2010). The first definition means an adaptation of typography (size, selection) that makes it easier to read than average text but does not make the meaning of the sentence easier to comprehend. The second definition means an adaptation of both the meaning and the typography that makes both reading and comprehension easier. Successful reading is not just a matter of decoding the anatomy of letter forms, meanings, and words. Reading should lead to the acquisition and stimulation of thoughts and emotions (Nomura, 2010). Avoiding the use of colloquial and complex jargon by using plainly-stated language is at the heart of “easy-to-read” materials. In the solution space the end user should understand and comprehend the intended message.
1-2. Legibility and Readability
Legibility and readability are extremely large factors when considering typographic selections. Legibility refers to the ability to distinguish and identify characters and word shapes. Reading is directly affected by legibility. When text is legible, we read more quickly and accurately; when legibility is compromised, we read more slowly and are prone to mistake. Legibility can be thought of as the ease at which users can recognize individual letters and characters inherent in the type’s design. This gives users the ability to distinguish one letter form from the other. As we read, we identify the overall shapes of familiar words rather than processing individual letters and assembling them into phonetic groups (Visocky O’Grady, 2010). This process of typographic recognition allows a user to make connections to the content quickly.
Legibility and readability are two distinct factors that are components of each other. Readability is the clarity and speed at which a reader can make connections with words, sentences and paragraphs. Legibility is a component of readability as it deals with the recognition of letter forms and both factors come into play when making typographic selections for “easy-to-read” materials. 29
2. Aspects of Legibility
A long-standing typographic rule is that the most legible typefaces are
“transparent” to the user, that is, they don’t call unnecessary attention to themselves
(Hayley, 2010). The metaphor of typefaces that are “transparent” was coined by Beatrice
warde, infamous marketing manager of Monotype Imaging during the 30s (Hayley, 2010).
Warde championed the idea that the best typefaces do not hinder the communication
process; these faces are virtually invisible and allow the words, not the typography to
make a statement on the reader. This is expert advice, especially dealing with a group of
people who possess reading difficulties. However, if this principle is followed too closely,
the value of graphic communication would be lost entirely (Hayley, 2010).
2-1. X-Height’s Relationship to Legibility
To understand what makes a typeface legible, a closer look at the anatomy of
letter forms is required (Figure 2-1). When referring to type, x-height refers to the height
of the main body of a letter for a particular typeface (Lupton, 2004). The x-height is
determined by the size of the lowercase “x” in any given font, hence its name.
figure 2-1. typographic anatomy chart
bar x-height
baselineAeofqxcounter descender
a typographic anatomy chart showcasing the important aspects of a font that can aid or hinder accessibility. 30
X-height is an extremely important factor in determining the legibility of the font;
the larger the x-height on a font is the more accessible it is (Figure 2-2). The x-height needs
to be large enough so that characters like “a,” “e,” and “s” appear clear and distinct to a
reader. The length of ascenders and descenders can affect legibility as short ascenders
can make letters such as “d” and “b” difficult to differentiate (Visocky O’Grady, 2008).
figure 2-2. x-height comparison chart
cap height x x-height x a xtypographic comparison chart showing the various x-heights using thex sentence case x letter form of jigsaw,x adobe garamond pro, bookman and aphont. all these x letter forms are at the same point size which showcases how crucial the relationship between legibility and x-height can be.
X-height is closely connected in a relationship with other anatomical portions of
a letter form. A by-product of a large x-height typically results in the presence of larger,
open counters creating a figure-ground relationship that assists in legibility. Counters are
the white space within a closed-letter form, such as “o,” “e,” and “g”. Most typographers
agree that larger counters in relationship to large x-height help aid in character recognition
for a reader. It’s an important task to make sure the x-height is balanced as exaggerated
x-heights at either extreme (too small, too large) negatively affect legibility as they begin to
distort the commonly recognized shape of the letter form (Visocky O’Grady, 2008).
Over 95% of the letters we read are set in lowercase, because the human eye reads
the shape of sentence case and not the individual words, these important typographic
features being balanced result in a more legible typeface (Hayley, 2010). The relationship
between the positive stroke and the negative counter affect the legibility, or quick 31
recognition of the letter (Visocky O’Grady, 2008). Fonts that are considered to be more
legible have a balanced proportion of form and counter form. Letters are created by
positive and negative shapes. The positive shape is referred to as the form, the negative
shape is called the counter form, or in letters like “e,” “o,” and “g” the counter (Figure 2-3).
figure 2-3. typographic form-counter form relationship
FORM FORM
COUNTERFORM COUNTERFORM
a closer look at the relationship between form and counterform present in the letter “e” set in aphont and clarendon. this figure-ground relationship is defined by the positive and negative shapes of a letterform and this is an important efactor in legible typefaces. data collected frome the information design handbook.
These typographic features are particularly important when dealing with a
community of people who have vision disturbances. Because of this fact, the ADA sets
down body-width to height and stroke-width to height ratios for the use of appropriate
typefaces in signage systems (Figure 2-4). These standards insure that more uniform
and legible typefaces are used in order for greater accessibility. While these standards
are an excellent starting point, it may be necessary to consider additional factors in
regards to typeface selection for people with vision problems (AIGA, 2006). 32
figure 2-4. ada body-width to stroke-width ratios for signage and wayfinding
body width must be 60% to 100% the height of the letter form.
Stroke width must be 10% to 20% Hthe height of the letter form. the americans with disabilities act (ada) sets down body-width to height and stroke-width to height ratios for the use of appropriate typefaces in signage systems.
3. Typographic Selections
Type comes in a variety of styles from roman to sans-serif, however there
is some debate as to which works better for “easy-to-read” legibility. Modern
typographical development went hand-in-hand with the modern design trends of the
first half of the 20th century in art, architecture and publishing (Berger, 2014). The
modernists of the early 20th century encouraged rules governing typographic layout
by limiting typefaces to a low, “acceptable” number (Davis, 2014). Further reinforcing
the use of classical typefaces were such books as James Craig’s Designing with Type
(1971) and the International Typographic Style, which featured limited families of
type as representatives of various historical classifications (Figure 3-1). Designers in
the twentieth and twenty-first century have continued to create new typefaces based
on historic classifications and guidelines (Lupton, 2004). Fonts selections now come in
over thousands of different style choices with various purposes for their use. 33
figure 3-1. typographic historic classifications
Classification Type Name Year Old Style Garamond 1615
Transitional Baskerville 1757
Modern Bodoni 1788
Slab Serif Clarendon 1845
Sans Serif Helvetica 1957 data and research collected from thinking with type by ellen lupton. this figure shows the historical classifications of type, many more modern classifications exist.
The purpose of typography selections is to get one’s point across (Lupton, 2004).
While visual solutions can be successful or unsuccessful, the ultimate goal is that the user acquires the information. There is a time and a place for all styles of typeface selections but not all are proper choices for accessibility. This is especially important when it comes to body copy and legibility for people with MS and who may have issues with visual perception of certain typefaces. When making typographic selections for
MS communications, it is imperative that a design team does everything possible to make a solution comprehensible and to avoid distraction. Letter forms selected should be consistent and well-balanced in form, but distinct in character to provide easier access. 34
There is no definitive answer to which type style is more accessible and
scientific study on the topic has been inconclusive. It is widely accepted that for printed
body copy the most readable fonts are straight-forward serifed fonts (Wheildon, 1995).
Although it is clear that each letter within the alphabetic system must be unique to
ensure accurate identification, reading efficiency is supported by similarities across
the set of letters (Beier, 2012; Sanocki, 1988; Sanocki & Dyson, 2012; Walker, 2008).
Typeface designers aim to develop fonts that consist of a series of letter forms that
have distinguishing shapes but that also have a certain level of continuity between
letter forms. By sharing certain visual features a rhythm and flow across the letter set
is developed that contributes to the overall look and feel, or ‘personality’, of a typeface
(Cheng, 2005).
According to Dr. Myra Thiessen’s article Brainy Type: How the Brain Processes
Typography, this author contends that “typefaces that balance distinct and related visual
features are likely to be more legible because they may do more to facilitate accurate
letter identification as well as capitalising on the consistency.”Although it seems many
organizations rely on “best practices” of what font works best for their specific
audience. Typefaces have been developed specifically for low vision. These fonts are
the APHont developed by American Printing House for the Blind and the core font
family of the NMSS, Jigsaw (Figure 3-2). Both of these type styles take into account
proper stroke to width ratios, as well as, form to counter form relationships making
them smart selections for design teams dealing with accessibility issues. According
to an article written in Text Matters which has been supported by several additional
secondary research sources, “the choice of typeface is less important than contrast, type
size, weight and the spacing of characters.” In summary it seems that regardless of the
style, selection or historical classification of a typeface, what is important to remember
is that well-balanced features overall are what aid in legibility and readability. 35
figure 3-2. “jigsaw” and “aphont” typography
APHont Regular 1234567890 abcdefghijklmnopqrstuvwxyz ABCDEFGHIJKLMNOPQRSTUVWXYZ
APHont Bold 1234567890 abcdefghijklmnopqrstuvwxyz ABCDEFGHIJKLMNOPQRSTUVWXYZ
APHont Italic 1234567890 abcdefghijklmnopqrstuvwxyz ABCDEFGHIJKLMNOPQRSTUVWXYZ
APHont Bold Italic 1234567890 abcdefghijklmnopqrstuvwxyz ABCDEFGHIJKLMNOPQRSTUVWXYZ
aphont (left) embodies characteristics that have been shown to enhance reading speed, comprehension, and comfort for large print users. jigsaw (right) is a geometric sans serif font family with a stroke width which is almost monolinear and was designed to have a high level of readability and legibility thus making it an optimal choice for the core type selection for the nmss.
3-1. Serif Versus Sans-Serif
Much controversy exists over the issue of comparative legibility when it
comes to serif or sans-serif with no definitive answer (Figure 3-3). To achieve greater
accessibility in typography for both print and web, design teams need to consider
making the eye strain on the user as low as possible with their type selections (Sheedy,
2008). It is generally understood that for printed artifacts serif is the preferred font for 36
highest accessibility, while sans-serif does a better job on the Internet. No matter what
the selection, each type has unique characteristics and specific issues when taking into
account legibility and readability.
figure 3-3. serif typography versus sans serif typography
SERIF SANS-SERIF
serif (left) is classified by the small line attached to the end of a stroke in a letter or symbol. while conversely a sans-serif (right) font style does not have the small projecting features at the end of their strokes.
Attentiveness to the features of a typeface is important, legibility and readability
help the user to access the information. It is important to keep in mind that it’s less to
do with the font selection and more to do with the actual anatomy of the letterforms.
Serif fonts tend to have larger x-heights and counters, thus creating a figure-ground
relationship that assists a user in reading large amounts body copy. Specifically, fonts
that are contemporary interpretations of “Old Style” designs, such as Monotype Bembo,
Clarendon and ITC Weidemann, tend to come by this trait of large x-heights and open
counters most naturally. There is documented evidence that serif typefaces reinforce the
horizontal flow of each line and offer more character definition (Carter, 2015). 37
3-2. Typographic Sizes
Either serif or sans-serif, the typeface should be clear and fairly large with an
appropriate x-height. In speaking with Mr. Serratoni, Director of Creative Services for
the National MS Society, he indicated for print a type size of 14- to 24-points in serif for
running body copy is considered “best practice.” It is important to keep in mind that
the relationship between readability and point size differs somewhat among typefaces
(Arditi, 2007). While large type may seem like the best way to address accessibility
concerns, a range of issues make this approach difficult (Visocky O’Grady, 2010). These
issues range from the need for increased page real estate; a larger document being
produced; to additional costs associated with production of larger documents for users
with accessibility concerns.
Fonts are, to a large extent, a matter of judgment, best practices and experience.
There is no one font that is ideal for all uses (Hedrick, 2003). As previously stated,
most typographers agree that larger counters in relationship to large x-height aid in
character recognition. There are many elements outside of typography that can be
adjusted to assist in creating more accessible design solutions. These recommendations
depend on the typeface and weight used. The end goal is not to create a rigid set of
design guidelines for the MS community but, instead, to offer suggestions and starting
points for further research into the matter.
3-3. Type Weights
According to the Royal national Institute for the Blind, “the tendency has
been to set text in bold because of its contrast on a white page.” According to the IFS,
conducted in 2015, primary survey results indicated that a medium or semi-bold weight
may be more legible for people with MS and to avoid font weights that appear too light
as this may affect readability. The weight of the stroke and counters within letter forms 38
is extremely important when dealing with accessibility. It is the relationship between
stroke and counter that determines letter recognition (Visocky O’Grady, 2010) (Figure
3-4). A narrower letter changes the form/counter form relationship significantly,
causing letters to have extreme vertical postures that can alter eye movements and
reading patterns ultimately diminishing legibility (Carter, 2015).
figure 3-4. typographic weight comparison Qq Qq Qq Qq Qq Qq Qq Qq Qq Qq Qq
the ratio of form to counter form plays a crucial role in letter form legibility. in this figure we see the variations between the different weights of clarendon, aphont, and univers. when strokes are very thin and counters too large the letter is more difficult to read. too bold or too thin, the letter forms will lose their readability.
Traditional italic typefaces should be avoided where they only serve a visual
function (Round Table on Information Access for People with Print Disabilities, 2011).
Italic versions of most serif fonts are very different from their Roman equivalents
(Lupton, 2004). It is because of this that many of these italic fonts impede reading;
extreme slants slow down the reading process. Sans-serif fonts do not have the same
issues. In most cases the italic variants are normally just sloped versions of the Roman
and thus do not pose the same potential problems with accessibility (Hedrick, 2003).
Italics should only be used as a way of providing emphasis and never used for large
bodies of text. 39
3-4. Expanded and Condensed
Many fonts contain expanded and/or condensed versions for a very specific
purpose. Additional factors in regards to typeface selection need to be considered when
considering an audience that has reading difficulties. Condensed fonts, for example, can
be an optimal design solution for text that is going into a narrow column, however these
fonts have a very noticeable impact on the text’s readability and legibility (Figure 3-5).
figure 3-5. extended/condensed comparison Qq Qq Qq Qq Qq Qq Qq Qq Qq
in this figure we see univers condensed and expanded. these strokes are very thin and counters at times are very large, making the letter more difficult to read. expanded and condensed fonts serve a very specific purpose and are not an optimal choice for body copy.
As a general rule, condensed and expanded fonts do not lend themselves to
readability. In condensed typefaces letters and line spacing are tight thus making blocks
of text harder to comprehend. Large blocks of text should not use a condensed font as
readability will be a concern. These narrow fonts can also be hard to pair with other
typefaces. A condensed font next to a wide type face may make the narrow font appear
more thin than it actually is. This can be jarring to read to a user and overall limits
access to the body copy. Though many font families contain expanded and/or condensed
versions for varied reasons, these fonts should be avoided for use as body copy. Expanded
or condensed version should be used for headlines, subheads and quotes only, as a way of
calling attention but not limiting accessibility or inclusion. 40
3-5. Spacing Issues with Typography
Leading is known as the spacing between lines of text, a common tool for
designers working in print who want to give optimal space for body copy. Leading is
critical when looking at accessible typography because many people with vision problems
may have difficulty finding the beginning of the next line while reading if the leading is
too tight (Arditi, 2007). With too much space between lines, they lose their connection to
one another and thus the body copy becomes inaccessible. The exact amount of leading
required often times depends on the font (Hedrick, 2003). This is related to a major
issue that exists within typography: x-height consistency. As Charles Hedrick states in
Guidelines for Typography, some fonts are “big on their body.” That is to say that some
fonts look larger than other fonts at the same size. For that reason, they must be set in
a smaller size than usual and may require additional leading considerations. Spacing
between lines of text should be at least 1.25” because many people with partial sight have
difficulty finding the beginning of the next line while reading (Kailes, 2000).
3-6. Typography Conclusions from IFS
A large portion of the IFS was devoted to establish a baseline for preference on
both style, and size of typography. Final results from the IFS indicate a strong
preference towards sans-serif body copy with sixty-two percent of survey participants
preferring the sans-serif APHont and Jigsaw examples over traditional serif fonts.
Reasons for the preference on a sans-serif typeface ranged from letters being larger
and more distinct, to the serifs’ character causing too much eye strain on the user. The
IFS also polled the readability of certain sizes of typography with eighty percent of
survey respondents selecting typography between 16-points to 24-points as being the
easiest to access.
There is no way to establish a baseline for which is better to use for accessibility,
with serif being preferred for print and sans-serif for web. Ultimately letters exhibiting 41
a well balanced proportion of form and counter form either serif or sans serif are the
most legible (Visocky O’Grady, 2008). Regardless of the font selection, making sure the
balanced relationship of form and counter form are present within your type selection
is of the utmost importance when determining both a legible and readable type for
body copy.
Dyson (2013) brings to attention the differences in disciplinary approaches to
typography, but aims to highlight, that both typographers and psychologists share
goals and points to a mutually beneficial approach of collaboration as a means to
further our understanding of typography, typeface design, and design for reading.
It is, however, pertinent to mention that there also appears to be a gap between the
knowledge generated through research and its application in typographic practice.
This may be due to the fact that legibility studies are typically guided by the
interests of those undertaking the work and who are motivated by the issues that are
relevant in their area of expertise (e.g. psychology or engineering) and that these
interests do not typically extend to visual features and variations of letter forms
relevant to typeface design (Beier & Dyson, 2013). The ability to easily ascertain
essential distinguishing features is important for accurate letter identification where
these features are first identified and then used to determine the complete letter form
(Grainger, 2008). This implies that the easier that these unique or distinguishing
features are to access, the less cognitively demanding letter recognition will be.
4. Page Layout and Grid Structure
The overall appearance of documents — which includes visual attributes
related to page layout as well as typeface — can influence the reader’s impression of
the content and this may extend to the perception of the elements such as difficulty,
importance, seriousness, or trustworthiness of the content (Gonzales Crisp, 2012;
Moys, 2014; Schriver, 1997). The utilization of a classic design grid structure give a 42
design solution unity and consistency. Grids are the invisible glue that holds a design
together, so whether one works in print or on the web, designers absolutely must
understand how grids can be applied. A grid can be used in artifacts like posters or
postcards that are single pages, or it can be used in a larger documents with multiple
pages like a magazine or an annual report. It gives designers more control over a
final solution’s consistency and visual language. That consistency is especially vital
for readers with visual disabilities, who appreciate having signposts to help identify
content and quickly process meaning (Visocky O’Grady, 2010).
A grid structure (Figure 4-1) gives a designer room to utilize document margins,
white space and typography in an effective way to make a design solution as
comprehensible and understood as possible. Page layout and grid are the visual
organization of information on the page and can help the reader find information
efficiently (Majewski, 2001). Thus, it is considered a critical tool in understanding how
a design team can craft more accessible and inclusive solutions for the MS community.
figure 4-1. various grid systems
the rhythm and meter of a layout is an important part of making the content accessible, helping the viewer to understand where to find the next piece of information within the layout. think of a grid as providing the road map along which your users travel. 43
4-1. Line Length
Overall page layout has a great deal to do with accessibility to a design solution.
In well-set material, the width of a line is normally from 50 to 80 characters (Lupton,
2004). According to the Royal National Institute for the Blind, some visually impaired
people may prefer even shorter line lengths than this. Anything more than 50 to 80
characters and it becomes hard to read a line at a time (Figure 4-2). This is why magazines,
annual reports and newspapers tend to use multiple columns: their paper is wide enough
that a single column of text would affect accessibility and readability (Hedrick, 2003).
figure 4-2. line length figure
50 Characters per Line
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Id et velesci tatium cus, id quia volut omnisquis mi, sedis sequi cores am aut ut esed quamusciam evelestio blautem quis volest reptibus as necus sit peri- bus.Abores re voluptam faccumque peres acepre cus volo of cia volorectat quam re nem consere ctianition con poritati que cus.Mi, sam, cum qui berrovit ipsam utem doluptatem qui undaepr ernatur, quatur, to maximi, volorae samendel
this figure shows what most typographers consider to be the optimal line length. Research indicates the people with visual disturbances may prefer even shorter line lengths than 50 characters.
This presents somewhat of an issue for standard documents as 8.5” x 11” paper is
really too wide for one column of text, but two columns strikes most people as looking
odd in a memo or report (Hedrick, 2003). This has some significant design ramifications
when design teams aren’t considering the characters per line when choosing a column 44 width for their body copy. Typically they pick a column width and stick with it which is an imperfect approach. Every decision a designer makes, especially those involving composition design and typography, should have a meaningful rationale behind it. This is especially important when dealing with an audience of individuals who have visual disturbances and issues with reading.
This is where the grid structure can really assist design teams in tackling these issues. The graphic and informational hierarchy should be apparent in all design but is particularly important in complex pieces where an explicit logical order benefits readers of varying abilities (Visocky O’Grady, 2010). As it turns out, the Golden Ratio
(Figure 4-3) provides us with a blueprint for proper typesetting. We can use this grid structure to make more informed choices about the spatial aspects of our designs and create more accessible typography. Ultimately your typography should dictate how wide your columns of text are, not vice-versa which is a stronger, more informed approach when used in conjunction with a grid system.
4-2. Typographic Alignment
Though perhaps considered a part of typography, the alignment of body copy has more to do with page layout and column structure than most people assume.
In western cultures, left-aligned type is the easiest for people to read quickly — for the obvious reason that we read from left to right (Visocky O’Grady, 2010). It has historically been traditional to “justify” text, which creates an even left and right margin (Hedrick, 2003). However, with the advent of more word processing programs and page layout programs, many do a poor job at justifying text leading to uneven spacing. These uneven word spaces, sometimes called “rivers,” make justified text harder to access for people with visual difficulties according to research from
Lighthouse International. Looking at other alignments for type center-aligned and right alignment also create issues for accessibility. When large blocks of copy are aligned 45
to the right or to the center, the inconsistency of the ragged edge makes it more
difficult for readers to find the starting point (Visocky O’Grady, 2010).
Before the advent of computers provided for optical and metric letter spacing
for bodies of type, typewriters had to do the job. In contrast to many of the variable-
width fonts previously discussed certain typewriters used monospace font styles. A
monospace type is a font whose letters and characters each occupy the same amount of
horizontal space. These typefaces were ideal for typewriters because most had striker
arms which contained the letter form, that were all physically the same width. There are
often times reasons for use of monospace fonts today such as source code for websites,
tabular figures and screenplays. It is important to keep in mind though that these letter
forms with equal horizontal spacing and alignment affect readability for users who may
have visual disturbances. In summary, the easiest typographic alignment for a user to
access in Western society is left-aligned.
4-3. White Space is not Negative Space
A common mistake among people outside the realm of design is to think that
white space is a bad or unwanted thing. White space can feel like a blank page or an
empty canvas; something to be replaced with elements throughout. It can be one of the
most challenging elements that designers face when dealing with printed artifacts.
Creating a successful hierarchy including white space can make or break a composition.
As a designer, the job is clear; creating the most accessible and understood artifact
using white space as another tool to create the best experience for a user. In regards to
MS and other visual issues, adequate white space can be an important tool in making
sure a layout is structured and organized. It can be helpful for design teams working
on issues of accessibility in times where fonts with larger x-heights, larger type sizes,
leading and overall increased elements must be present. In conclusion, white space
shapes the positive space and is a vital tool for any design team. 46
4-4. The Golden Ratio
when dealing with compositions and general shape, there’s a common mathematical ratio (1.61803398875) found in nature that can be used to create pleasing, natural-looking hierarchy in design work. It is known as the Golden Ratio, which describes the perfectly symmetrical relationship between two proportions.
Approximately equal to a 1:1.61 ratio, the Golden Ratio determines the most pleasing set of proportions for an element, and is simplified to the ‘rule of thirds’ (Figure 4-3). figure 4-3. the golden ratio
the side lengths seen here in this figure defines the golden ratio, plotting the relationships in scale provides us with a spiral that can be seen in nature all around us.
The golden ratio (also known as the golden mean) when used in combination with a grid, size, position, and proportion can help ensure a layout feels coherent within itself, but also appealing and accessible. Using the golden ratio, makes the content more accessible to the reader. 47
4-5. Grid and Layout Insights from Survey
while the ability to identify letter forms and efficiently read texts is essential to the design of written content, reading is also influenced by preference and expectation.
These expectations are based on long-standing psychological principles that influence not only the way a user perceives content but also how they interact with it. Due to grid structure being such an important element in how a user interacts and accesses a document, portions of the IFS gauged the knowledge the participants had of grid and layout structures.
80% had never heard of the typographic grid before taking the IFS, while the remaining 20% were aware of its use in print communications. After being asked about the grid, the survey provides a detailed explanation over what the grid is and it’s importance. After being given a visual and detailed explanation over page layouts and grid, the survey polled users if they began to understand its use in compositions. 68% of survey respondents indicated they access a composition better when a grid is in use versus when it is not. The remaining 32% found that the grid neither helped nor hindered the overall composition.
In conclusion of grid structures, as designers working on communications for an audience of people who many have issues with access, it is important to remember that keeping a design and layout consistent throughout the publication aids in access to the content. Always keep the layout clear and logical with easy to follow contents list and headings. Body copy is easier to read when broken up into short paragraphs with plenty of space. never try and fit more text into a space by reducing the spacing between letters, words, or lines. Using visual communication and design as a way to remain inclusive through the establishment of greater knowledge about access and opportunities for inclusion, strengthens any organization’s ability to reach a greater audience of individuals. 48
5. “Gestalt” Principles.
The “Gestalt” principles are the psychological theories that attempt to analyze
the areas of how our sight works. These principles explain how people perceive visual
objects, grid systems and how variations in arrangement, perspective, and/or size
in a layout can alter perception. These principles are important to all designers but
especially to those working on page layouts. “Gestalt” principles are related to, but
are considered separate from, layout and grid considerations (Figure 5-1).
figure 5-1. principles of visual perception “gestalt”
SIMILARITY PROXIMITY
CLOSURE CONTINUATION FIGURE & GROUND
in this figure we see the rules of gestalt in play: closure, proximity, continuity, similarity and figure ground are the five principles that govern the “gestalt” principles which aid designers in making design and communications more cohesive, unified and accessible.
Psychologists Max Wertheimer, Wolfgang Kohler and Kurt Koffka developed
theories on sight perception that became foundational to modern design in the early
twentieth century (Bonner, 2014). The theories expand on Aristotle’s classic axiom,
“The whole is greater than the sum of its parts,” as applied to visuals (Behrens, 2014). In
1954, decades after Wertheimer first started his work, Rudolf Arnheim compiled and
boiled down the “Gestalt” principles into the book Art and Visual Perception: A
Psychology of the Creative Eye. As designer Carolann Bonner suggests, there are five
principles that can make designs and printed artifacts more cohesive, unified and
accessible to all users. 49
5-1. Similarity
when objects in a composition or layout look related, the user will perceive these objects as being similar. This is what this specific “Gestalt” principle states; objects that look the same are perceived as similar. By creating two elements with a similar visual thread, designers can explain their purpose in a way that feels intuitive.
The similarity between different elements can be shape, color, size, texture or value. The more commonality that individual elements have, the greater the sense of coherence (Figure 5-2). This can be an important tool in helping a user who has cognitive dissonance or vision troubles navigating a page as the intuitive nature of similarity allows a user to access these elements of the page quicker and in a more efficient way. figure 5-2. principles of similarity
similar typography
similar illustrative treatment similar elements will be perceived as being part of a system. this is due to the principle of similarity. design elements that can be a part of the similarity prinicple include but are not limited to: shape, color, size, rotation, typography systems, photography and illustration. 50
5-2. Figure-Ground Relationship
The relationship between figure and ground is one of the most important
relationships in design. It exists in many different elements of design from typography
to layout. As discussed earlier, the relationship is extremely important in the
comprehension of typography and groups of words. In this regard of layout on a page,
the figure is what the viewer notices and the ground is everything else. They are
inseparable and interrelated, the edges of one forms the edges of the other. The figure
ground relationship is extremely important, as the designer must consider all of the
composition when designing. It is a mistake to only plan the figure and this is at the
heart of what this principle is about; balancing the figure-ground relationship can lead
to more successful solutions overall. The entire area of the page must be given careful
consideration, especially in regards to accessibility and inclusion (Figure 5-3).
figure 5-3. principles of figure-ground relationship
ground
figure
in using gestalt principles, the relationship between figure and ground allows a user to be able to identify a figure from the background. 51
5-3. Closure
Closure is perhaps the most commonplace of all the “Gestalt” principles. The
concept of closure relates to the ability of the human eye to have a tendency to see
closed shapes even if it’s open. If an object is incomplete or the interior space of an
element is not fully closed, the viewer will often still perceive a complete shape (Figure
5-4). The brain does the work of filling in the missing information. This technique is
often associated with stenciled artwork, but is also very common in many logo forms.
This may present a particular problem in people with visual or cognitive disturbances
as they may lack the ability of filling in a shape in instances where it is open.
figure 5-4. principles of closure and continuation
closure and continuation
this logo used for the multiple sclerosis society of australia utilizes the “gestalt” principle of closure. In this regard this logo is visually representing both the disease and the principle of closure.
5-4. Continuation
Closely related to the principle of closure, continuation is the principle through
which the human eye is drawn along a line or curve, preferring to see a single
continuous figure than separate lines (Bonner, 2014). This can be used as a way to
subtly point towards another element in the composition. It gives incredible and unique 52
power to lines in a layout design as users typically register curved lines and straight
lines as interrelated to one another (Figure 5-4).
5-5. Proximity
The principle of proximity is the process ensuring users perceive related design
elements as a part of a group. Close proximity indicates that design elements are
connected or have a relation to each other. Visual units created by proximity (Figure
5-5) help designers give structure to layouts, which is an important tool for designers
working on artifacts or designs for people with issues with vision. Making sure designs
and artifacts are comprehensible by use of not only proximity but selected “Gestalt”
principles is crucial.
figure 5-5. principles of proximity
proximity
this ad designed by ms society of auckland shows the “gestalt” principle of proximity, here the blocks that make up the form allow us to create the shape of a man based on proximity. 53
5-6. Conclusions
The reason artists and designers alike embraced “Gestalt” theory is that it
provided, in their minds, scientific validation of age-old principles of composition and
page layout (Behrens, 2012). As Ellen Lupton and J. Abbott Miller characterize visual
communication in Design Writing Research, that “design is, at bottom, an abstract,
formal activity…” in which the “…text [or subject matter] is secondary, added only after
the mastery of form.” It is important to use “Gestalt” theory principles the same as one
would use any other element of design from typography to color. It should never be the
main focus of any composition or layout. When abstraction or design elements are
made the primary focus of design thinking, there is a social and inclusive aspect to
design that is lessened or ignored all together. In summary, using key design principles
is important to making a form or artifact aesthetically pleasing to a user. The final
solution, needs to be inclusive of all people and that principle should be placed above all
other considerations for design teams dealing with an audience of people who may have
visual disturbances or cognitive dissonance.
6. Color
MS can produce changes in perception that ultimately reduces the visual
effectiveness of certain color combinations. Two colors that contrast sharply to
someone with normal vision may be far less distinguishable to someone with a visual
disorder (Arditi, 2005). It is important to understand that it is the contrast of colors, one
against another, that makes them more or less discernible rather than individual colors
themselves (Arditi, 2005) (Figure 6-1). When designing artifacts that require clarity
and ease of access, colors should be chosen for perceptibility and legibility above all
other considerations. Designers often over-apply or misapply color to the point of
reducing the usability of their designs (Horton, 2003). 54
figure 6-1. range of color contrast
high contrast
low contrast
data collected from lighthouse international, showing a range of low contrast and high contrast selections using specific hues.
The ADA has set precedents for color and color contrast when dealing with
signage and wayfinding in an actual environment. People with low vision and visual
perceptual difficulties require at least a 70% contrast in colors to read comfortably
both in print and in three-dimensional spaces (Smithsonian Guidelines, 2012). One of
the primary factors affecting text legibility is color contrast; the difference between
the text color and the background color (Horton, 2003). In designing for inclusion, the
task is to determine which level of contrast is accessible for the user. While at least 70%
contrast may be a good place to start, users with more advanced MS symptoms may
require a higher contrast for easier access. 55
6-1. Color Contrast, Hue and Lightness
Contrast, or the study of visual oppositions, is easy to comprehend: light versus
dark, small versus large, geometric versus organic — the options seem almost endless
(Visocky O’Grady, 2008). There is scientific merit in color contrast and modern
computer programs such as Adobe Photoshop Creative Cloud give a design team the
tools for evaluating the accessibility of their color selections. The use of contrast to
control information utilizes the human ability to see patterns, notice differences and
fixate on anomalies (Arditi, 2005). Color contrast is most affected by two factors and
there are a number of ways to achieve contrast with color using the hue spectrum and
the lightness/value spectrum (Arditi, 2005).
The simplest definition of hue is that it is the color of a color, the attribute of a
color by virtue of which it is discernible. For instance, red, green and yellow are all
considered hues. Hue comes into play when considering users who may have vision
problems, with red and green being the most problematic colors (Horton, 2003). Color
differentiation is most influenced by the lightness spectrum (Figure 6-2). Lightness
is the amount of white or black present in a color. Pairing black text with a white
background provides the greatest lightness contrast because white is 100% in
brightness value and black has a brightness value of 0%. There is significant evidence
to suggest that balanced color contrast improves the legibility of a design piece.
There are many different color combinations that provides for easier access to
a design artifact. The access is highest when the background and foreground have at
least 80% lightness contrast between them (Arditi, 2005). It’s important to consider the
audience and, in this instance, referencing various personas can be a useful tool. For
example, many people with low vision need to use high contrast settings, such as bold
white or yellow letters on a black background. Others people may need just the
opposite; bold black text on a white or yellow background. 56
figure 6-2. color wheel showing effective/ineffective contrast
effective
not effective
data collected from lighthouse international, showing a range of ineffective and effective color combinations on a color wheel.
6-2. Typography and Color
Incorporating color into typography can either positively or negatively affect
legibility. The most important consideration when working with type and color is
to achieve an appropriate contrast between the typography and the background
(Carter, 2015). The degree of legibility rests in the hands of the design team but
the recommendation given by the ADA of 70% is a good starting point. Long
considered standard for contrast is black type on a white background and while this
does provide optimal contrast it does not offer the most robust option for designers.
There are alternatives that may offer equal, if not improved, legibility due to improved
digital and printing technologies. This is due to the fact that color is a relative 57 phenomenon (Carter, 2015). All colors possess characteristics of hue and lightness/ value. In the combination of color and typography, balancing these properties is a critical legibility concern (Carter, 2015) (Figure 6-3). figure 6-3. typography and color diagram
Type Type Type
Type Type Type
Type Type Type
data collected from the information design handbook and lighthouse international, showing a range of low contrast and high contrast selections regarding typography and color. The bottom row uses the ada standards of at least seventy percent between the foreground type color and background color.
Complementary colors, for example, offer extreme contrast, but when used as type and background can quickly cause strain to a user reading large amounts of body copy set this way. When typography is set in this manner, the type color competes with the background color for reader attention. Legibility can be improved by creating a tint or shade of one of these colors. Of all the properties of color, value affects legibility most significantly (Visocky O’Grady, 2008). Proper value contrasts effectively preserve the shape and formal detail of the letters, making them more recognizable (Carter, 2015). In 58
general, for the purpose accessibility, it is recommended to avoid setting large
amounts of body copy in a color. If it is necessary to present body copy this way,
increasing the space between lines may increase the accessibility of the type.
6-3. Color Insights from Survey
An extensive portion of the IFS was dedicated to understanding certain
individuals with MS interact with certain color combinations. In the IFS, certain color
combinations were shown, as well as trying to gauge personal feelings and thoughts
about color theory. These questions on color engaged in both the systematic and
theoretical. On the systematic end of the color portion of the IFS, specific questions
about typography set in color and if these colors affected readability and legibility were
asked of participants.
when looking at typography set in color (Figure 6-3), over 80% found colored
typography does affect legibility and access to the content. Green, red, and yellow were
cited as the hardest colors to access on a white background. Blue was noted as being
easier to access than the other colors, however it is clear from the IFS that typography
set in black on white provides the highest contrast for users with MS. A design team
should always refer to the ADA standards of 70% color contrast as a starting point if
black is restricted for any reason. Limiting color for body copy typography doesn’t
mean there are not opportunities to use colored type elements, but it should be
reserved for headlines, subheads and pull quotes.
Survey members were asked a specific prompt to gain awareness of certain
colors associated with corresponding emotions they feel: Do you associate certain
feelings with colors? Interestingly, 10% of survey participants answered “no” meaning
they do not associate color with feelings at all. Many survey members showed a
particular interest in the color red as being related to feelings of “strength” 59
or “urgency” and also related orange to feelings of “happiness” and “power.” These
colors are in use in major MS communications. The NMSS’s main branding is in orange
and MS Canada’s is in red. Blues and greens were also recurring colors when asked
about color theory, with most taking the IFS associating feelings of “peace” and
“calmness” with these colors. These answers aided in the persona research and also in
attaining a understanding if color has lasting impact on access.
7. Photography & Representation
Visual symbols like photographs and illustrations can be an extremely powerful
or negative tool in regards to understanding any community that we are not a part
of. Photography is a medium that is consistent with an objective view of the world
and the public’s appetite for images (Davis, 2014). The power of images as authentic
representations of a community’s life not only resides in their mechanical production,
but also in a photographer’s choice to forgo both sensationalistic journalism and the
artifice of prevailing artistic conventions (Davis, 2014).
7-1. Poster-Children
Photography in relation to disability historically has taken on the form of
a “poster child” (Shapiro, 1994). The “poster child” (Figure 7-1) is a visual symbol used
when referring to a stereotype of a community. It is a representation or personification
of a specific cause or group. No other visual signifier of disability is more loved by
American culture and more shunned by the disabled community itself (Shapiro, 1994).
Many people within health communities have come to find the “poster child” to be an
oppressive symbol, and like many minority groups before them, are challenging the
views, clichés, and stereotypes that surround their communities. Rejected by these
communities is the visual symbol of “poster child,” the notion that disabled people 60 are childlike, dependent and in need of pity (Shapiro, 1994). However nothing could be further from the truth. Disability is not a tragedy to these communities and visual symbols that reinforce this notion should not be present in print communications. figure 7-1. poster children example
this poster designed by registered disability savings plan for the canadian government contains photos of adults with disabilities and parents. this example exemplifies the idea of poster children, that disability requires the need of help and that these people are childlike and helpless.
7-2. Disability as a Symbol—Visual and Metaphoric
whatever the physically impaired person may think of themselves, the greatest impediment to a person’s taking full part in their society are not their physical flaws. Rather, the issue of incorrect visual symbols, photography and shared misunderstandings that society attaches to them, causes social barriers (Murphy, 113).
Even when a disabled character is presented as a victim of prejudice or discrimination 61
in literature, film or visuals, many of these visual symbols send a message that
disability makes social integration impossible (Longmore, 1987). “While viewers are
urged to pity Quasimodo (Hunchback of Notre Dame) or Lennie (Of Mice and Men), we
are let off the hook by being shown that disability or bias or both must forever ostracize
severely disabled persons from society” (Longmore 1987).
By articulating a disability this way, these visual symbols remove disability
from any form of social integration and the social barriers become much greater than
a disability or a particular character’s struggle in media. Is it possible to shift these
visual symbols towards something more positive? When portraying disabled people
with visual symbols, the general public may have little insight into the environmental
and social barriers that may be symptomatic of the inability to live full and active lives.
Living with disability means being confronted with environmental and social barriers
daily. This is especially true of MS, as many people may not display any disability at
times. Like the persona “Molly” and “Gared” many people have “invisible” symptoms
like fatigue or vision trouble that may not be observable to the outside world.
Any portrayal of the disabled community, in whatever context, which does not
reflect a true experience is both inaccurate and a major cause of the negative visual
symbols in media (Shapiro, 1994). These negative visual symbols ultimately lead to
a lack of understanding from society. Media and the visual representation of people
with MS will continue to be important venues for constructing knowledge and shared
experiences. That being said, photographic representations of people with MS are
an extremely important tool for any design team. Illustration and photography that
reinforces positive social symbols is vital, it allows this community to share their story
in a truthful way and inspire others throughout the world. According to the NMSS’s
Brand Guidelines (Figure 7-2), “photography of the MS community should demonstrate grace,
determination and hope.” 62
figure 7-2. national ms society imagery example
this poster designed by the national multiple sclerosis society elaborates on their brand ideals showing people with ms in a positive and uplifting light, as independent and functioning members of society.
7-5 Photography Insights from Survey
when photography is used, these images should be clear and should not contain a lot of detailed information which could be lost to readers with vision abilities.
Photography should always utilize good contrast. When tonal values of colors in an image are similar to each other, contrast is low and accessibility to the image is affected.
High-contrast images are best with 83% of people in the IFS citing a preference to color images. Illustrations and photography should always be as large as possible without reducing image quality to ensure maximum accessibility. 63
8. Production
Final production is an important component when talking about print
communications and design. Certain types of substrates may actually affect
accessibility to a document. To accommodate varying vision abilities, it is important
to choose paper or printing materials that minimize glare (Visocky O’Grady, 2010).
Instead of using a gloss stock for paper, selecting papers that utilize a matte, silk or
uncoated finish is one way of reducing glare. The reason for this recommendation
is because gloss papers tend to reflect light and obscure print (Round Table on
Information Access for People with Print Disabilities, 2011).
Avoid using papers that may contain watermarks or textures as another
recommendation. Paper thickness, sometimes referred to as weight or pound, is another
important component of accessibility in production. It is important to choose paper that
has enough weight, so that the text printed on one side cannot be seen on the other side.
This is sometimes called “show through” in the design community. The extent of show
through can vary, however, and it can interfere with legibility. If it is not possible to
choose a paper stock that is thick enough to prevent show through, printing on a single-
side can help (Round Table on Information Access for People with Print Disabilities, 2011).
The color of the paper is another important component in selection of substrate.
Choosing a paper that will give the optimal contrast between text and background
promotes inclusion for the document. White paper with black text produces the best
contrast (Kailes, 2000). For some readers, this produces too much contrast or glare,
so a warm white or off-white is preferred (Round Table on Information Access for
People with Print Disabilities, 2011).
64
8-1. Binding Methods
Document binding is a subject somewhat open for debate. It is generally
understood that documents bound on the left to enable them to be opened out flat have
the greatest accessibility. People who may rely on magnifiers to access a document need
the ability to place the document flat. According to the the Round Table on Information
Access for People with Print Disabilities, the number of pages in the document
correlates to the binding methods a design team chooses. Some book binding methods
can make it difficult to open a document so that it is completely flat. Staples or
gluebinding work well for shorter documents. While not the most attractive binding
selection, wire binding allows a larger document to be bound and still be opened out
flat for use under a magnifier allowing for the optimal accessibility. This is especially
important when considering larger type may be used in cases of designing for inclusion.
In regards to a larger document that may have some physical weight to it after
production, it may be important to consider separating the document into pieces and
parts for a user who has physical limitations because of their MS. Overall an increased
typographic size ultimately means a larger document and thus more expensive to
produce. Cost may be a concern, however a final produced artifact that is also inclusive
is of the utmost importance. This is especially the case when dealing with a community
who may have various issues with access both physically and with cognitive dissonance.
8-2. Digital Files
There may be opportunities when files originally created and produced as
physical real world artifacts may then need to function on a TV screen or a computer
monitor as well. This process of conversion can be very time-consuming or very
streamlined depending on the original document source. If the files are obtained
from a source that didn’t take into account disability access, the time to convert the 65
document to make it inclusive can be intensive. It will expedite the conversion to large
print if the files are correctly and clearly formatted initially. It may be worth providing
specific guidelines to raise awareness of issues to make the production of large print
more efficient (Kailes, 2000).
Generally speaking, all legibility guidelines related to working with typography,
color and photography in print need adjust when working on the computer screen and
digital spaces. It’s been established that designers working in print design have
great control over typographic details on a micro- and macro-level, but designers
and developers working on the web do not have the same level of control. With the
current amount of screen sizes available on the market it makes the ability to monitor
accessibility issues like type size and typographic selection much more difficult than it
once was (Marcotte, 2011).
9. Conclusion
The intention of the “MS Inclusion Framework” is to assist graphic design teams as well
as copywriters, photographers, illustrators, health organizations and educational
institutions among others by offering suggestions. These recommedations hope to
address any inclusion shortfalls present in the current system of communications. The
purpose of the framework is not to provide a rigid set of standards. Instead the intention
is to offer suggestions for further areas of study and points to take into consideration for
design thinking when targeting communities of people with disability. 66
Chapter VIII
Focus Groups
1. Development
A form of primary research, anonymous focus groups, were gathered by various
means including online blogging community and through assistance of the NMSS. The
focus groups sought to engage people within the MS community about their
perceptions, opinions, and attitudes in regards to the secondary research and survey
results. Questions were asked in an interactive setting where participants were
encouraged to engage in conversation with each other that grew out of structured,
formal questions. Conceived as an iterative process, each focus group altered in some
slight way over the previous to provide a wealth of opportunities for inclusion in both
design and in thought process.
Due to the lifelong and progressive nature of MS, drawings made by focus group
participants, coupled with their explanations, thoughts, and critiques on the
framework research would offer a valuable source of data about the meaning, social
impact, and inclusion present currently and if there are any holes or gaps that could be
corrected. The drawings serve as a visual methodology used within primary research.
They serve the research as a way of helping people outside this community better
understand the challenges and issues people with MS face. For many in the disability
research field, the phrase ‘visual methodology’ or ‘visual guidelines’ reminds people
of tests like the Rorschach or the Draw-A-Person to detect personality disorders and
assess mental status (Cross, 2006). At the heart of these visual tests is the assumption
that a patient possesses vital information about their state of being that they are
unaware of, and which can only be accessed and interpreted by trained experts or
medical professionals. Nothing could be further from the truth. 67
There are many ways in which illustrations and visual methods are used in
research today, including ethnographic video, photography, print media, material
artifacts and drawings (Cross 2006; Rose 2001). There is no current widespread
consensus about how these visual methods should be used (Cross, 2006). For the
purpose of this research the visual methods and illustrations serve as a tool for
understanding, to breathe more life into the personas and to offer more opportunities
for inclusion by helping people outside this community gain visual knowledge and
insight about MS.
Guillemin (2004) is a vocal proponent of visual methods and believes the
more traditional research tools such as surveys, field notes and transcripts “limit the
extent to which, as researchers, we can explore the multiple ways in which illness is
understood and enacted.” She further argues that drawings, when used properly, offer
an effective way of gaining deeper insight into the multiple of ways persons interpret
their own health conditions.
2. Focus Group 1
This focus group consisted of four anonymous individuals. This focus group
was held in person with the individuals interacting directly with the researcher
during the hour and a half-long focus group. Interviews, including all questions and
responses related to the focus group, were digitally recorded and stored to facilitate
analysis. Participants were prompted with a series of open-ended questions related to
the survey data results. These questions often lead to further discussion in regard to
the research. This was followed by a series of visuals with multiple-choice selections
and ended with a series of drawings the participants created under a given scene
prompt. The following section will outline highlights and overviews, for select
transcripts of conversations and figures see Appendix C: Focus Group Appendix.
68
The open-ended questions related closely to the findings of the survey, this served as a
second check point to test out results from the IFS survey. They are listed as follows:
1. Have you ever felt your Multiple Sclerosis has prevented you from access to
print communications or reading materials?
2. Do you struggle with reading certain sizes of type?
3. Do you feel integrated and connected with the MS community?
4. What types of design items (artifacts) do you find yourself interacting with most
frequently (this excludes apps or websites, you can list them but please try to
think of printed and tangible design items)?
From these questions, participants had further discussion among themselves
regarding each of their journeys with MS. These personal experiences were
collected and considered primary research, and their anecdotal qualities helped
define and refine the final personas. The next phase of the focus group was to show the
respondents a collection of different typefaces at various sizes and styles. These
typefaces were selected from secondary research gathered for the inclusion framework.
Along with the typefaces, users were shown different treatments of line leading,
paragraph shape and size and grid structures with the ability to choose the selection
each user preferred (Figure 7-1). In summary, this phase of the focus group had most
participants split between preferences in line length, leading and alignments. There
were no conclusive results during this phase. Further refined testing on line leading
and length needs to performed in a more controlled setting to ascertain if there are any
issues with access in the current best practices and guidelines. 69
figure 7-1. focus group testing document
examples of focus group 1 testing document, for a further look at the testing document see focus group appendix.
The third and final part of the focus group was to have users draw how they see
their MS “visually” given the following scene prompt:
During this section you will be asked to complete a drawing of how you see your
MS visually in your mind. Please know that you do not have to be an artist.
Artistic ability is not important, all that is asked is that you do the best you
can. Just like the question and multiple choice selections, there are no right
or wrong answers, or in this situation, images. Any image you create is simply
an expression of your feelings and thoughts. They can be as advanced or as
simple as you want. They can be abstractions, there is no limits on the drawings
you create. 70
Drawings were included in the research as a way of exploring the potential to reveal
unique data about the processes of community integration and social inclusion (Cross,
2006). All members of the focus group were given a sheet of white non-coated matte paper
and a variety of colored pens, markers and pencils to use as tools for their visualizations.
For the drawing, the prompt was: ‘Draw how you see MS in your mind visually.’
The wording of the above scene is written to be as non-descript as possible. The goal
for the participants was to portray themselves visually however they saw fit, as literal
as bodies in motion or more metaphorical and/or abstract. The focus groups and the
drawings are the final element in primary research collection. Because of the finality
of these interactions, the instructions being open-ended enough to encourage whatever
thoughts or feelings that may have gone unexpressed was very important.
After finishing each drawing, these participants were asked to explain their
drawing, a full account of these interviews and drawings can be found in the Drawing
Appendix section. These drawings gave insight into how these particular participants
visualize themselves, their emotions, social integration and activities through the
open-ended nature of the scene prompt (Figure 7-2).
figure 7-2. drawing multiple sclerosis visually
various drawings from each of the three focus groups, for further drawings please see later chapters and for a complete collection of the drawing activity please reference the drawing appendix. 71
7-2: Focus Group 2
This focus group consisted of six anonymous individuals. This focus group was
held via a Google plus hangout with an out-of-state MS support group who showed
interest early on after taking part in the IFS survey. Individuals interacted with this
researcher via a computer for an hour and one-half. As an iterative second step in the
focus group process, certain methods and questions changed or were refined for the
secondary focus group. For a selected log of transcripts see Focus Group Appendix.
Based on the successful outcome of the first set of open-ended questions
performed in focus group one, the same set of questions were asked of the second
group of the participants along with two additional questions that were created
from anecdotal conversation recorded during the first group interactions. These two
additional questions are listed below and are as follows:
5. Do you know any other individuals with MS in your real life?
6. Do you find environmental barriers a challenge in your everyday life?
These new questions address the conversation the first focus group had about
community inclusion, social interaction and environmental barriers they have faced
in their lives. While not specifically related to graphic design, these new questions are
related to the communication that these individuals have in their daily lives. This is
crucial in understanding how to make informed decisions in regards to accessibility in
all realms. Due to the inconclusive nature of line leading and size that was tested in the
first focus group, these participants were not asked about line length and typography.
The second and final phase of this focus group was the drawing exercise.
For the drawing activity, the scene prompt was unchanged with participants
drawing ‘how you see MS in your mind visually’. However due to this being an online 72
focus group, the materials provided such as the paper, colored pencils and pens were
sent beforehand to the support group’s founder so the conditions could be as close
to the first focus group’s. As with the first set of drawings, the thoughts and emotions
conveyed visually relate back to any gaps that may have been missed in the more
traditional research methods also used.
7-3: Focus Group 3
The final focus group consisted of five anonymous individuals. This focus group
was held in person with the individuals interacting directly with this researcher
during the final hour focus group. Based on the iterative nature of the prior focus
groups, this focus group was tasked with an edited set of questions that dealt with
social integration and language that is viewed as non-discriminatory for this particular
community. The final set of questions for the last focus group were as follows:
1. Do you feel integrated and connected with the MS community?
2. Do you know any other individuals with MS in your real life?
3. Do you find environmental barriers a challenge in your everyday life?
4. Do you find the word disabled offensive, explain yes or no?
5. Has MS changed your daily life?
These questions represent the recurring trends found both in secondary and
primary research. They aided the framework in a greater understanding of disability
culture and where MS falls in that spectrum. This focus group also reviewed final 73 survey results which assisted in helping the researcher to understand any gaps that were missed in the survey. This focus group agreed with major conclusions with the
IFS results, such as showing a preference for sans-serif typefaces with larger form to counter form relationships and x-heights which echoed the final survey results. The final phase was participation in the drawing exercise which went unchanged between focus group one to this final group.
7-4. Conclusion
These final focus groups and interactions provided valuable data in this research. The drawings and related discussions added to the knowledge about how people with MS understand their own condition and how it has an impact on their lives. The interactions, stories and data obtained in the final phase of primary research helped craft and refine a better framework. They also are directly related to the personas that work in conjunction with the framework.
One of the largest takeaways from this process was the understanding of how this community struggles with social integration in the everyday world. Also in the process of reviewing the drawings, it became apparent how some people feel like MS is a part of them just as their hair or eyes, while other participants felt separate from it entirely. It became clear another round of secondary research was needed to better understand, social and language barriers this community faces. This research hopefully can help graphic designers transition into new more lasting roles as social innovators for change and inclusion through visual means.
In conclusion of the focus group research, the drawing exercise was the most successful in terms of focus group activities. These drawings, coupled with explanations, gave the researcher a greater understanding of MS and avenues for social innovation which could assist in creating more lasting, accessible, and inclusive communications. 74
Chapter IX
Quantifying the Drawings
1. Background
The hope for the drawing exercise outcomes was that the results would be
informative and aid in knowledge about MS. The following section describes the use of
drawings in conjunction with the framework research project aimed at understanding
the personal experience of MS. From these drawings an outside individual can learn
more about how this disability is experienced and how MS challenges traditional social
roles and identities. It was expected that an understanding of how people with MS
seek and achieve participation through social inclusion in their everyday lives would
be gained. Using thematic analysis of all the drawings, and by highlighting key points
present in the drawings, demonstrates a wider knowledge for inclusion and accessibility.
Following Throop, in this sense drawing is, at its core, a phenomenological
experience and may be ‘pre-contemplative’ in the sense that it captures the ‘real-time
reflective unfolding of social action’ (Throop, 2003). This makes drawing a coherence-
making enterprise whereby both the drawer and the audience for the drawing come to
know more about the phenomenon or task at hand. Due to the interest in the drawing
activity, additional drawings were collected through various methods including
anonymous online interactions and interested support groups.
2. MS as a part of ‘self’
These drawings represent a characteristic of many individuals in both the
survey and the focus groups. The participants represented themselves with their
gait difficulties or wheelchair doing something that they enjoyed (Figure 8-1). These
drawings showcase feelings of independence, strength, and ultimately a sense of MS
being a part of their ‘selves.’ 75
figure 8-1. multiple sclerosis as a part of ‘self’
Describing the following picture, this participant said:
“This is something I enjoy doing — taking
care of my bees in my backyard. It’s nearby
so it’s not difficult for me to accomplish with
my gait difficulties. Though some days are
harder to get around than others I always feel
tied down due to issues with my legs resulting
from my battle with MS.”
When asked why there were no other
individuals present in the drawing the focus group participant replied that was
because they are almost always alone. The individual considered themselves a
relatively extroverted person and this change of always being out and about to a
more solitary life bothered the participant a great deal. Although these feelings
were tangentially evident earlier in the focus group, the depth and intensity of the
individual’s feelings were not fully recognized until the drawing was completed. When
questioned further about these drawings in which activities and MS symptoms are
present these people seemed to have accepted their disability but show hope about
being able to one day regain mobility either through medicine or a cure for MS.
3. Figures Addressing Symptoms
This collection of drawings represented various insights into the symptomatic
nature of MS. These participants represented themselves with a figure, mostly simple
in composition, that addressed symptoms that person felt (Figure 8-2). These specific
drawings give key understanding through simple visual methods of how MS affects 76
and changes the lives of the people who are diagnosed. These drawings like the first
group of drawings show how these individuals feel connected to their identity as a
person with MS, if at all.
figure 8-2. figures addressing symptoms
Describing the following picture, this participant said:
“This is how I see my MS, as a constant struggle I am faced with everyday of my life. Though I might have MS, I am not MS. At night I am very confused, fatigued and moody before my diagnosis I did not have these symptoms. My walking is sometimes affected and most days my feet feel very heavy due to drop foot in both of my feet.”
This participant was aked to further explain their feelings of being separate
from MS. This participant offered a great deal of insight into the fact they feel as
if they are not a part of the MS community. Rather, they just want to deal with the
symptoms as one would a cold and move forward in their life. This person sees
themself as separate from their condition. When questioned about knowing any other
individuals with MS this participant responded ‘no’ and that they didn’t feel the need to
seek outward community support due to the strong family unit this person has. Similar
feelings were shared from other participants with similar drawings. These drawings
are almost medical in nature, addressing symptoms rather than a journey, abstraction
or an activity this person enjoys. This reiterates the fact these people could potentially
feel separate from their MS and outside of the larger MS community. 77
3. MS as a Metaphor or Abstraction
These drawings represent a stark and dramatic difference from the other two
categories; these participants selected to focus on a metaphor or an abstraction to
visually describe their MS. The participants represented MS in an abstract way, with a
various range of drawings (Figure 8-3). These drawings showcase feelings of inclusion,
change, and creativity. These people considered themselves somewhat artistic and as
such the content of these drawings is open to analysis and interpretation. The content
of the drawings suggest that further questions could be asked, and they were.
figure 8-3. ms as a metaphor
Describing the following picture, this participant said:
“The saying is — sort of — if you see a flower, and you love it, don’t pick it, because then it ceases to be what you love. Appreciate it just the way it is. I’m a whole person or flower. Losing petals over the years — which will die due to my MS— but I am a strong flower! I may lose a little something with each flare-up. But just because I am picked — or have MS — doesn’t mean that I will not fight to stay alive!”
This participant showed great interest in the larger MS community. This person
was an administrator of a Facebook support group and as such felt compelled to assist
people with recent diagnosis: “because it’s scary.” This participant had a relative with
MS as a child and as such felt a strong link to the MS community stating: “I want my MS
community, friends, family with it to be helped in any way.” When asked about what the 78 petals in the drawing represented the participant reasoned that these are the abilities they had lost due to their MS. As addressed in Chapter 2, many individuals with MS suffer from optic neuritis as this person did which has caused this once avid reader to stop reading books. They did make it clear they use tablets and easy readers to still enjoy the printed word. They are no longer able to utilize most tangible, printed books with this participant saying: “I miss the smell of a book, holding it open, reading is such a chore now, the words get jumbled, run on after run on and I have a hard time keeping up.” With each abstract drawing a recurring trend of hope and strength in spite of numerous daily challenges was observed. It is these drawings that give the most insight of all the primary research into a greater understanding and insight of MS. These important and personal findings about social inclusion, accessibility of type were an important component when developing the framework and personas for inclusive design communications. 79
Chapter X
Barriers to the Everyday World
1. Introduction
Individuals with disabilities will tell you that one of the more painful and
effective barriers to their full participation in community life comes from attitudes
displayed by people everyday (Allan, 1992). A recurring trend during data collection was the concept of people feeling separated within their community and/or not included in everyday mainstream society. This concept of barriers that prevent access
to the everyday world is not the major focus of this thesis research but is closely related
to the framework guidelines in the sense of it being another level that could prevent
access and inclusion to this community.
Understanding these barriers as graphic designers can help them make smarter
and wiser choices for the goal of social innovation. Currently, one of the largest barriers
for non-disabled people is connecting and understanding people within disabled
communities due to a lack of shared knowledge and communication on the subject.
Cultures need to expand their horizons so that MS, and other disabilities, are not
something to be thought of in a shameful or hidden way.
People within the disabled community can feel excluded from participation with mainstream society as a result of physical, organizational and social barriers
(Whitehouse, 2oo1). These barriers prevent various factions of the disabled community
from gaining equal access to information, communication, education, employment and recreational opportunities. Using service-based professions such as graphic design and
communications helps to advance knowledge and bridge the gap in understanding for
people outside of the disabled community (Shapiro, 1994).
80
As an outsider of this community, embracing it with an open mind helps to
advance the cause for all disabled people further. Empowering disability allows
people with disabilities and non-disabled individuals to form their own user-led
organizations similar to the National MS Society. These organizations serve as a
springboard for promoting confidence among disabled people, enabling them to lobby
and campaign for changes to social practices and government policies.
2. Language
It is not uncommon that most people don’t know what is “acceptable” or
“appropriate language” to use when speaking with various “disabled” people. With MS
specifically, because many of the challenges and struggles are invisible to the majority
of the outside world it’s important to always make sure that people with MS are treated with the utmost respect. Focus group 3 delved into this concept with those participants
saying they did not find the word “disabled” to be offensive or off-putting. However
most agreed they would not classify themselves as “handicapped” and found this word is not indicative of the challenges and struggles of most individuals who have MS.
Language is the basis of human thought, emotion and attitudes about the world
around us. To communicate effectively and appropriately on the subject of disability, researchers and authors must be cognizant of what is current and appropriate language.
Using “people first” language that emphasizes the individual and the community is key.
This means always refer to a “person” first, then to their disability. For example,
say a “person with a disability” rather than a “disabled person.”
By referencing a person with their disability, it inappropriately makes
that characteristic more important than their status as a person. It’s important to remember to emphasize abilities and not limitations when dealing with a community of individuals with disabilities. Specifically for MS, always reference a person with MS or 81
the MS community. Never identify and isolate symptoms, always remember the person
first and disability second. People with disabilities are an integral part of the general
public and as such language that strengthens and reconstitutes that these principles are important to all visual communicators, researchers, designers, and authors. 82
Chapter XII
Concluding Remarks
This thesis study resulted in proposed framework and personas for use when
designing print communications aimed at the MS community. The framework and
personas were developed by way of secondary and primary research into existing
standards and guidelines. The findings and outcomes were then streamlined and
compartmentalized into a final guidelines document that works as the final product
of the thesis research.
At the end of this primary research, it is clear that a case for more in-depth, interdisciplinary research is key. This research focused specifically on printed, tangible
documents and artifacts. Limitations were present, to understand the value that design
plays in cognitive dissonance, for one, requires use of an MRI to see what areas of the
brain are affected by typography, color and image selections in print. Through interaction, personal stories, and collection of interviews, the researcher was able to
make up for this lack of technology. However there is room for future interdisciplinary
study into the value of typography, color and image in the realms of disability.
This research was focused specifically on print communications. To apply these
same principles to an online or web environment would not be advised. Typography,
color, and even photography have a very different presence on the web. There are many
devices in use today from computers to phones and for each screen ratio, type adjusts to
the screen width leaving uncertainty as to how it will be displayed. In conclusion of the
framework research, the next step would be to take these concepts forward and evolving
and adapting them to apply to web and online environments.
It also worth highlighting the key insights discovered during the visual analysis 83
of drawings. It is worth mentioning that using visual methods to study the experience of
disability was extremely helpful in uncovering important facts about the MS community.
These drawings, coupled with their explanations, provided some of the most valuable
data in the entire process.
Further interdisciplinary research studies into the value of accessible design
need to be conducted, as there are historically differences in approaches that the design
and medical communities take in regards to research. Medical studies are typically
guided by the interests of those researchers undertaking the work. These interests
do not typically extend to visual methods or features. However, the ability to easily
access, interact, and share communications allows people to grow and become a part of
society. Thus knowledge into the value of design that accessible and inclusive to the MS
community is pertinent both in research and in application. Ending with a final quote
by Stevie Wonder, which strengthens the validity of this research and inspires others
to continue research in the same area: “We need to make every single thing accessible to
every single person with a disability.” 84
Appendix A
Survey Appendix Survey Questions and Selected Survey Data 85
Appendix A
Select Survey Questions
For the MS Community: 1. When were you diagnosed with Multiple Sclerosis (MS)? 2. What symptoms are most common with your Multiple Sclerosis? (Cognitive issues, fatigue, double vision, etc)
3. Do you know anything about Visual Communication and Design? 4. Do you ever received MS-related communications (direct mail either from the national MS society, WALKMS, BIKEMS, drug companies promoting new medicine or any other MS-related communication pieces) Please answer yes or no. 5. What kind of MS-related printed communications do you receive, if any? 6. Can you relate to any part of the communications, such as text, photography and/or other imagery? (If yes, go to next question. If so, skip ahead to question 9) 7. If yes, please explain. 8. If you answered yes, please explain. If you answered no skip this question. 9. If no, please explain types of print materials you do relate to? 10. Do you know what a typographic grid is? 11. Of these two typefaces a serif and a sans-serif, which do you, find easiest to read? 12. Can you explain why you choose serif/sans-serif? 13. Organizations advocating for the visually impaired recommend anywhere from 16- to 24-point for large amounts of text in print communications, do you feel this is in an appropriate size for readability? 14. Do you prefer imagery set in color or in black and white? 15. Do you associate certain feelings with colors? (If so please explain in detail) 16. Orange is the color associated with the National MS society and the majority of their communications what are your feelings on this use of color? 17. Do you find the word disabled offensive, explain yes or no? 86
Appendix A
Select Survey Responses and Data 87
Appendix A
Select Survey Responses and Data 88
Appendix A
Select Survey Responses and Data 89
Appendix A
Select Survey Responses and Data 90
Appendix A
Select Survey Responses and Data 91
Appendix A
Select Survey Responses and Data 92
Appendix A
Select Survey Responses and Data 93
Appendix B
Personas Appendix 94
Appendix B
Personas Appendix
Molly Relapsing-Remitting Multiple Sclerosis
“I always hear, ‘You look so healthy still!’ when people ask about my disease.”
Quick facts about Molly About Molly: Inclusion Opportunities
Design Knowledge Beginner Molly is in her late-20’s For Molly important Novice and has been newly design elements that Expert diagnosed with MS. Molly is could affect her access to Job Situation Unemployed active, is healthy most days print communications are Employed and at times feels as if the components like typography,
MS Symptoms Fatigue disease has no hold on her. substrate and color. Cognitive Molly has relapsing-remitting Double-Vision Blurred Vision MS (RRMS) and as such she Recommendations Optic Neuritis has “relapses”, where her MS • Use 14-18 point type. Assistance Yes symptoms flare up. Relapses • Low-glare paper stocks. No are followed by a period of Minor recovery time with little to no • Avoid gloss coated stocks. MS Diagnosis 1 year symptoms often referred to • Use sentence case for as ”remission.” During these bodycopy. times of remission Molly feels normal and her MS is not • Use a simple serif font for progressing any further. bodycopy
• Avoid condensed or Molly’s Symptoms: extended fonts and italics. Molly has slight eye pain • Uniform leading between and double vision consistent lines to try to give as with her RRMS. These much cohesion from line symptoms were her first to line as possible. in diagnosing her MS. 95
Appendix B
Personas Appendix
Gared Secondary-Progessive Multiple Sclerosis
“Managing my daily symptoms has become a part of my everyday life”
Quick facts about Gared About Gared: years Gared has struggled with increasing fatigue Design Knowledge Beginner Gared is in his 40’s and has Novice had MS longer than fifteen and cognitive dissonance. Expert years. Gared has issues Gared’s fatigue and cognitive Job Situation Unemployed walking and may use a cane struggles causes him Employed or leg braces. His walking to become irritable and impatient doing things he MS Symptoms Fatigue is noticeably affected from Cognitive MS and he leads a more once did with ease. Double-Vision Blurred Vision sedentary lifestyle than Optic Neuritis Molly does. Gerald has Inclusion Opportunities Assistance Yes transitioned from RRMS Like Molly — typography, No to Secondary Progressive substrate and color are Minor MS (SPMS). 80% of people key points for Gared’s MS Diagnosis 15-20 years with RRMS eventually accessibility. For Gared access will transition into SPMS to communications is an (National MS Society, 2013). important part of his life and elements like accessible page Gared’s Symptoms: layout/grid structure and avoiding the use of complex With Gared, periods of jargon may offer greater “remission” and “relapse” opportunities for inclusion. are less distinct and unpredictable. Gerald has eye pain and double vision, as well as two occurrences of optic neuritis, which have cleared up. The last ten 96
Appendix B
Personas Appendix
Bea Primary Progressive Multiple Sclerosis
“No wheelchair Today!”
Quick facts about Bea About Bea: Inclusion Opportunities
Design Knowledge Beginner Bea is in her late 50’s and has Bea has cancelled many Novice had MS for 30 years. Bea has subscriptions recently citing Expert been confined to a wheelchair that mainstream magazines Job Situation Unemployed the last ten years when her and newspapers have gone Employed legs became too weak to to the practice of using
MS Symptoms Fatigue support her walking. Bea smaller and lighter font to Cognitive lives a sedentary lifestyle grab attention of standard Double-Vision Blurred Vision very different from when readers. Opportunities for Optic Neuritis she was first diagnosed inclusion in print design for Assistance Yes with RRMS.In general Bea are similar as the other No Bea requires assistance in two personas but greater Minor her daily life to complete attention must be given in MS Diagnosis 30 years everyday activities. Bea’s scenario due to her
advancing symptoms. Bea’s Symptoms: Bea, like Gared, has had several flare ups of optic neuritis which have greatly hindered her vision over the course of her life. Bea’s fatigue and cognitive struggles causes her to struggle understanding things she once did with ease. 97
Appendix B
Personas Appendix
Anthony Progressive-Relapsing Multiple Sclerosis
“I’m not a part of the MS Community”
Quick facts about ANthony About Anthony: Inclusion Opportunities
Design Knowledge Beginner Anthony is in his 30s and For Anthony, opportunities Novice has the rarest form of MS for inclusion are vast from Expert of the four disease courses. community engagement to Job Situation Unemployed Progressive-Relapsing MS printed design materials Employed (PRMS) occurs in about five that he has never taken the
MS Symptoms Fatigue percent of the MS population time to sign up for. The same Cognitive (National MS Society, 2012). considerations for the other Double-Vision Blurred Vision With Anthony’s type of three personas are crucial Optic Neuritis MS being so rare he feels but here a sense of social Assistance Yes the majority of the MS inclusion and integration No communications he received could be an option to make Minor are not necessarily aimed at Anthony more aware of the MS Diagnosis 5 years him. Unlike the other three cause and perhaps change personas, Anthony struggles his stance on not being part with finding his place within of the MS community. In the MS community and the same regard trying to doesn’t identify with members reach Anthony may not of the community. be within the realm of a traditional marketing Anthony’s Symptoms: campaign however outside Anthony has very bad vision chances for social integration disturbances and optic and inclusion may be an neuritis which has prevented opportunity for Anthony. him from reading things he used to love. 98
Appendix C
Focus Group Appendix 99
Appendix C
Focus Group Appendix
Photo 1 and 2. Leading Test
12 point / 14 point APHont
Henia in con et vellaccatur aped quate dus nonsect otatiam, im alicium, nobis dolo tem quatur?Perum ut labores sim faccabo rroris se magnatur? Elecae quo estia pro desseni mincto eos eaqui nonsedicit abor molore aceatque volorehenis si ipit, venes experum non paris dollaces aut re si sus. Itat autemol upidebi tatiberumeni Particpants in Focus Group 1 were dolupic aborumet aut oditatium sum esequia idis ut verro maximinctor arita nimagni magnima dolupturem ut unt ratem. Ihilluptatis aspis aut quae. Nam, ium doluptatur sunto volore cum es voluptis comnit as dolupiet id eicidus. Cia is magniet quae et ut optaque nonsequatem quat millaborepta accullaut aditatu riosto shown this document and asked to is dolum exerio volent reste pro essitas es voluptas delendunte ea quatecaerat accusan tiunt, exceperciis sedio et eruptatum quundis parci ipiendi alitati ssimus adis volorep tatiur, cuptus maximo cor autate perum fugit qui cullaboria voluptur, audi imendi dolo ende select which of these three typogaphic sizes they were able to read with ease. 14 point / 18 point APHont Henia in con et vellaccatur aped quate dus nonsect otatiam, im alicium, nobis dolo tem quatur? Perum ut labores sim faccabo rroris se magnatur?Elecae This proved to be inconclusive as these quo estia pro desseni mincto eos eaqui nonsedicit abor molore aceatque volorehenis si ipit, venes experum non paris dollaces aut re si sus. Itat four particpants all selected a different autemol upidebi tatiberumeni dolupic aborumet aut oditatium sum esequia idis ut verro maximinctor arita nimagni magnima dolupturem ut unt ratem. Ihilluptatis aspis aut quae. Nam, ium doluptatur sunto volore cum es voluptis selection. Due to the inconclusive nature comnit as dolupiet id eicidus.Cia is magniet quae et ut optaque nonsequatem quat millaborepta accullaut adittu riosto is dolum exerio volent reste pro of this part of the iterative focus groups,
16 point / 20 point APHont this segment was dropped in hopes of Henia in con et vellaccatur aped quate dus nonsect otatiam, im alicium, nobis dolo tem quatur? Perum ut labores sim faccabo rroris se magnatur?Elecae quo estia pro desseni mincto eos eaqui focusing on strengthening the other nonsedicit abor molore aceatque volorehenis si ipit, venes experum non paris dollaces aut re si sus. Itat autemol upidebi tatiberumeni two phases that gave more successful dolupic aborumet aut oditatium sum esequia idis ut verro maximinctor arita nimagni magnima dolupturem ut unt ratem. Ihilluptatis aspis aut quae. Nam, ium doluptatur sunto volore cum insights. They are included for reference and with further testing could produce results that are more conclusive.
12 point / 14 point Clarendon Henia in con et vellaccatur aped quate dus nonsect otatiam, im alicium, nobis dolo tem quatur?Perum ut labores sim faccabo rroris se magnatur? Elecae quo estia pro desseni mincto eos eaqui nonsedicit abor molore aceatque volorehenis si ipit, venes experum non paris dollaces aut re si sus. Itat autemol upidebi tatiberumeni dolupic aborumet aut oditatium sum esequia idis ut verro maximinctor arita nimagni magnima dolupturem ut unt ratem. Ihilluptatis aspis aut quae. Nam, ium doluptatur sunto volore cum es voluptis comnit as dolupiet id eicidus. Cia is magniet quae et ut optaque nonsequatem quat millaborepta accullaut aditatu riosto is dolum exerio volent reste pro essitas es voluptas delendunte ea quatecaerat accusan tiunt, exceperciis sedio et eruptatum quundis parci ipiendi alitati ssimus adis volorep tatiur, cuptus maximo cor autate perum fugit qui cullaboria voluptur, audi imendi dolo
14 point / 18 point Clarendon Henia in con et vellaccatur aped quate dus nonsect otatiam, im alicium, nobis dolo tem quatur? Perum ut labores sim faccabo rroris se magnatur? Elecae quo estia pro desseni mincto eos eaqui nonsedicit abor molore aceatque volorehenis si ipit, venes experum non paris dollaces aut re si sus. Itat autemol upidebi tatiberumeni dolupic aborumet aut oditatium sum esequia idis ut verro maximinctor arita nimagni magnima dolupturem ut unt ratem. Ihilluptatis aspis aut quae. Nam, ium doluptatur sunto volore cum es voluptis comnit as dolupiet id eicidus.Cia is magniet quae et ut optaque nonsequatem quat millaborepta accullaut adittu riosto is dolum exerio volent reste pro
16 point / 20 point Clarendon Henia in con et vellaccatur aped quate dus nonsect otatiam, im alicium, nobis dolo tem quatur? Perum ut labores sim faccabo rroris se magnatur? Elecae quo estia pro desseni mincto eos eaqui nonsedicit abor molore aceatque volorehenis si ipit, venes experum non paris dollaces aut re si sus. Itat autemol upidebi tatiberumeni dolupic aborumet aut oditatium sum esequia idis ut verro maximinctor arita nimagni magnima dolupturem ut unt ratem. Ihilluptatis aspis aut quae. Nam, ium doluptatur sunto volore cum 100
Appendix C
Focus Group Appendix
Photo 3 and 4. Typography and
Serif Faces Color Preferences The quick brown fox jumped over the lazy dog
The quick brown fox jumped over the lazy dog Participants in focus group 1 were shown this document and asked to The quick brown fox jumped over the lazy dog select which of these three typographic
The quick brown fox jumped over the lazy dog styles they were able to read with ease. This proved to be inconclusive as these
Sans-Serif Faces four participants all selected a different The quick brown fox jumped over the lazy dog selection. It was decided after this intial
The quick brown fox jumped over the lazy dog round of testing that this phase would be dropped out. The quick brown fox jumped over the lazy dog
The quick brown fox jumped over the lazy dog The second photo shows data collected from Lighthouse International, and was used to gain insight on understanding
This is research collected from Lighthouse International, please select the effective of color contrast for this community. color combination you prefer and explain briefly why you selected this over the others. Also pay close attention to the non effective colors, and explain if you issues perceiving these colors. While this proved to provide slightly more conclusive results, color is a Effective relative phenomenon. Because of this
Not as fact there is a degree of personal bias effective when it comes to color selection.
Effective With further testing and a larger
Not as pool of focus group participants this effective segment of testing could produce more conclusive results. Effective
Not as effective 101
Appendix C
Focus Group Appendix Selected Conversation Transcripts
Participant 1 from Focus Group 1: 1. Have you ever felt your Multiple Sclerosis has prevented you from access to print communications or reading materials? Yes, most definitely. I’ve lost the vision in my left eye permently. In addition when I have a relapse I tend to loose all but a very tiny spot in my right eye. So it’s difficult to see most things when that happens even things designed for accessibility. In my everyday life I need much more light to function in my day to day activities. I also have lost my depth perception and at times it’s severe. I honestly prefer to have fonts which are darker and bolder.
2. Do you struggle with reading certain sizes of type? Anything under 14 points is extremely hard for me to read. Until late recently it was hard for me to read print which I’ve always loved. With my IPad and Kindle, reading is much easier as I can change the fonts or make the back ground dark and print white. These things go have allowed me to go back to reading.
3. Do you feel a part of the multiple sclerosis community? That’s a hard one. I love my Facebook groups. I haven’t been successful in getting involved with the MS Society or MS Foundation. In addition I’ve had a very hard time finding a good local support group. I need one that offers lots of information and doesn’t sit around as a pitty party. I need positive uplifting groups, and they are hard to find. So the Facebook groups have been awesome.
4. What types of design items (artifacts) do you find yourself interacting with most frequently (this excludes apps or websites, you can list them but please try to think of printed and tangible design items) The MS Focus magazine, HGTV magazine. Internet searching new treatments. Like stem cell therapy. Also sites or catalogs that deal with assisting devices, fashion catalogs, my bible, both book and on my tablet. I love craft books and magazines, most of them are hard to read though. I craft and make jewelry for a living. 102
Appendix C
Focus Group Appendix Selected Conversation Transcripts
Participant 2 from Focus Group 1: 1. Have you ever felt your Multiple Sclerosis has prevented you from access to print communications or reading materials? Yes all the time.
2. Do you struggle with reading certain sizes of type? Yes- just the other day I was given a new medication that came pre- packaged. And eye drop. I knew the dose, because the doctor had told me, but the instructions on the bottle were impossible to read. Any medications that are over the counter are hard. If they are for me, I typically know the dose. But, if I were watching my small nieces or nephew, and they were to need, oh, let’s say Tylenol, the size of the print is too small. I would have to make sure to ask the druggist, or have someone help me.
3. Do you feel a part of the multiple sclerosis community? No, However I think social media is by far a better avenue than one on one groups. In the past my experiences with support groups has not been good.
4. What types of design items (artifacts) do you find yourself interacting with most frequently (this excludes apps or websites, you can list them but please try to think of printed and tangible design items) Magazines like National Geographic with pictures to help get my head around what is being talked about. With my cognitive struggles itt helps to look at the pictures if I miss some words. Time is one of my favorites- those specialty magazines like 100 most influential pictures of all times.MS Focus and various art magazines are also some of my favorite print items. 103
Appendix C
Focus Group Appendix Selected Conversation Transcripts
Participant 1 from Focus Group 2: 1. Have you ever felt your Multiple Sclerosis has prevented you from access to print communications or reading materials? I can’t say that it has personally, no. I know that there are several individuals with MS that do struggle with this though.
2. Do you struggle with reading certain sizes of type? Yes! Anything smaller than 12 put due to my MS with Optic Neuritis. I use reading glasses where I once did not have to.
3. Do you feel a part of the multiple sclerosis community? Yes and no. I search out forums or blogs and such, if I need a pick me up, or answers. My doctor is great, and she gives me periodicals to help stay on top of things. But locally, I have not reached out to others. It is still “taboo” many times to discuss an illness, and I think that stifles people.
4. What types of design items (artifacts) do you find yourself interacting with most frequently (this excludes apps or websites, you can list them but please try to think of printed and tangible design items) Well, once again, things that are in print are hard for me to read. On Facebook there is a group called Overcoming MS. I go there frequently. The National MS society is a great resource. Living with Multiple Sclerosis is probably the one I visit, and interact with the most. My neurologist gives me a monthly publication “AWARE” that comes to her office. It is bold, large type, and has tips for things like cognitive issues that are helpful. One of the drug companies publishes it.
5. Do you know any other individuals with MS in your real life? No, I do not. I know may on social media through Facebook and MS Connection.
104
Appendix C
Focus Group Appendix Selected Conversation Transcripts
Participant 1 from Focus Group 2:
6.1. Do you find environmental barriers a challenge in your everyday life? I do fine at home, and areas that I know well, but larger stores, such as Target or Walmart make me nervous. If someone is there with me, I am fine, but if I am by myself, and get turned around, it’s hard. I know that “superstores” are the wave of the future, but for those of us with difficulties walking and seeing, it is a barrier. One of the things that I would like to see, is aisle markers closer to the shelves. They are always up high, hanging over the aisles. For me, looking up and around like that make my brain spin, and I become unbalanced. And, many times I can’t see the categories. Assistance is another barrier, although I am lucky John is retired and home to take me places, and help. Because I can no longer drive, it becomes hard to just “get out and go”. I have heard others say to hire a taxi. Well... for one thing I live rural, and it would cost and arm and a leg. And I live in a small town, which is another barrier, because there aren’t many services for me. And attitude is a barrier. Not so much now, but when I was working. My manager had no clue about MS, and wasn’t about to find out. A few simple accommodations would have helped so much, and, by law should have been approved. I truly believe had they worked with me two years ago, I would not be in the shape I am in now. Stress plays a big part in MS, as you know. I was stressed and had an exasperation that got worse, because my place of employment was ignorant. I actually had an HR rep ask me “ How long I was expected to have MS”. Work places are so worried about the “team environment”, but many fall short on educating management on the fundamentals of working with individuals that need accommodations, and by law should be guaranteed those rights. They have lost great employees because of fear and ignorance. 105
Appendix C
Focus Group Appendix Selected Conversation Transcripts
Participant 1 from Focus Group 3:
1. Do you feel integrated and connected with the MS community? Yes.
2. Do you know any other individuals with MS in your real life? I didn’t but my Facebook group has lead to me meeting friends from that page in reality and I have made two close friends because of that.
3. Do you find environmental barriers a challenge in your everyday life? Yes, many times my symptoms may seem invisible or do not have a physical detractor. I have been yelled at for using a handicapped parking sticker with people claiming ‘You’re not disabled’ or leaving notes on my vehicle. So I find understanding of the disease to be a huge barrier that I face in my life.
4. Do you find the word disabled offensive, explain yes or no? I don’t think the word disabled is a bad word because people who have MS or have physical problems, like for me, the way I walk and certain issues. I think disability is a fine word. Where it’s a hard word for me, is when people have invisible MS symptoms. So people outside the MS community have a hard time understanding and relating to someone who has invisible MS symptoms.
5. Has MS changed your daily life? Yes, I’ve gone from being a very active person to living a more sedentary lifestyle because of my MS. 106
Appendix D
Drawing Multiple Sclerosis Visually 107
Appendix D
Drawing Multiple Sclerosis Visually
Photo 1. MS is breaking nerve connections due to Myelin being destroyed. MS has caused a shift also due to lost friendships, lost family, loss in myself as if the bridges to return to normality have all been broken.
Photo 2. On the left shows a normal world, before MS, or, when you are not in the middle of a exacerbation. Things are good, or as good as they can be with MS. The right side shows the uphill battle. Stress- climbing that hill. It takes the smile off of your face if you let it. I never give up hope.
Photo 3. MS is causing me to feel fatigued on a regular basis which causes me to feel angry. I also have jitters, bladder issue which is why I drew myself all twisted up. Most days I feel twisted like a pretzel. My legs feel like two cinder blocks 108
Appendix D
Drawing Multiple Sclerosis Visually
Photo 1. MS has caused me to feel like an outsider even when I’m with friends. This drawing depicts how when I’m out with friends I may feel the symptoms of my MS and my friends will tell me to “blow it off” because I don’t look or act like someone who is sick.
Photo 2. It’s like the petals falling from a flower, I loose a little something with each flare up. The thorns on the stem of the flower represent the times my MS becomes really hard and life gets a little tough, but I always remember that I am a beautiful flower with or without MS.
Photo 3. Addressing my MS visually allows me to show people my confusion and how my body feels all tight and itchy which is represented by the green lines. I also have a lot of bladder issues and pain in my fingers in toes which is represented by the blue and pink. 109
Appendix D
Drawing Multiple Sclerosis Visually
Photo 1. My fatigue most days is my most present symptom so I drew my MS as a windup toy that is always needed wound but never has enough energy to get tasks accomplished that I want to.
Photo 2. My Multiple Sclerosis could be visually drawn as a tree loosing leaves before winter. Similar to that cold chill in the air, I feel a relapse coming on and I know I am going to loose some small ability somewhere that may or may not return.
Photo 3. My struggles with my cognitive ability and understanding has been greatly hindered by MS. Somedays it feels like there is a wire shortage somewhere in my head. The words are there but I cannot seem to find them to get them out. 110
Appendix D
Drawing Multiple Sclerosis Visually
Photo 1. This drawings depicts something I love to do even with my MS which is so sit outdoors with a good book and just let my mind waunder. MS has left me in a wheelchair but I try to get as much outdoor activity as I can even with my wheelchair.
Photo 2. This depicts how I feel about my MS, most days I am bed ridden crying out for my old way of life. It breaks my heart to think about the things I was once able to do which I am no longer able to do.
Photo 3. The raindrops signify my MS and how it can “pour down” in my life. However I try to keep a good attitude about my life and my battle with MS. The sun and rainbow let you know that no matter what MS will not take my happiness away from me. 111
Appendix D
Drawing Multiple Sclerosis Visually
Photo 1. This is how I see myself — confined to a wheelchair by my MS but still with a smile on my face hopeful that tomorrow will bring a new day with less pain and hope for a cure.
Photo 2. My MS affect my thinking and reading abilities on a daily basis for me and with regards to your research, graphic design and print materials sometimes feel like a brick wall I cannot get through because of MS.
Photo 3. When I think of MS (black), I think about how I have seen it shown in medical textbooks with the nerves being attacked. This is what I drew because nothing show the invasion of this disease better than seeing it break down the nerves (green). 112
Appendix D
Drawing Multiple Sclerosis Visually
Photo 1. MS feels like a see-saw most day, I never know how I am going feel day to day. This confusion causes me to feel at times like there is no hope. However my MS does not define me and I am a strong person with more good days than bad.
Photo 2. My brain no longer functions like it used to, thinking and processing of everything from text to images is complicated anymore. My MS has caused me to need a lot of help in my daily life from my friends and my family.
Photo 3. Pain and spasms have caused me to use a wheelchair most days. I also have really bad back trouble which is represented by the lines towards my back. Most days I struggle to put a smile on my face because of my MS. 113
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