Web Page Design Recommendations for People with Down Syndrome Based on Users’ Experiences

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Article Web Page Design Recommendations for People with Down Syndrome Based on Users’ Experiences

Lucía Alonso-Virgós 1, Luís Rodríguez Baena 1 , Jordán Pascual Espada 2 and Rubén González Crespo 1,* 1 School of Engineering and Technology, Universidad Internacional de La Rioja, Avda. de la Paz, 137, 26006 Logroño, La Rioja, Spain; [email protected] (L.A.-V.); [email protected] (L.R.B.) 2 Department of Information Technology, Universidad de Oviedo, Calle Valdés Salas 11, 33007 Oviedo, Spain; [email protected] * Correspondence: [email protected]

Received: 21 October 2018; Accepted: 15 November 2018; Published: 20 November 2018

Abstract: At present, there is a high number of people with Down syndrome interested and trained to be an active part of society. According to the data extracted by our surveys we know that only 6% of the population with Down syndrome feels isolated in daily activities. However, when the activity requires the use of a computer, the percentage of people who feel isolated increases to 18%. This means that there are obvious website accessibility barriers that make it difficult for users with Down syndrome. To solve this problem, it is considered necessary to make an exhaustive study about Down syndrome. We know that the trisomy of chromosome 21 causes a series of symptoms that directly affect ones Internet browsing capabilities. For example, speech disturbances make communication and speed difficult. This guide is based on a neurological study of Down syndrome. Alterations in listening make understanding audio, retention of audio concepts and speed difficult. The alterations in the physiognomy of movement make it difficult for them to act quickly. Many of these alterations are caused by cognitive disability. After assessing the needs, the benefits of Web Content Accessibility Guidelines 2.0 (WCAG 2.0), and the existing usability guidelines are analyzed and those that may be useful for this profile are extracted. User tests are carried out through two websites developed specifically for this study with the aim of demonstrating the level of effectiveness of each of the planned guidelines. Considering the neurological characteristics of this intellectual disability, research is developed that seeks to extract a list of useful accessibility and usability guidelines for web developers.

Keywords: website accessibility; website adaptation; Web Content Accessibility Guidelines 2.0 or WCAG 2.0; Web Content Accessibility Guidelines 2.1 or WCAG 2.1; Down syndrome

1. Introduction Down syndrome was considered a serious intellectual disability 30 years ago, but in recent years, several programs have helped to change the classification of Down syndrome to a medium-level intellectual disability [1]. The most important programs that have made this disability go from being considered a severe intellectual disability to medium-level intellectual disability are early care programs, educational inclusion programs and technological advances. In the field of website accessibility there are no studies on the evaluation of such guidelines. For this reason, the purpose of this research is on the one hand to draw conclusions about the opinion of the users with Down syndrome to know what their most pressing needs are, and, on the other hand, to test all those accessibility and usability guidelines to check if they are indeed useful for this user profile. The objective is to conclude with a series of useful recommendations for web developers

Sensors 2018, 18, 4047; doi:10.3390/s18114047 www.mdpi.com/journal/sensors Sensors 2018, 18, 4047 2 of 39 interested in website access for people with Down syndrome. To achieve this objective, two studies were carried out:

(1) A study whose purpose was to know the real needs of users with Down syndrome. To this end, surveys were prepared and sent to 87 Spanish associations related to Down syndrome. These surveys were answered by the users with Down syndrome, there were a total of 112 volunteer participants. (2) User tests to verify the results of the surveys. These tests were specially designed for the study.

In this article we define the importance of website accessibility for the inclusion of people with Down syndrome. We defined the existing accessibility and web usability guidelines and analyzed the newly approved Web Content Accessibility Guidelines 2.1 guidelines. We present our intervention, which consists of carrying out a survey and different user tests. The survey aims to find the needs that the users with Down syndrome believe themselves to have. The tests are intended to demonstrate the effectiveness of existing guidelines. We present the trials that were conducted during the research, including those trials that were modified during the tests to better fit the search for the result. We offer the results of each test and a series of useful recommendations for web developers. In the conclusions we make an analysis on the importance of working this method in web accessibility and usability. The concepts of accessibility and usability are analyzed first in this paper. Especially the advantages offered by web accessibility and WCAG to people with cognitive disabilities. As our goal is to direct the research towards a specific user profile, surveys are conducted and sent to 87 Spanish Down syndrome-related associations. There were 112 volunteers with Down syndrome interested in participating. The methodology of the surveys is explained in this paper in terms of its design and its resolution. Many of the results of the surveys are published in this paper. The purpose of these results is to be able to design some tests that prove a series of web design recommendations. So, these results and the references of author and WCAG are considered for the approach of the recommendations and for the design of the tests. There are 45 essays distributed in 14 tests, web tests or eye tracking tests. The methodology of all of them is detailed in this paper. As well as also the most relevant results obtained. Finally, interesting conclusions are drawn. These conclusions represent useful recommendations for developers or web designers.

2. Background Within the field of website accessibility, there are several recommendations, ordered according to their purpose. In this research, we will analyze those that benefit users with Down syndrome, according to the results of the surveys we conducted and according to the previous and exhaustive study of their profile. After completing the research, new Web Accessibility Initiative (WAI) guidelines appeared, which from now on we will call WAI, many of them aimed at people with cognitive disability. Although they have not yet been formally approved, we analyze them based on the results of our work in this paper. Although they had not been formally approved when we did our tests, we analyze them based on the results of our work in this paper.

2.1. Usability and Accessibility Technology plays an important role in the lives of people with disabilities [2]. In web development, we have a series of universal procedures divided into accessibility and usability. The purpose of website accessibility is to ensure that a website can be used by as many people as possible, regardless of their knowledge or skills or of the technical characteristics of the equipment to be used. This is done, thanks to four principles: Perceivable, Operable, Understandable and Robust. Each of these principles has a series of guidelines that describe how to apply each of the guideline [3]. In the field of accessibility, there are also guidelines to people with cognitive disabilities [4], however, there are no published Sensors 2018, 18, 4047 3 of 39 studies on the evaluation of such guidelines. We cannot guarantee that the guidelines are effective or how effective they are. The purpose of usability is to ensure that the use of a website is practical, simple and effective. The navigation is intended to be effective, efficient and satisfactory for the user [5,6]. Considering the appropriate usability guidelines can reduce the risk of errors during navigation and increase the ease of use, which not only benefits the user but also their objectives and context [7,8]. In the field of usability, we find a study that tests different usability guidelines for mobile devices in people with Down syndrome. Although our work is not focused on mobile devices, we find this study interesting, since there are very few works aimed at the technological inclusion of people with Down syndrome. The tests are performed by people with cognitive disabilities and determined that the most effective navigation method is “drag” [9].

2.2. Website Accessibility There are guidelines on website accessibility and usability that aim to solve all or almost all the needs that different disabilities or difficulties demand. Regarding Down syndrome, the importance of getting the computer to this user profile in other occasions has been demonstrated [10]. However, at least until now, there are few works on website accessibility aimed specifically at users with Down syndrome. The interest of this user profile is its complexity. Syndrome means “set of symptoms”. All individuals differ from each other and not all have to present the same degree of disability in each symptom. However, the sum of several symptoms can be an inclusion handicap, especially the one concerning cognitive disability. Almost all existing research related to Down syndrome assesses their physical and non-cognitive difficulties. For example, in the field of mobility, it is known that for users with Down syndrome it is easier to use a mouse than a keyboard, since they show difficulties in entering text using keyboards [10]. This statement was demonstrated through surveys of users aged 4–21 years. However, it would be necessary to test this hypothesis. There are also a multitude of surveys aimed at finding the existing difficulties, but these surveys may have limitations, since they are aimed at very diverse users and usually begin with people of 4 years of age. For example, people under 6 years old may not have learned to write and it is natural for them to feel more comfortable with the mouse than with the keyboard [10]. To date, there has not been an analysis of the real abilities of Down syndrome patients, but there are ethnographic studies that show that users with Down syndrome have sufficient skills to perform basic tasks on computers, such as text processing or data entry [11]. There are also works related to the advantages of the computer in education, communication or entertainment activities [12]. It is interesting to know how computers can help the educational development of students with Down syndrome and how they can help their professional development and independence. There is a study that collects the navigational difficulties of 600 children with Down syndrome and raises the related design challenges [13]. These studies show the possibility of inserting people with Down syndrome into work activities, even those that require the use of new technologies.

Website Accessibility for Cognitive Disability We analyze that in the field of website accessibility it is possible to distinguish the need for a cognitively accessible website. However there has been little work to date in this area. WAI recommendations related to cognitive disability present evaluation difficulties because they are general recommendation [14]. Currently, it is intended that WCAG improve the guidelines, including guideline specifically for cognitive disability. In June 2018, a new WCAG recommendation was approved. The WCAG 2.1 includes guideline specially oriented to cognitive disability. There are 17 novel guidelines. Of the 17 new guidelines of conformity (success criteria) there are those that are more related to cognitive disability: Criterion 1.3.5 “Identify Input Purpose”, which aims to offer content in different formats, for example, with a simpler composition. Criterion 1.3.6 “Identify Sensors 2018, 18, 4047 4 of 39 purpose”, aims to determine by code the purpose of the user interface components, icons and regions. This can be useful for people with memory problems. Criterion 1.4.10 “Reflow”, aims to facilitate the content by avoiding the scroll bar. The criterion 1.4.11 “Non-text Contrast” aims that all the content (including graphical objects) have a contrast of 3:1. The criterion 1.4.12 “Text Spacing” aims that the textual content is offered visually in an appropriate way. Criterion 1.4.13 “Content on Hover or Focus” which aims that the hidden content is not lost. Criterion 2.2.6 “Timeouts” aims to preserve the privacy of minors when there is inactivity and the data is retained. Criterion 2.5.1 “Point Gestures” intends that all functionality that uses multipoint gestures, can be used with a single pointer gesture. Criterion 2.5.2 “Pointer Cancellation” relative to the “singer pointer” functionality. Criterion 2.3.3 “Animation from Interactions”, which aims to disable the animations that are triggered by some user interaction. This can be useful for people with attention problems. Criterion 2.5.3 “Label in Name” intends that visible and non-visible labels have consistency. Criterion 2.5.4 “Motion Actuation” which aims to include alternative methods of interaction to the movements of the device (to shake the mobile) or the movements of the user detected by a camera. This can be beneficial for people with spasms, or with cerebral palsy. Criterion 4.1.3 “Status Messages” also refers to screen readers. Although the intention is to improve the field of cognitive accessibility, it is emphasized that they do not cover all the needs of these users. To date, no evaluations have been published on web guidelines for people with cognitive disabilities. There are no specific developmental guidelines that have been tested with users with Down syndrome [14]. For this reason, this research aims to address this problem and quantitatively evaluate the WAI and existing guidelines on usability aimed at cognitive disability to determine if they are indeed useful. In addition to evaluating existing guidelines, the research concludes with a list of useful website accessibility and usability recommendations aimed at developers who want to create cognitively accessible web pages.

3. Research Development This study presents two complementary studies: a survey that aims to find out the real needs of users with Down syndrome and two types of user tests that aim to extract a list of useful guidelines for access and use. The purpose of the survey is to find the needs that the users themselves believe they have. With the results obtained in the surveys and with the previous analysis of the neurological profile of Down syndrome, it is determined which guideline of the existing ones can be effective. The user tests intend to determine if these guidelines are effective. Alternatives are proposed to many of the guideline to fit the real needs of the participants. The aim is to conclude with a series of useful recommendations for web developers.

3.1. Survey It is difﬁcult to learn new words and to understand and express oneself through linguistics for people with Down syndrome. The most common problems during reading are the confusion of phonemes, the replacement of words with similar ones and the inversion in the order of letters or syllables. Also, there are typographies that can be confusing because they prioritize their aesthetic character to the functional character. For example, the Gill Sans font offers letters different with the glyph so similar that they do not differ from each other. In this typeface, an “l”, an “i” and the number “1” with the font type Gill Sans offers identical characters, I-I-I. So, that the volunteers understood the text was a priority for us. Many of the recommendations collected for the design of the survey were related to typography, grammar and format [15]. The survey design complies with the accessibility recommendations on format and writing. For this to be fulﬁlled, and before sending the surveys to the associations, a test survey was designed. The test survey was sent to three associations and the recommendations offered by the expert staff were recorded. When the three centers approved the format and the writing, it was sent to the 87 associations planned. Sensors 2018, 18, 4047 5 of 39

3.1.1. Survey Design Methodology The design and structure of this survey is the result of work and consultations with a lot of associations. A series of published guidelines were obtained for the preparation of the survey form too. The purpose of these guidelines is to improve the format and content [16]. Our main difficulty was the use of appropriate language and wording understandable by the interested users, so we also sought advice from specialized personnel. For example, they told us what kind of questions more easily answered and what number of answers are appropriate. It was preferred to use the same communication scheme used by the associations to avoid disorienting users when accessing information and answering forms. The review by the staff of the different associations has been very useful. The tests were in paper format, not online. The first survey design was reviewed by an expert in the creation of teaching materials. Since the survey was part of the investigation and we were not sure if the theoretical recommendations would be useful, trial and error tests were made with several participants. This helped to adjust the writing, until the questions could be answered autonomously by a specific profile. There were 25 participants who fulfilled the study profile. They participated only in the survey tests, not in the web tests or in eye tracking tests. A series of new recommendations were collected. The surveys were modified and considered valid. With the new survey format all participants responded without any use problems:

• Text was left justiﬁed, and not centered, to avoid confusing the users with the space between words. • White background and dark gray letters were used, instead of black, to prevent the text from causing blurring. Color was only used on the cover, as a persuasive method. Do not forget that participation is voluntary. • The questions were written using secondary language, avoiding technicalities, complex words, or redundancies. Double meaning is not used either, the sentences are literal and short (less than 15 words). • Serif typography is used, avoiding italics and using the bold font to highlight the text. The typeface used is Sans Serif.

The survey is divided into four different sections that motivate its completion.

• A form that collects data to establish the sample characteristics (sex, age, level of studies, etc.). Personal information such as name, city or school was not collected in any of the cases. The field is by selection, so the respondent must select one of the proposed answers. • A form that assesses the difficulty level of different computer activities based on four variables (never, sometimes, many times or always). The field is by selection, so the respondent must select one of the proposed answers. The results of these types of questions are useful to find out if users have obvious access difficulties and if they are aware of them. It must be remembered that the surveys are answered by the interested parties, so that in these reports it is expected to find problems identified by the users. • Open space that collects the most navigated portals. The field is free form. • Alternative space to provide complementary data. The field is free form. This field was not obligatory and nevertheless 48% of the respondents answered it voluntarily.

All questions offer a section of alternative answers so that users can respond differently to the questionnaire. For example, a free copy space is included in the ﬁelds in which the respondent must select one of the proposed options. In this way the respondent can respond either by selecting the option that interests them, or by writing their own answers:

• Multiple choice type answers, with a maximum of six possible answers. • Various shipping formats, paper and digital format with auto response boxes were offered. Sensors 2018, 18, 4047 6 of 39

3.1.2. Methodology to Increase the Participation in the Survey Results The surveys are sent to 87 Spanish Down syndrome-related associations and was answered by 112 voluntary users (67% of the eligible candidates contacted). It is important to emphasize that to participate not only must the user agree, but also his/her family. Both the tests and the survey required proof of project approval signed by the families. There was no age limit, however there was a greater number of participants between 15–35 years old. The average age of the participants was 17 and the deviation is 26. It is not surprising that this has been the most prominent age range. On the one hand, students with Down syndrome have access to secondary school with several levels of curricular lag. This means that they enter secondary school with at least 15 years old. In secondary school, TIC competence is compulsory, so it is logical that those are students are interested in computers. On the other hand, the number of students enrolled in advanced courses, such as vocational training, has increased considerably since 2008. The insertion in the labor market demands that workers have skills in new technologies (telephones, PDAs, computers). For this reason, it is understandable that there is a high number of people under 35 years of age was interested in participating in the survey. It is important that the users be able to respond to the survey without any help. However, there was always an assistant. The assistant should only clarify doubts about the questions or serve as a guide as to how to respond. The assistant cannot give the answers. Participants did not receive any help to collect information related to their writing, expressions, etc., directly from them.

3.1.3. Survey Results Tables1–4 shows the statistics of the participants’ data. The surveys show that 3.5% of people with Down syndrome use the Internet daily, 40% of whom need to use the Internet at school or at work. This is a signiﬁcant fact, considering that the ﬁgure does not depart much from the total percentage of people with Down syndrome between 15–35 years old, 78.57%. It could be concluded therefore that more than 50% of people with Down syndrome in the 15–35 years old age group need to use the Internet daily. We know that the trisomy of chromosome 21 causes a series of symptoms that directly affect ones Internet browsing capabilities [17].

Table 1. Gender data.

Man Woman Does Not Answer Gender 46.43% 52.68% 0.89%

Table 2. Age data.

<14 15–34 35–54% >55 Does Not Answer Age 2.54% 78.57% 17.03% 1.79% 0.07%

Table 3. Studies data.

Does Not High Primary Vocational Training Does Not Know to Read School Other Studies Education Studies Studies Answer Nor to Write Studies 2.68% 39.29% 34.82% 0.89% 4.46% 10.71% 7.14%

Table 4. Work data.

Yes No Does Not Answer Work 52.68% 47.32% 0.00% Sensors 2018, 18, 4047 7 of 39

Figure1 shows the statistics of the day-to-day activity questions. That is, questions that a priori are not related to the Internet. Many of these answers served as motivation for the study. For example, of the total number of volunteers, there are 17% of users who suffer navigation problems daily and 5% of people who cannot use the Internet due to access problems. There is 18% of people with Down syndrome who feel discriminated against when they participate in activities that require the use of a computer. This ﬁgure is important, since it differs greatly from the percentage of people who usually feel discriminated against because of their disability (6%, Figures2 and3). That is, there is a 12% of people who do not feel discriminated against on a regular basis but feel discriminated when the activities are related to the computer [16]. Sensors 2018, 18, x FOR PEER REVIEW 8 of 39

Most relevant questions related to day to day 90%

80%

70%

60%

50%

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Never Sometimes (1-2 times a week) Many times (3-4 times a week) Constantly (> 5 times a week)

FigureFigure 1. 1.Most Most relevantrelevant questions related to to daily daily activities. activities.

Sensors 2018, 18, x FOR PEER REVIEW 9 of 39

Most relevant questions related to computer use Sensors 2018, 18, 4047 80% 8 of 39

Sensors 2018, 18, x FOR PEER REVIEW 9 of 39 70%

60% Most relevant questions related to computer use 80% 50% 70% 40% 60% 30% 50%

40%20%

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20% 0% 10%

Never Sometimes (1-2 times a week) Many times (3-4 times a week) Constantly (> 5 times a week) Never Sometimes (1-2 times a week) Many times (3-4 times a week) Constantly (> 5 times a week)

Figure 2. Most relevant questions related to computer use. FigureFigure 2. Most 2. Mostrelevant relevant questions questions related to relatedcomputer to use. computer use.

Figure 3. Structure of the web user test.

According to the surveys, 51.1%Figure of the 3.responden Structurets of presented the web difficultiesuser test. during the reading, 23.2% said that they had difficulties alwaysFigure or 3. Structurealmost always. of the Approximately web user test. 55.3% find it difficult to express themselves through abstract language. These data are useful in the iconography tests. According to the surveys, 51.1% of the respondents presented difficulties during the reading, FigureAccording2 shows to the results, the statistics 74.1% of ofrespondents the questions said they about make Internet mistakes while use. performing It should betasks noted that the 23.2%answersthrough said the were that computer. given they byhadThere the difficulties was participants a 25% alwayswho themselves. made or mialmoststakes This always.always means or Approximately almost that they always. are Providing not55.3% objective find it answers,difficult tobut express rather personalthemselves appreciations through abstract about language. their abilities. These data are useful in the iconography tests. AccordingIn the web to tests the weresults, were 74.1% able to of obtain respondents more objective said they statistics make mistakes about competencies, while performing based tasks on throughactual results, the computer. not assumptions. There was Some a 25% users who mention made the mi technologystakes always they or used. almost Only always. 1% use Providing adaptive tools, such as accessible mice or keyboards. Thanks to these results we adjusted the tests. For example, in color tests the screen configuration responses gave us the idea of including an additional web test. This test consisted of an adaptable Sensors 2018, 18, 4047 9 of 39 menu for simple changes of the webpage appearance, for example, the color of the background, the color of the buttons, etc. The most visited websites were YouTube, administration websites, medical services websites. The most used search engine is Google. In this paper, percentages are not included on the most used website because the field of answers was free form. These data serve as motivation for future tests. The results of the surveys were compared with the recommendations proposed by the WCAI and useful conclusions were drawn for the design of the next test. The percentage of respondents who work or had worked was 46%. In the autonomous communities of Spain there are a series of job options oriented to the workforce insertion of people with Down Syndrome. These jobs include baker’s assistant, janitor assistant, operator, sales assistant, service assistant, telephone operator, etc. Many of these professions require the use of Personal Digital Assistants (PDAs) and other technological tools. According to the surveys, 23.2% of the users experienced daily problems to learn how to use technological tools. In addition, 48.2% of respondents found it difficult to find tools or buttons without help or supervision. From the results of the surveys it is concluded that only 15.2% of users need help almost always to maintain or change body posture. Although it mainly refers to users older than 55 years, this data is useful with the eye tracking test. Just in case, for this test we have a help person. From the results of the surveys it is concluded that 51.8% of the users have problems with the keyboard and that 26% usually have problems with the mouse. This problem may be due to a cognitive deficit, rather than a motor deficit. These data are useful for the development of the tests. For example, in the text link test, the working time is measured using only the mouse. In all web browsing tests, the use of the keyboard is avoided, except in those in which the use of the keyboard is tested. According to the surveys, 69.6% of respondents need more time to perform tasks related to the Internet, of which 42% require more time in all or almost all their connections. These data are useful for visible stopwatch tests. According to the surveys, 51.1% of the respondents presented difficulties during the reading, 23.2% said that they had difficulties always or almost always. Approximately 55.3% find it difficult to express themselves through abstract language. These data are useful in the iconography tests. According to the results, 74.1% of respondents said they make mistakes while performing tasks through the computer. There was a 25% who made mistakes always or almost always. Providing information about how to correct errors allows people with Down Syndrome to fill out forms and identify and correct their mistakes while browsing. According to surveys, 9% of users have problems with the colors of the web. This has been considered for background and text color tests, and for button color tests. Although only 11% believe they present common problems reproducing a multimedia element, it was considered useful to perform tests to verify this claim. There is a 20% that manifests having problems with reading a web page. Typography tests were therefore carried out.

3.2. Tests The access barriers suffered by people with Down syndrome are related to a series of physical and neurological conditions caused by the total or partial copy of chromosome 21 [18]. This research proposes a series of user tests that aim to extract a list of access and use recommendations [16,19] useful for web developers. There were two types of tests: Web tests. These tests consisted in presenting users Down syndrome with two websites, one inaccessible and one accessible, considering usability and accessibility guidelines. The inaccessible website was intentionally inaccessible to check the time lost that is invested when certain guidelines are not considered. Several tests were carried out, all of them related to the navigation activities most demanded by this user profile. It should be noted that the navigation preferences of this user profile are the same as those of user profiles without intellectual disability [18]. Time comparisons were Sensors 2018, 18, 4047 10 of 39 made between the two websites, the accessible website and the inaccessible website. These tests were performed with 25 volunteers with Down syndrome aged between 18–35 years old and with interest in new technologies. Eye tracking test. With these tests it was possible to measure the movement of the retina of the participants, in this way information about the attention can be obtained. People with Down syndrome usually have attention deficit [20]. With these tests we try to find out which are the most useful web design and development strategies to fix the attention of a user with Down syndrome. These tests were aimed at 25 volunteers with Down syndrome between 11–25 years old and with an interest in new technologies. In these tests, a limit was established in the age of participants. The average age of the participants was 18. The deviation is 4.2 years old (Table5). In this table the ages of the test participants are presented. These participants were filtered by our requirements, so information about their age is important. They are people who attend secondary education centers, have access to new technologies and an IQ suitable for inclusion centers. There are also people integrated into jobs, who use new technologies and who have adequate skills to carry out some activities. All these participants were part of both the user tests and eye tracking tests. For the objectivity of the tests, it is important that none of the participant have additional symptoms, aside from Down Syndrome and that none of the volunteers have diagnosed ADHD.

Table 5. Age of participants in the user test and eye tracking test.

Age Average 18.0 Rank 14.0 Variance 17.7 Typical deviation 4.2

The results of the tests must seem reliable to the public for whom the results are intended. Volunteers with a range of IQ between 50–70 were selected for the tests. A mild or moderate IQ will facilitate the conclusion of the tests. In addition, all volunteers must have a relationship with computers, for example, in their school or workplace. None of the participating users was new to the Internet. All those tested uses the Internet at least three times a week. This makes the resolution of the tests easier and it also makes the results more objective in terms of the need for website accessibility.

3.2.1. Web Test Methodology Before the tests, prototypes of how the user tests will be carried out were developed. To do this, certain requirements are extracted from the conclusions presented above and collated with author references. The web tests consist of the design of two websites, one accessible and the other inaccessible according to the recommendations included in the previous conclusions. Both websites have similar tasks to make comparison easier. The two websites have the same structure: one HOME page and five PAGES where the tests are hosted (Figure3). The user tests have text, audio, images, video with and without subtitles, configuration and a form. The results of the tests are extracted with quantitative data, measuring the reaction times of each user and finding temporary gains in the application of certain guidelines, but qualitative results are also extracted, according to the reactions of the users, their comments and their impressions after the tests. This was very useful to understand the level of frustration. Before beginning the tests, a script was designed with the dialogues and enough technical indications to be able to carry out the test. There is a script for the two tests, one for the web tests and another for the eye tracking tests. It is important to learn the memory dialogues, since its wording has been specially designed so that a person with Down Syndrome may understand the test without needing help. The script in paper format has a space on both sides to note possible interferences of linguistic comprehension during the tests, so if more than two people with Down Syndrome show a Sensors 2018, 18, 4047 11 of 39 lack of comprehension somewhere in the established script, it must be modified before continuing with the rest of the tests. While the users do the tests, they must indicate their step by step progress, to ensure that they understand the objective of the tests and to consider their speed of reaction and understanding. Their gestural or verbal responses were also annotated. This test is done individually and in a separate room. The users enter one by one and they are explained the content of the tests according to the script. The same order is not always used. Volunteers completed each of the tests in an arbitrary way, so that they do not learn from the experience and the results are more objective. The methodology and the arbitrariness of the tests vary with each subject, since each presents different needs from the rest. That is, not everyone participates in all the tests, or because their disability does not allow them to understand some of the sections, or because fatigue prevented them from continuing. It is considered that people with Down Syndrome are prone to distraction. The objectivity of the results could be altered if they are distracted by fatigue. For the performance of each test, users work on a specific page of the website resolving the tasks by their own means and narrating each of their steps in a loud voice. They are offered an assistant during the tests because one of the objectives of the research is that people can develop their own autonomy. The assistant cannot provide clues about the tasks, and only resolves doubts as to the meaning of buttons or phrases that the volunteer may not know. The volunteer is explained the meaning of those buttons and tools that may be more problematic, such as the CONFIGURATION button, before initiating each test. Help is offered to them to solve specific doubts in the understanding of the task during the tests. The users can use the time they wish to perform each of the tests, up to a maximum of 10 min per attempt. This time is proposed on the basis to the recommendations of the workers of the collaborating associations. According to the recommendations of the experts, if a volunteer takes a long time it is possible that they get tired and lose concentration, so as the time of each test depends on the speed of the user, breaks are offered between the tests so as not to exceed the anticipated maximum time. The tests are recorded on the computer with a screen recording software that provides information regarding the time and duration of each test. However, all tests are manually timed.

3.2.2. Eye Tracking Test Methodology In addition to the web tests, an eye tracking tool was used to verify that the retina of the users followed the prompts of the contents. One of the most representative physical characteristics of Down’s syndrome is the presence of slanted eyes. It is common to have visual deficit that causes loss of attention. In addition, they present difficulty in spatial representation, visuospatial orientation and planning. The visual deficit is linked to underlying problems related to other areas of cognition [21]. The testing of the eye tracking tests is done individually and in an independent room. The subject user must be seated in front of the computer screen and with the back straight without being able to move the head. This was a challenge for people with Down syndrome, since some had postural problems, so a laptop was used to be able to tilt the screen according to the needs of each user. For the tests, all screens of the two websites, website A (accessible) and website B (inaccessible) in the software were loaded. The test consisted of each user viewing each screen and responding to a series of location questions, for example: “look for the CONFIGURATION button”. The results provide statistical data of the total number of visual visits that a specific area of each of the screens presented; data on the response time of the retina to locate a specific area; and heat maps of the areas most visited by the retina of each subject. The user cannot move his head during testing. This is a challenge so tests were simulated before the true testing. The same eye tracking software does a pre-run check that verifies the characteristics of the retinas of each subject during simulation tests. Once the demanded objective is found, the user must say “I found it” out loud. For those subjects who presented communication problems, it was enough for them to make an approval sound indicating that they had found the indicated button, for example, many chose to say “already”. With this it is possible to configure and adjust the eye Sensors 2018, 18, 4047 12 of 39 tracking glasses to each user. The real tests start after the adjustments of the simulation tests. Two types of results are extracted from eye tracking tests:

• Statistical data, that record the global time that users take to locate a certain part of the website; • and heat maps, that registered the areas most reviewed by the users.

3.2.3. Multimedia Element Evaluation During the perception of multimedia content not only does one need to see and hear the content, but the user also needs to understand it [22]. The frontal lobe of Down syndrome subjects presents a reduced volume, larger microcolumns and fewer cells. This causes a lesser development of linguistic skills and memory, less ability for verbal work, memory problems and difficulties in abstract thinking, which can cause reasoning problems in long or complex sentences, and a low understanding of content with figurative meaning [17]. The Internet is one of the largest communication channels and demands discursive skills [12]. Subtitles that are too long or with more than three sentences can cause the same comprehension problems as complex words. The parieto-occipital-temporal lobe of people with Down syndrome has a normal volume but presents alterations of the microstructures of the pyramidal cell. This has negative effects on visual and/or facial recognition. For example, during a conversation between several participants, the difficulties in visual recognition and in the differentiation of the interlocutors can affect the understanding of the dialogues [16]. Memory is another skill demanded by the Internet [23,24]. The temporal lobe of people with Down syndrome has a reduced volume, a reduced number of granular cells and an alteration of the microstructure of pyramidal cells [25]. This causes less episodic memory, which can cause problems during the dialogue follow-up.

3.2.4. Multimedia Elements Test There were six trials on two websites for this test. This test is designed to determine which method of reproduction of multimedia content is most appropriate for people with Down Syndrome. For this, three trials will be carried out with 31 s long videos with the option of looping. The objective is for the user to pause the video when the content indicates it. For example, the narrator may say “pause the video when you see an apple”. This statement can be issued aurally, without a narrator, or verbally with and without a narrator. That is, the message is offered through audio and/or text:

• Audio + video + narrator. Audio + video. Tests 1–2: This essay consists of playing two files with audio and video. One of them with a visible narrator, and the other without visible narrator (Figures4 and5). • Audio + subtitles + video + narrator. Audio + subtitles + video. Tests 3–4: This essay consists of playing two files with audio, subtitles and video. One of them with a visible narrator, and the other without visible narrator. • Video + subtitles + narrator. Video + subtitles. Tests 5–6: This essay consists of playing two files without audio. One of them with subtitles and narrator visible, and the other with subtitles and no visible narrator.

The tests ask the user to perform a concrete action. It is concluded that the user has understood the test when the action is carried out efficiently. In this case, volunteers are expected to pause the file when they see a specific object. There were 25% of the users who do not finish the test when there is audio and no narrator. There was a 0% of users who do not finish the test when there is audio and a narrator. It can be concluded that the incorporation of a visible person inhibits the abstraction and helps the understanding of the content. The temporal gain visualizing a narrator is 166 s. The guideline 1.2.1 Audio-only and Video-only (Prerecorded), 1.2.8 Media Alternative (Prerecorded) and 2.2.2 Pause, Stop, Hide. The temporary gain applying these guidelines is 86.1% (Figure5). Sensors 2018, 18, x FOR PEER REVIEW 13 of 39 Sensors 2018, 18, x FOR PEER REVIEW 13 of 39 is for the user to pause the video when the content indicates it. For example, the narrator may say is“pause for the the user video to pause when theyou video see an when apple”. the This conten statementt indicates can it. be For issued example, aurally, the without narrator a maynarrator, say “pauseor verbally the videowith andwhen without you see a narrator.an apple”. That This is, st theatement message can is be offered issued through aurally, audiowithout and/or a narrator, text: or verbally with and without a narrator. That is, the message is offered through audio and/or text: • Audio + video + narrator. Audio + video. Tests 1–2: This essay consists of playing two files with • Audioaudio +and video video. + narrator. One of Audiothem with+ video. a visible Tests 1–2:narrator, This essayand the consists other ofwithout playing visible two files narrator with audio(Figure and 4–5). video. One of them with a visible narrator, and the other without visible narrator • (FigureAudio +4–5). subtitles + video + narrator. Audio + subtitles + video. Tests 3–4: This essay consists of • Audioplaying + subtitlestwo files +with video audio, + narrator. subtitles Audio and video+ subt.itles One + of video. them Tests with 3–4:a visible This narrator,essay consists and the of playingother without two files visible with narrator. audio, subtitles and video. One of them with a visible narrator, and the • otherVideo without + subtitles visible + narrator. narrator. Video + subtitles. Tests 5–6: This essay consists of playing two files • Videowithout + subtitles audio. One + narrator. of them Videowith subtitles + subtitles. and Tests narrator 5–6: visible,This essay and consists the other of with playing subtitles two files and withoutno visible audio. narrator. One of them with subtitles and narrator visible, and the other with subtitles and no visible narrator. The tests ask the user to perform a concrete action. It is concluded that the user has understood the testThe when tests askthe theaction user is to carried perform out a efficiently.concrete acti Inon. this It case,is concluded volunteers that are the expected user has tounderstood pause the thefile testwhen when they the see action a specific is carried object. out efficiently. In this case, volunteers are expected to pause the file when they see a specific object. Sensors 2018, 18, 4047 13 of 39

Figure 4. Multimedia test. Audio with and without narrato narrator.r. Without subtitles. “Pause the video when Figureyou seesee 4. anan Multimedia apple”.apple”. test. Audio with and without narrator. Without subtitles. “Pause the video when you see an apple”.

Sensors 2018, 18, x FOR PEER REVIEW 14 of 39

Audio-only and Video-onlyFigureFigure 5.5. AudioAudio(Prerecorded), ++ video + narrator.1.2.8 Media Audi Audio oAlternative + video. Test Test (Prerecorded) 1–2 results. and 2.2.2 Pause, Stop, Hide. The temporaryFigure 5. gain Audio applying + video +these narrator. guidelines Audio + is video. 86.1% Test (Figure 1–2 results. 5). AllThere the were test subjects 25% of ﬁnishedfinishedthe users thethe who test,test, do navigatingnavigating not finishWebsite Website the test A Awhen and and Website Websitethere is B. audioB. The The incorporation andincorporation no narrator. of of a narrator,aThere narrator,There was plus wereplusa 0% subtitles subtitles 25%of users of and theand who moreusers more do audio whoaudionot finishdo offers offers not the an finishan averagetest average thewhen test temporal temporal there when is gain theregainaudio ofof is 9and9 audio s.s.If Ifa comparedcomparednarrator. and no narrator.It with can the be Thereresultsconcluded was obtained athat 0% inofthe theusers incorporation previous who do test, not theof finish a temporal visible the test differenceperson when inhibitsthere is signiﬁcant.significant. is audiothe abstraction Whenand a subtitlesnarrator. and arehelpsIt can added thebe concludedtheunderstanding narrator that ceases ofthe the to incorporation becontent. essential The for temporalof the a understandingundersta visible gain ndingvisualizingperson of theinhibits a message. narrator the Applying abstractionis 166 s. The the and guideline helps 1.2.1 the understandingAudio-only andand of Video-only theVideo-only content. (Prerecorded), The (Prerecorded), temporal 1.2.3 gain Audio1.2. visualizing3 DescriptionAudio a Descriptionnarrator or Media is 166 Alternativeor s. MediaThe guideline (Prerecorded), Alternative 1.2.1 1.2.8(Prerecorded), Media Alternative 1.2.8 Media (Prerecorded) Alternative and(Prerecorded) 2.2.2 Pause, and Stop, 2.2.2 Hide Pause, there Stop, is a Hi temporaryde there is gain a temporary of 41.6% (Figuregain of 641.6%). (Figure 6).

FigureFigure 6.6. AudioAudio ++ subtitlessubtitles ++ video + narrator. Audio + subtitles subtitles + + video. video. Tests Tests 3–4. 3–4.

All (100%) of the users finished the tests without audio, with and without a visible narrator. The incorporation of a narrator plus subtitles and without audio offers an average temporal gain of 30 s. Audio is an important element during the inhibition of abstraction in multimedia content, especially when there is a narrator. The reduction of time of the test without audio using visible narrator and subtitles, fulfilling the guideline 1.2.1, 1.2.8, 2.2.2 is 43.7% (Figure 7).

Figure 7. Video + subtitles + narrator. Video + subtitles. Tests 5–6.

If all the tests are compared to each other, we can put for the several recommendations: 50.2% of the users understand the message more efficiently if there is a narrator, while 25.3% of the users understand the message with more efficiency if there are only subtitles. A 24.9% of users understand the message more efficiently if there are subtitles plus audio. No users understand the message if there is only audio plus a visual image, but without a narrator that provides audio (Figure 8). • The presence of a visible narrator disinhibits the abstraction when there is a file with audio. The temporary gain including a visible narrator to an auditory file is 86.1% with respect to the rest of the options.

Sensors 2018, 18, x FOR PEER REVIEW 14 of 39

Audio-only and Video-only (Prerecorded), 1.2.8 Media Alternative (Prerecorded) and 2.2.2 Pause, Stop, Hide. The temporary gain applying these guidelines is 86.1% (Figure 5). All the test subjects finished the test, navigating Website A and Website B. The incorporation of a narrator, plus subtitles and more audio offers an average temporal gain of 9 s. If compared with the results obtained in the previous test, the temporal difference is significant. When subtitles are added the narrator ceases to be essential for the understanding of the message. Applying the guideline 1.2.1 Audio-only and Video-only (Prerecorded), 1.2.3 Audio Description or Media Alternative (Prerecorded), 1.2.8 Media Alternative (Prerecorded) and 2.2.2 Pause, Stop, Hide there is a temporary gain of 41.6% (Figure 6).

Sensors 2018, 18, 4047 14 of 39 Figure 6. Audio + subtitles + video + narrator. Audio + subtitles + video. Tests 3–4.

All (100%) (100%) of of the the users users finished ﬁnished the the tests tests without without audio, audio, with with andand without without a visible a visible narrator. narrator. The Theincorporation incorporation of aof narrator a narrator plus plus subtitles subtitles and and withou withoutt audio audio offers offers an an average average temporal temporal gain gain of of 30 30 s. s. AudioAudio isis an important element during the inhibition of abstraction in multimedia content, especially whenwhen therethere isis aa narrator.narrator. TheThe reductionreduction ofof timetime ofof thethe testtest withoutwithout audioaudio usingusing visiblevisible narratornarrator and subtitles, fulﬁllingfulfilling thethe guidelineguideline 1.2.1,1.2.1, 1.2.8,1.2.8, 2.2.22.2.2 isis 43.7%43.7% (Figure(Figure7 7).).

FigureFigure 7.7. Video ++ subtitles + narrator. Video + subtitles. Tests 5–6.

IfIf allall thethe teststests areare comparedcompared toto eacheach other,other, wewe cancan putput forfor thethe severalseveral recommendations:recommendations: 50.2% of the users understand the message more efficientlyefficiently if there is a narrator, whilewhile 25.3%25.3% of thethe usersusers understand the message with more efficiencyefficiency ifif therethere areare onlyonly subtitles.subtitles. A 24.9% of users understand thethe messagemessage moremore efficiently efficiently if if there there are are subtitles subtitle pluss plus audio. audio. No usersNo users understand understand the message the message if there if isthere only is audio only audio plus a plus visual a visual image, image, but without but wi athout narrator a narrator that provides that provides audio audio (Figure (Figure8). 8).

• The presence ofof aa visiblevisible narratornarrator disinhibitsdisinhibits thethe abstractionabstraction whenwhen therethere isis aa ﬁlefile withwith audio.audio. The temporarytemporary gaingain includingincluding aa visible visible narrator narrator to to an an auditory auditory ﬁle file is is 86.1% 86.1% with with respect respect to to the the rest rest of theof the options. options. • The inclusion of subtitles and audio in parallel can affect the user’s attention. The temporary gain

suppressing subtitles is 41.6%. • When the audio is deleted, and the subtitles are preserved, the temporary gain is 43.7%. • During the test, looping of the multimedia files was allowed. The intention was to verify that a user reacts better to the message when he can pause and restart the video. It is verified that when a message is reproduced half-heartedly, without starting from the beginning, the user’s understanding is 0%. • Users show greater security in the face of the written text, especially if it is accompanied by a narrator. When only audio is broadcast many users were left bewildered. There was a 68% that showed frustration before the audio without a narrator and without written text. That frustration is manifested with gestures or sounds of displeasure. Record this percentage during the test was not intended as an objective, but it was considered interesting because there was a high percentage. All (100%) of the users demanded a “pause” button, and 87% restarted the video because they did not understand the message correctly during the first reproduction. Sensors 2018, 18, x FOR PEER REVIEW 15 of 39

• The inclusion of subtitles and audio in parallel can affect the user’s attention. The temporary gain suppressing subtitles is 41.6%. • When the audio is deleted, and the subtitles are preserved, the temporary gain is 43.7%. • During the test, looping of the multimedia files was allowed. The intention was to verify that a user reacts better to the message when he can pause and restart the video. It is verified that when a message is reproduced half-heartedly, without starting from the beginning, the user’s understanding is 0%. • Users show greater security in the face of the written text, especially if it is accompanied by a narrator. When only audio is broadcast many users were left bewildered. There was a 68% that showed frustration before the audio without a narrator and without written text. That frustration is manifested with gestures or sounds of displeasure. Record this percentage during the test was not intended as an objective, but it was considered interesting because there was a high

Sensorspercentage.2018, 18, 4047 All (100%) of the users demanded a “pause” button, and 87% restarted the 15video of 39 because they did not understand the message correctly during the first reproduction.

Figure 8. Evaluation 1. 3.2.5. Sound Evaluation 3.2.5. Sound Evaluation Down syndrome causes hearing impairments in the middle ear, which can cause hearing Down syndrome causes hearing impairments in the middle ear, which can cause hearing problems [23]. However, this would not be a problem if there were no problems with attention problems [23]. However, this would not be a problem if there were no problems with attention deficit. deficit. The attention deficit is caused by alterations in the cerebellum, frontal lobe and temporal The attention deficit is caused by alterations in the cerebellum, frontal lobe and temporal lobe [25][20]. lobe [20,25]. The tests ask the user to perform an action. It is concluded that the user has understood The tests ask the user to perform an action. It is concluded that the user has understood the test when the test when the action is carried out efficiently. In this case, volunteers are expected to go to the the action is carried out efficiently. In this case, volunteers are expected to go to the “tools” option “tools” option and change the background color. Since the word “tools” can be an abstract word, a text and change the background color. Since the word “tools” can be an abstract word, a text link that link that says “here” is used for this test. says “here” is used for this test. 3.2.6. Sound Test 3.2.6. Sound Test There were nine trials on two websites for this test. This test has been designed to determine the efficiencyThere were of dBnine control trials on of auditorytwo websites messages for this and test. background This test has noise, been issuingdesigned two to messagesdetermine that the inviteefficiency action: of dB one control reproduced of auditory at 15 messages dB with a and slight background background noise, noise, issuing and anothertwo messages at 15 dB that without invite backgroundaction: one reproduced noise, and the at same15 dB at 20with dB a and slight 50 dB.background On the other noise, hand, and two another types of at file 15 weredB without offered: onebackground with sound noise, adjustment and the same tools, at pause 20 dB options, and 50 etc.,dB. On and the another other thathand, played two type automatically.s of file were All offered: audios containone with messages sound adjustment that ask the tools, user topause complete options, a task. etc., In and this another way, listening that played is not automatically. only measured All in time,audios but contain also by messages understanding that ask the message,the user to Figures comp9lete and a10 task.. Alterations In this way, in listening, listening cognition is not andonly socialmeasured skills in of time, this but profile also may by understanding affect the use ofthe the mess Internet.age, Figures For example, 9 and 10. when Alterations a user searchesin listening, for Sensorsinformationcognition 2018, and18, or x FORsocial needs PEER skills to REVIEW memorize of this profile necessary may conceptsaffect the while use of browsing the Internet. [5]. For example, when 16a userof 39 searches for information or needs to memorize necessary concepts while browsing [5].

Figure 9. 15 dB message with a slight background noise with sound adjustment tools. Figure 9. 15 dB message with a slight background noise with sound adjustment tools.

Figure 10. Audio message: “Go to configuration and select the color (…)”.

There was a 16.7% of the test subjects that does not finish the hearing test of 15 dB. None of the subjects did not finish the test with a volume higher than 20 dB. The temporary gain by raising the volume is 118 s. People with Down syndrome have physical alterations that affect the ear and can cause hearing loss. However, according to surveys, only about 1% use a hearing aid. This test does not aim to help people with severe hearing problems, but it does want to help users with mild hearing problems. The reduction of time of the test fulfilling the criterion 1.4.7 Low or No Background Audio and using 20 dB, instead of 15 dB, is 82.73% (Figure 11).

Figure 11. Tests 14–15. Website A: 20 dB without a slight background with sound adjustment tools. Website B: 20 dB without a slight background noise without sound adjustment tools.

If all the results are compared, some conclusions can be drawn. There is a 37.0% of users that use audio settings. There is a 33.7% of users who do not use the audio settings but respond well to

Sensors 20182018,, 1818,, xx FORFOR PEERPEER REVIEWREVIEW 1616 ofof 3939

Sensors 2018, 18, 4047 16 of 39 Figure 9. 1515 dBdB messagemessage withwith aa slightslight backgroundbackground noisenoise withwith soundsound adjustmentadjustment tools.tools.

Figure 10. Audio message: “Go to configuration and select the color ( . . . )”. Figure 10. AudioAudio message:message: “Go“Go toto configurationconfiguration andand selectselect thethe colorcolor (…)”.(…)”. There was a 16.7% of the test subjects that does not finish the hearing test of 15 dB. None of the There was a 16.7% of the test subjects that does nott finishfinish thethe hearinghearing testtest ofof 1515 dB.dB. NoneNone ofof thethe subjects did not finish the test with a volume higher than 20 dB. The temporary gain by raising the subjectssubjects diddid notnot finishfinish thethe testtest withwith aa volumevolume highhigher than 20 dB. The temporary gain by raising the volume is 118 s. People with Down syndrome have physical alterations that affect the ear and can volume is 118 s. People with Down syndrome have physical alterations that affect the ear and can cause hearing loss. However, according to surveys, only about 1% use a hearing aid. This test does not cause hearing loss. However, according to surveys, only about 1% use a hearing aid. This test does aim to help people with severe hearing problems, but it does want to help users with mild hearing not aim to help people with severe hearing problems, but it does want to help users with mild hearing problems. The reduction of time of the test fulfilling the criterion 1.4.7 Low or No Background Audio problems. The reduction of time of the test fulfilling the criterion 1.4.7 Low or No Background Audio and using 20 dB, instead of 15 dB, is 82.73% (Figure 11). and using 20 dB, instead of 15 dB,dB, isis 82.73%82.73% (Figure(Figure 11).11).

Figure 11. TestsTests 14–15. 14–15. WebsiteWebsite A: A: 20 20 dB dB without without a a slight slight background background withwith soundsound adjustmentadjustment tools.tools. Website B:B: 2020 dBdB withoutwithout aa slightslight backgroundbackground noisenoise withoutwithout soundsound adjustmentadjustment tools.tools.

IfIf allall thethe the resultsresults results areare are compared,compared, compared, somesome some conclusionsconclusions conclusions caca cann be be drawn. drawn. There There is a is 37.0% a 37.0% of users of users that thatuse audiouse audio settings. settings. There There is a is33.7% a 33.7% of users of users who who do do notnot not useuse use thethe the audioaudio audio settingssettings settings butbut but respondrespond respond wellwell to to messages of 20–50 dB. There is a 29.39% of users that do not use the audio settings but respond well to

messages of 20–50 dB with a slight background noise (Figure 12).

• When a message is issued between 20 dB and 50 dB there is a temporal gain of 82.7%. • Background sounds cause incomprehension of the message. There was a 13% of volunteers with Down syndrome who do not understand a message issued at a normal volume of 20 dB or 50 dB with background noise. • Having control over volume and reproduction allows users to be autonomous, and 91% of the volunteers reproduced the audio more than once. Sensors 2018, 18, x FOR PEER REVIEW 17 of 39

messages of 20–50 dB. There is a 29.39% of users that do not use the audio settings but respond well to messages of 20–50 dB with a slight background noise (Figure 12). • When a message is issued between 20 dB and 50 dB there is a temporal gain of 82.7%. • Background sounds cause incomprehension of the message. There was a 13% of volunteers with Down syndrome who do not understand a message issued at a normal volume of 20 dB or 50 dB with background noise. • SensorsHaving2018, 18, 4047control over volume and reproduction allows users to be autonomous, and 91%17 of of the 39 volunteers reproduced the audio more than once.

Figure 12. Evaluation 2. Figure 12. Evaluation 2. 3.2.7. Textual Content Evaluation 3.2.7. Textual Content Evaluation People with Down syndrome may have problems during language learning and during communication,People with due Down to frontal syndrome and temporal may have lobe involvement.problems during These language problems learning can hinder and figurative during language,communication, abstract due language, to frontal non-literal and temporal language, lobe andinvolvement. discourse, These where problems the use of can episodic hinder memory figurative is requiredlanguage, [25 abstract]. Some language, websites use non-li theirteral own language, jargon, which and discourse, refers to a wh dailyere language the use of with episodic abbreviations, memory acronymsis required and [25]. Anglicisms. Some websites Thisincludes use their words own suchjargon, as LOL,which TIC refers oremoticons to a daily that language can lead with to comprehensionabbreviations, acronyms problems dueand toAnglicisms. the difficulty This that incl Downudes syndromewords such presents as LOL, with TIC abstraction. or emoticons that can lead to comprehension problems due to the difficulty that Down syndrome presents with 3.2.8.abstraction. Textual Content Test A test was designed to determine the importance of understanding complex words to people 3.2.8. Textual Content Test with memory difficulties. According to the surveys carried out during the research, it is concluded that 23.2%A test of was people designed with Downto determine syndrome the haveimportance comprehension of understanding problems complex always or words almost to always people consideringwith memory the difficulties. slang commonly According used duringto the surveys the navigation carried through out during the network.the research, For example,it is concluded when facedthat 23.2% with wordsof people like with Configuration, Down syndrome or abbreviations. have comprehension Three tests problems are carried always out for or this: almost always considering the slang commonly used during the navigation through the network. For example, • Unusual word + definition. Unusual word. Tests 16–17: an unusual word is included in a specific when faced with words like Configuration, or abbreviations. Three tests are carried out for this: text of the two websites. A definition is offered on a website at the same time as it is needed • (FigureUnusual 13 word). The + definition definition. is Unusual not included word. in Tests the other16–17: website. an unusual It is word concluded is included that itin offers a specific the definitiontext of the of two said websites. word at theA definition e moment is in offered which iton is a needed, website provides at the same the user time with as it a temporalis needed gain(Figure of 68.4%. 13). The definition is not included in the other website. It is concluded that it offers the • Abbreviateddefinition of said words. word Test at the 18: e moment the same in procedurewhich it is asneeded, in the provides previous the test user is with followed, a temporal but abbreviationsgain of 68.4%. are used instead of complex words. In one web the abbreviation is included • andAbbreviated in the other words. web the Test word 18: withoutthe same abbreviating procedure is as used. in the It is previous concluded test that is using followed, complete but words,abbreviations instead are of abbreviations, used instead of provides complex the words. user with In one a temporal web the gainabbreviation of 75.5%. is included and • Memoryin the other test, explanationweb the word 30 minwithout before. abbreviating Test 19: people is used. with It Down is concluded syndrome that are using affected complete in the frontalwords, lobe, instead responsible of abbreviations, for linguistic provides development the user with and memory.a temporal After gain analyzing of 75.5%. the benefits of • theMemory previous test, vocabulary explanation tests, 30 amin third before. test was Test carried 19: people out related with Down to the syndrome reading level. are affected in Sensorsthe 2018 frontal, 18, x FOR lobe, PEER responsible REVIEW for linguistic development and memory. After analyzing18 ofthe 39 benefits of the previous vocabulary tests, a third test was carried out related to the reading level.

FigureFigure 13. 13.Unusual Unusual word word + +definition. definition. TestTest 16. 16. To know that the test is finished an action is proposed. The unusual words used in this test are an To know that the test is finished an action is proposed. The unusual words used in this test are essential part of an activity statement. For example, “Configuration”. If the user does not understand an essential part of an activity statement. For example, “Configuration”. If the user does not their meaning, they will not be able to finish the test, so the objective is to seek a solution considering understand their meaning, they will not be able to finish the test, so the objective is to seek a solution considering complex language so that certain users can navigate without needing to understand it. As solutions to this problem we propose the immediate explanation to the complex word, text links above the concrete word or use of a simpler vocabulary. This profile has anomalous formations in the speech device. These alterations they cause pronunciation problems of lingual consonants, lip consonants and rounded vowels. The morphology and neurological development of the phenotype with Down syndrome may be related to atypical patterns that negatively affect the development of specific language. And to the storage and phonological recovery skills. They get used to simple words because of their memory and pronunciation [26]. None (0%) of those tested knew the word Configuration. In Test 1 Website A 100% of users completed the test with the definition of the unknown word. In Test 1 Website B 52% of the users did not finish the test because no definition was added. A 75% of users finished the test in an average time of 128 s and a 45% of users took more time to finish Test 1 on Website B compared to the Test 1 on Website A. There is an average temporal gain of 277 s when a textual explanation is added at the same time as it is required, as opposed to explaining the word >30 min before. People with Down syndrome have memory and attention problems, which affect the retention of concepts in the short term [20]. For this reason, it is better that the definitions be included at the time they are needed and not before. The reduction of time in the test fulfilling the criterion 3.1.3 Unusual Words is 68.4% (Figure 14).

Figure 14. Unusual word + definition. Unusual word. Tests 16–17.

There were 76% of users who do not complete the test during navigation on Website B with abbreviations. There is a temporal gain of 394 s when words are not offered with abbreviations. Of the people who successfully completed the test that did not contain an abbreviation 60% had negative results in the test that offered an abbreviation. Abbreviated words are difficult for people with Down syndrome because of their abstract reasoning. The reduction of the time in the test fulfilling criterion 3.1.4 is 75.5% (Figure 15).

Sensors 2018, 18, x FOR PEER REVIEW 18 of 39

Figure 13. Unusual word + definition. Test 16.

To know that the test is finished an action is proposed. The unusual words used in this test are Sensorsan essential2018, 18, 4047part of an activity statement. For example, “Configuration”. If the user does18 ofnot 39 understand their meaning, they will not be able to finish the test, so the objective is to seek a solution considering complex language so that certain users can navigate without needing to understand it. complexAs solutions language to this so problem that certain we propose users can the navigate immediate without explanation needing toto understandthe complex it. word, As solutions text links to thisabove problem the concrete we propose word the or immediateuse of a simpler explanation vocabulary. to the complex This profile word, has text anomalous links above formations the concrete in wordthe speech or use device. of a simpler These vocabulary. alterations This they profile cause has pr anomalousonunciation formations problems inof the lingual speech consonants, device. These lip alterationsconsonants theyand causerounded pronunciation vowels. The problemsmorphology of lingual and neurological consonants, development lip consonants of the and phenotype rounded vowels.with Down The syndrome morphology may and be neurological related to atypical development patterns of thethat phenotype negatively with affect Down the development syndrome may of bespecific related language. to atypical And patterns to the storage that negatively and phonologic affect theal recovery development skills. of They specific get language.used to simple And words to the storagebecause and of their phonological memory recoveryand pronunciation skills. They [26]. get used to simple words because of their memory and pronunciationNone (0%) [26 of]. those tested knew the word Configuration. In Test 1 Website A 100% of users completedNone (0%)the test of with those the tested definition knew of the the word unknow Configuration.n word. In Test In Test1 Website 1 Website B 52% A of 100% the users of users did completednot finish the the test test because with the no definition definition of thewas unknown added. A word. 75% Inof Testusers 1 finished Website Bthe 52% test of in the an users average did nottime finish of 128 the s and test becausea 45% of no users definition took more was added.time to Afinish 75% Test of users 1 on finished Website the B compared test in an averageto the Test time 1 ofon 128Website s and A. a 45%There of is users an average took more temporal time togain finish of 277 Test s when 1 on Website a textual B explanation compared to is theadded Test at 1 the on Websitesame time A. Thereas it is is required, an average as temporalopposed gainto explaining of 277 s when the word a textual >30 explanation min before. is People added with at the Down same timesyndrome as it is have required, memory as opposed and attention to explaining problems, the wordwhich >30 affect min the before. retention People of withconcepts Down in syndrome the short haveterm [20]. memory For this and reason, attention it is problems, better that which the defin affectitions the be retention included of at concepts the time in they the shortare needed term [and20]. Fornot thisbefore. reason, The itreduction is better thatof time the definitionsin the test befulfilling included the at criterion the time they3.1.3 areUnusual needed Words and not is before.68.4% The(Figure reduction 14). of time in the test fulfilling the criterion 3.1.3 Unusual Words is 68.4% (Figure 14).

FigureFigure 14.14. Unusual word ++ deﬁnition.definition. Unusual word. Tests 16–17.

There were 76%76% ofof usersusers whowho dodo notnot completecomplete thethe test duringduring navigation on Website BB withwith abbreviations. ThereThere isis a a temporal temporal gain gain of of 394 394 s whens when words words are are not not offered offered with with abbreviations. abbreviations. Of theOf peoplethe people who who successfully successfully completed completed the the test test that that did did not not contain contain an an abbreviation abbreviation 60% 60% hadhad negativenegative resultsresults inin thethe test that offered an abbreviation. Abbreviated words are difficultdifficult forfor peoplepeople withwith Down syndromesyndrome becausebecause ofof theirtheir abstractabstract reasoning.reasoning. The reduction ofof thethe timetime inin thethe test fulfillingfulfilling criterioncriterion 3.1.4 is 75.5% (Figure(Figure 1515).). If the results are compared, some conclusions can be drawn. It must be said that this comparison includes the results of another test that will be explained later because we considered that its results are useful for textual content too. There was a 29% of users that needed complete words and not abbreviations. There was a 26.3% that needed immediate definitions of certain words. There was a 24.7% of images with low level of iconicity that are preferred to text. No users preferred a lot of text, (Figure 16):

• Using a Secondary Education reading level there is a temporal gain of 51.4%. • By incorporating simple illustrations and with a low iconographic degree user can gain 64.3% of time. • Incorporating too much text can affect comprehension. During the reproduction of a message aloud, there was a 94.1% of volunteers who ignored words that consider additional information. Sensors 2018, 18, x FOR PEER REVIEW 19 of 39

Sensors 2018, 18, 4047 19 of 39

For example, in the phrase “click on the image when you see an orange”, the user remembers the word “orange”Figure and forgets15. Unusual the others.word + definition. He then responds Abbreviated to theword. oranges Tests 16–18. as soon as he sees them because he understands that the message is related to them. This does not mean however that the userIf the understood results are compared, the whole message.some conclusions can be drawn. It must be said that this comparison includes• Users the show results a lot ofof another frustration test that at incomprehensible will be explained words. later because There waswe considered an 86% that that showed its results their are usefulfrustration for textual by gesticulating content too. or emittingThere was sounds a 29% of of displeasure. users that Thisneeded response complete can words cause them and not abbreviations.to ﬁnish their There task, was and a 26.3% of course, that itneeded causes immediate their navigation definitio to bens unsatisfactory.of certain words. There was a 24.7%Sensors 2018of images, 18, x FOR with PEER low REVIEW level of iconicity that are preferred to text. No users preferred a lot of19 text, of 39 (Figure 16): • Using a Secondary Education reading level there is a temporal gain of 51.4%. • By incorporating simple illustrations and with a low iconographic degree user can gain 64.3% of time. • Incorporating too much text can affect comprehension. During the reproduction of a message aloud, there was a 94.1% of volunteers who ignored words that consider additional information. For example, in the phrase “click on the image when you see an orange”, the user remembers the word “orange” and forgets the others. He then responds to the oranges as soon as he sees them because he understands that the message is related to them. This does not mean however that the user understood the whole message. • Users show a lot of frustration at incomprehensible words. There was an 86% that showed their frustration by gesticulating or emitting sounds of displeasure. This response can cause them not to finish their Figuretask, and 15. Unusualof course, word it caus + definition. deﬁnition.es their navigationAbbreviated to word. be unsatisfactory. Tests 16–18.

If the results are compared, some conclusions can be drawn. It must be said that this comparison includes the results of another test that will be explained later because we considered that its results are useful for textual content too. There was a 29% of users that needed complete words and not abbreviations. There was a 26.3% that needed immediate definitions of certain words. There was a 24.7% of images with low level of iconicity that are preferred to text. No users preferred a lot of text, (Figure 16): • Using a Secondary Education reading level there is a temporal gain of 51.4%. • By incorporating simple illustrations and with a low iconographic degree user can gain 64.3% of time. • Incorporating too much text can affect comprehension. During the reproduction of a message aloud, there was a 94.1% of volunteers who ignored words that consider additional information. For example, in the phrase “click onFigure the 16.imag Evaluatione when 3. you see an orange”, the user remembers the word “orange” and forgets the others. He then responds to the oranges as soon as he sees 3.2.9. Content Design Evaluation 3.2.9.them Content because Design he Evaluationunderstands that the message is related to them. This does not mean however Thatthat the the user user understood knows what what the he he whole is is doing doing message. during during navigation navigation is is important important [8]. [8]. The The cerebellum cerebellum of ofa aperson• personUsers with with show Down Down a lot syndrome syndromeof frustration suffers suffers at incomprehensible from from hypopl hypoplasiaasia words.and and a a reducedThere reduced was number number an 86% of ofthat granulosa granulosa showed cells, their whichfrustration affectsaffects visuospatial visuospatial by gesticulating cognition, cognition, or emitting action action activities sounds activities of and displeasure. workingand working memory. This memory.response Working canWorking memory cause themmemory focuses not onfocuses attentionto finishon attentionand their operates task, and and operates in of seconds, course, in seconds, andit caus for andes that their for reason, thatnavigation reason, it is so toit importantisbe so unsatisfactory. important during during navigation navigation [23]. The[23]. alterationsThe alterations suffered suffered by the by parieto-occipital-temporal the parieto-occipital-temporal lobe affect lobe affect visual visual recognition. recognition. This can This cause can difficulties in understanding many web design elements [25]. It is concluded, therefore, that the design of a website can be a decisive factor in its understanding. In addition, the reduction of the frontal lobe can hinder abstract or figurative thinking, which makes it difficult to understand an icon if it does not incorporate an explanation [16].

3.3. Content Design Test This test is intended to determine the negative impact caused by a textured background. This test is carried out with eye tracking technology to analyze how the brain activity of volunteers responds to different web designs. We also wanted to determine if the labels are useful for people with neurological

Figure 16. Evaluation 3.

3.2.9. Content Design Evaluation That the user knows what he is doing during navigation is important [8]. The cerebellum of a person with Down syndrome suffers from hypoplasia and a reduced number of granulosa cells, which affects visuospatial cognition, action activities and working memory. Working memory focuses on attention and operates in seconds, and for that reason, it is so important during navigation [23]. The alterations suffered by the parieto-occipital-temporal lobe affect visual recognition. This can

SensorsSensors 2018, 18 2018, x FOR, 18, xPEER FOR REVIEW PEER REVIEW 20 of 3920 of 39 causecause difficulties difficulties in understanding in understanding many many web designweb design elements elements [25]. It[25]. is concluded, It is concluded, therefore, therefore, that that the designthe design of a website of a website can be can a dec be isivea dec factorisive factor in its understanding.in its understanding. In addition, In addition, the reduction the reduction of the of the frontalfrontal lobe can lobe hinder can hinder abstract abstract or figurative or figurative thinking, thinking, which which makes makes it difficult it difficult to understand to understand an icon an icon if it doesif it notdoes incorporate not incorporate an explanation an explanation [16]. [16].

3.3.Sensors Content3.3.2018 Content Design, 18, 4047 Design Test Test 20 of 39 This testThis is test intended is intended to determine to determine the negative the negative impact impact caused caused by a texturedby a textured background. background. This This testdifﬁculties, istest carried is carried suchout with asout Down witheye tracking eye syndrome, tracking technology and technology if theto analyze non-textual to analyze how contentthehow brain the is brain anactivity impediment activity of volunteers of volunteers or an aidto respondsthisresponds proﬁle. to different to different web designs.web designs. We also We wanted also wanted to determine to determine if the iflabels the labels are useful are useful for people for people with withneurological neurological difficulties, difficulties, such suchas Down as Down syndrome, syndrome, and ifand the if non-textualthe non-textual content content is an is an impediment• impedimentLabels. or Withoutan oraid an to aid labels.this to profile. this Tests profile. 18–19: The aim is to quantify the positive impact of a label. To do • Labels.• this,Labels. iconographyWithout Without labels. islabels. Tests used. Tests18–19: Two 18–19: testsThe aim are The done,is aim to quantifyis one to quantify without the positive the a label positive impact and theimpact of other a label. of witha label.To ado label.To do In this,the iconographythis, main iconography menu is the used. optionsis used.Two testsTwo are proposed aretests done, are done, one only without one with without icons a label ora andlabel icon the and + labelother the other (Figurewith awith label. 17 ).a label. TheIn timeIn theused mainthe to mainmenu perform menu the options the the icon options are comprehension proposed are proposed only test withonly with iconswith and iconsor withouticon or +icon label a label+ label(Figure is (Figure measured 17). The 17). time (FigureThe time 18 ). usedThis toused testperform to is perform also the done icon the in comprehensionicon a text, comprehension where abstractiontest wi testth andwith is without offeredand without a alone label a orislabel measured explained. is measured (Figure The (Figure time 18). used 18). to Thisperform testThis is test also the is textdone also comprehension donein a text, in a wheretext, where testabstractio with abstractio andn is withoutofferedn is offered alone a label aloneor isexplained. measured.or explained. The time The usedtime toused to performperform the text the comprehension text comprehension test with test andwith without and without a label a islabel measured. is measured.

FigureFigureFigure 17. Label 17. 17.Label Labelon website on onwebsite website A icon. AA Test icon. 18. Test 18.

FigureFigureFigure 18. An 18. 18. iconAn An on icon icon Website on on Website Website B without BB withoutwi athout label. a Test label. 19. Test Test 19. 19.

TheThe frontalThe frontal frontal lobe lobe reductionlobe reduction reduction of people of of people people with with Downwith DownDown syndrome syndromesyndrome hinders hinders their abstracttheir their abstract abstract thinking thinking thinking [24]. [24]. [24 ]. ThatThat isThat why is whyis itwhy is itdifficult it is is difficult difficult for them forfor them to understan to to understan understandd iconsd iconsif iconsthey if arethey if theynot are explained. arenot explained. not explained. For example, For example, For non- example, non- figurativenon-figurativefigurative representations, representations, representations, arbitrary arbitrary arbitrary schemes, schemes, schemes, motivated mo motivatedtivated schemes, schemes, schemes, pictograms pictograms pictograms or non-realistic or or non-realistic non-realistic figurativefigurativefigurative representations. representations. representations. In Webs In In Website Website B thereite B B there therewas wasa was 29.4%a a 29.4%29.4% of users ofof userswho didwho not did did finish not not finish the finish test the the due test test to due due to to incomprehensionincomprehensionincomprehension of the of of theicon. the icon. icon.There There There was wasa was 17.6% a a 17.6% 17.6% that does thatthat doesunderstanddoes understand the same the the sameicon same onicon icon Website on on Website Website B B B withwith awith label. a label. a label.There There There is an is average anis an average average temporal temporal temporal gain gainof gain 1 min of of 1 1 and minmin 6 and ands by 6incorporating s by by incorporating incorporating labels. labels. labels.The reduction The The reduction reduction of the time in the test fulfilling the guideline 1.1.1 Non-text Content and 2.4.6 Headings and Labels is 40.0% (Figure 19).

• No need to use scrollbars for text or images. Scrollbars for text or images. Tests 20–23. The aim was to quantify the negative impact of using too many components on the webpage. There were two webs, one that presents a long content on a single page that forces the user to use the scroll bar (Figure 20). The other website presents the same content but spread over several pages. In this case, text links are used. It is veriﬁed that the user completes the test in two ways: (1) Observing whether the user uses the scroll bar or supposes that the content ends to up where it can be seen; SensorsSensors 2018 2018, 18, 18, x, x FOR FOR PEER PEER REVIEW REVIEW 2121 of of 39 39 ofof the the time time in in the the test test fulfilling fulfilling the the guideline guideline 1.1.1 1.1.1 Non-text Non-text Content Content and and 2.4.6 2.4.6 Headings Headings and and Labels Labels is is 40.0%40.0% (Figure (Figure 19). 19). • • NoNo need need to to use use scrollbars scrollbars for for text text or or images images. .Scrollbars Scrollbars for for text text or or images. images. Tests Tests 20–23. 20–23. The The aim aim waswas to to quantify quantify the the negative negative impact impact of of using using t ootoo many many components components on on the the webpage. webpage. There There were were two webs, one that presents a long content on a single page that forces the user to use the scroll Sensors two2018, webs,18, 4047 one that presents a long content on a single page that forces the user to use the21 scroll of 39 barbar (Figure (Figure 20). 20). The The other other website website presents presents the the sa sameme content content but but spread spread over over several several pages. pages. In In thisthis case,case, texttext linkslinks areare used.used. ItIt isis verifiedverified ththatat thethe useruser completescompletes thethe testtest inin twotwo ways:ways: (1)(1) (2)ObservingObserving Verifying whether whether that the the userthe user user understands uses uses the the scroll scroll the content. bar bar or or supposes Thesupposes content that that tells the the users content content that ends ends the testto to up up has where where ended, it it thankscancan be be seen; thereseen; (2) for (2) Verifying theirVerifying participation, that that the the user user explains understan understan the importancedsds the the content. content. of their The The task, cont cont andentent askstells tells users them users tothat that leave the the totesttest a speciﬁchas has ended, ended, room. thanks thanks there there for for their their participat participation,ion, explains explains the the importance importance of of their their task, task, and and asksasks them them to to leave leave to to a a specific specific room. room.

FigureFigure 19. 19. Labels. Labels. Without Without labels. labels. Tests Tests 18–19. 18–19.

FigureFigure 20. 20. Website Website B B needing needing scrollbars. scrollbars. Images Images instead instead of of text. text. Test Test 23.23. 23.

A 70% of users had difﬁculties using the mouse and 85% of users use text links. There is an AA 70% 70% of of users users had had difficulties difficulties using using the the mouse mouse and and 85% 85% of of users users use use text text links. links. There There is is an an average temporal gain of approximately 22 s during navigation if the scroll bar is bypassed. That is, averageaverage temporal temporal gain gain of of approximately approximately 22 22 s s during during navigation navigation if if the the scroll scroll bar bar is is bypassed. bypassed. That That is, is, if you avoid long text or a list of images. In both tests the gain is similar. This is because people with ifif you you avoid avoid long long text text or or a a list list of of images. images. In In both both tests tests the the gain gain is is similar. similar. This This is is because because people people with with Down syndrome often have hypoplasia and orientation difﬁculties. That’s why they take more time. DownDown syndrome syndrome often often have have hypoplasia hypoplasia and and orientatio orientationn difficulties. difficulties. That’s That’s why why they they take take more more time. time. Breadcrumbs are a useful element for people with Down syndrome with some experience during BreadcrumbsBreadcrumbs are are a a useful useful element element for for people people with with Down Down syndrome syndrome with with some some experience experience during during navigation. However, it can become a distraction or an impractical textual component (Figure 21). navigation.navigation. However, However, it it can can become become a a distraction distraction or or an an impractical impractical textual textual component component (Figure (Figure 21). 21).

Sensors 2018, 18, 4047 22 of 39 Sensors 2018, 18, x FOR PEER REVIEW 22 of 39

Sensors 2018, 18, x FOR PEER REVIEW 22 of 39

Figure 21. Without need to use scrollbars, images.images. Scrollbars, images. Tests 22–23. Figure 21. Without need to use scrollbars, images. Scrollbars, images. Tests 22–23. The reaction time in this trial ma mayy also be due to physical barriers, in addition to the neurological ones. FromFromThe reaction thethe results results time of inof the thisthe surveys trialsurveys ma ity is alsoit concluded is be conc dueluded to that physical 51.8%that 51.8%barriers, of people of inpeople withaddition Down with to the syndromeDown neurological syndrome present difficultiespresentones. difficultiesFrom with the the results with use oftheof thethe use mouse.surveys of the Therefore,mouse.it is conc Thludederefore, anymeasure that any 51.8% measure that of avoidspeople that large avoidswith movementsDown large syndromemovements will be beneficial.willpresent be beneficial. difficulties The reduction The with reduction ofthe the use time of the in themouse.time test in fulfillingThtheerefore, test fulfilling the any guideline measure the guideline 2.4.4that avoids Link 2.4.4 Purpose large Link movements (InPurpose Context), (In will be beneficial. The reduction of the time in the test fulfilling the guideline 2.4.4 Link Purpose (In 2.4.5Context), Multiple 2.4.5 Ways,Multiple 2.4.8 Ways, Location 2.4.8 and Location 2.4.9 Linkand 2.4.9 Purpose Link (Link Purpose Only) (Link is 64.7%. Only) is 64.7%. Context), 2.4.5 Multiple Ways, 2.4.8 Location and 2.4.9 Link Purpose (Link Only) is 64.7%. • Context does not change. Context changes. Tests 24–25. Context changes can mislead the user. • ContextContext does does not not change. change. ContextContext changes. Test Testss 24–25. 24–25. Context Context changes changes can can mislead mislead the the user. user. The volunteer is asked to access a different page to continue with an activity. In one of the web TheThe volunteer volunteer is is asked asked to to access access aa differentdifferent page to to continue continue with with an an activity. activity. In In one one of ofthe the web web pagespages this this page page respects respects the the formatformat ofof thethe previouspreviousus one, one, the the user user knows knows th thatthatat he he is isin inthe the right right placeplace (Figure (Figure 2222). 22).). On On the the other other website website the back background,ground,ground, the the typography typography and and the the structure structure of ofthe the newnew page page are are different different fromfrom from thethe the ones onesones in inin thethe statementstatement and and generate generategenerate confusion, confusion,confusion, (Figure (Figure(Figure 23). 23 23). ). • Five element menu. Seven element menu. Tests 26–27: Understanding each element of a menu is • FiveFive element element menu. menu. Seven Seven element element menu.menu. Tests 26–27:26–27: UnderstandingUnderstanding each each element element of ofa menua menu difficult for a person with difficulties in abstraction. This test has two menus: in one there are is isdifficult difficult for for a aperson person with with difficulties difficulties in abstraction. This This test test has has two two menus: menus: in inone one there there are are fivefivefive elements elements and and in in the the other other seven.seven. It It is intendedintended to to find findfind out out if if the the number number of of elements elements affects affects understanding.understanding. The The test test is is shorter shorter thanthan thethe previous ones. ones. The The user user is is asked asked to to locate locate an an element element andand must must point point to to the the element. element. • • MonochromaticMonochromatic backgrounds. backgrounds. Textured Textured backgrou background.nd.nd. TestsTests Tests 28–29: 28–29: 28–29: The The The aim aim aim is is to toquantify quantify the the negativenegative impact impact caused caused by by a a textured textured background background onon a a person person with with Down Down Down syndrome. syndrome. syndrome. To To Todo do this, this, this, usersusers are are asked asked asked to to to locate locatelocate a a certain certain certain phrasephrase phrase on on two two websites,websites, websites, one one one with with with a awhite white a white background background background and and the and the theotherother other with with with a atextured atextured textured background, background, background, seesee see Figure Figure 24.24. 24 TheThe. The timestimes times of of ofthe the the four four four texts texts texts indicated indicated indicated in inthe the imagesimages are are timedtimed timed asas as T1,T1, T1, T2,T2, T2, T3T3 T3 andand and T4.T4.T4.

FigureFigure 22.22. StatementStatement context 1. 1. Tests Tests 24–25. 24–25. Figure 22. Statement context 1. Tests 24–25.

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FigureFigure 23.23. ContextContext change. Test Test 25. 25.

Figure 24. Test backgrounds on Website A and Website B. FigureFigure 24. 24.Test Testbackgrounds backgrounds on Website A and and Website Website B. B.

ThereThere is anis an average average motivational motivational indicator indicator ofof 33 s stronger stronger against against a amonochromatic monochromatic background background colorcolor because because it it does does not not interfere interfere with with thethe legibilitylegibility of the text. Less Less eye eye movement movement is isobserved observed in in the path of Website A (monochromatic background) than in Website B (textured background). thethe path path of Websiteof Website A (monochromatic A (monochromatic background) background) than than in Website in Website B (textured B (textured background). background). During During the tracking of Website B users registered greater brain activity. Probably when viewing so theDuring tracking the of tracking Website of BWebsite users registeredB users registered greater greater brain activity. brain activity. Probably Probably when when viewing viewing so many so many elements of distraction the user need more concentration. The reduction of time of the test elements of distraction the user need more concentration. The reduction of time of the test fulﬁlling the fulfilling the guideline 1.4.1 Use of Color, 1.4.6 Contrast (Enhanced), 1.4.8 Visual Presentation and guideline 1.4.1 Use of Color, 1.4.6 Contrast (Enhanced), 1.4.8 Visual Presentation and 3.2.2 On Input, 3.2.2 On Input, is 65.0% (Figure 25). is 65.0% (Figure 25).

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Figure 25. Monochromatic background. Te Texturedxtured background. Tests 28–29.28–29. Figure 25. Monochromatic background. Textured background. Tests 28–29. By comparing all content design trials, some conclusions can be drawn. A 26.9% of users use and understandBy comparing the all color content signals. design There trials, is asome 24.50% conc oflusions users whocan be surf drawn. better A with 26.9% a monochromaticof users use and background.understandBy comparing the There color all is content asignals. 22.6% design whoThere use trials,is labels.a 24.50% some There conc of userslusions is a 16.7% who can who surfbe drawn. preferbetter A menuswith 26.9% a withofmonochromatic users less use than and 5 items.background.understand There istheThere a 6.0%color is that asignals. 22.6% does who notThere present use is labels.a problems24.50% Ther ofe with usersis a a16.7% changewho whosurf of context.preferbetter menuswith There a iswithmonochromatic a 3.3% less that than has 5 noitems.background. problems There withisThere a 6.0% scroll is athat bars22.6% does (Figure who not usepresent26): labels. problems There is with a 16.7% a change who ofprefer context. menus There with is aless 3.3% than that 5 hasitems. no Thereproblems is a with6.0% scrollthat does bars not (Figure present 26): problems with a change of context. There is a 3.3% that •has noThere problems is a stronger with scroll motivation bars (Figure indicator 26): in a web with a monochromatic background. The temporal • gainThere when is a thestronger bottom motivation of the web indicator is monochromatic in a web is with 65.0%. a monochromatic background. The • There is a stronger motivation indicator in a web with a monochromatic background. The • Thetemporal color signalsgain when that highlightthe bottom or of transmit the web information is monochromatic are beneficial is 65.0%. for the user with neurological • temporal gain when the bottom of the web is monochromatic is 65.0%. deficit.The color The signals volunteers that gained highligh 71.4%t or of transmit time when information the content are offered beneficial informational for the colorsuser with (not • The color signals that highlight or transmit information are beneficial for the user with meaninglessneurological colors).deficit. The volunteers gained 71.4% of time when the content offered informational colorsneurological (not meaningless deficit. The colors).volunteers gained 71.4% of time when the content offered informational • Eliminating unnecessary elements in a webpage keeping only the menu, the toolbar and the • Eliminatingcolors (not meaningless unnecessary colors). elements in a webpage keeping only the menu, the toolbar and the • content (with title and navigation routes), helps to understand the web. A 32% of volunteers did contentEliminating (with unnecessary title and navigation elements routes), in a webpag helps toe understandkeeping only the the web. menu, A 32% the of toolbar volunteers and didthe not finish the tests in the web pages that contained more than five elements. notcontent finish (with the teststitle and in the navigation web pages routes), that contained helps to understand more than fivethe web.elements. A 32% of volunteers did • When there are design changes or content changes there is a 41% chance that the user will • Whennot finish there the are tests design in the changes web pages or content that contained changes more there than is a five41% elements. chance that the user will be • be wrong. wrong.When there are design changes or content changes there is a 41% chance that the user will be • There is a 68% of volunteers who show difficulties with the mouse, especially when there are • Therewrong. is a 68% of volunteers who show difficulties with the mouse, especially when there are • scroll bars. scrollThere bars.is a 68% of volunteers who show difficulties with the mouse, especially when there are • • Thescroll incorporation bars. ofof textualtextual contentcontent oror informativeinformative labelslabels reducesreduces browsingbrowsing timetime byby 40.0%.40.0%. • The incorporation of textual content or informative labels reduces browsing time by 40.0%.

Figure 26. Evaluation 4. Figure 26.26. Evaluation 4.

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3.4.3.4. FormForm EvaluationEvaluation CompletingCompleting aa formform effectivelyeffectively requiresrequires numerousnumerous neurologicalneurological activities,activities, suchsuch asas languagelanguage andand communicationcommunication (during(during thethe readingreading ofof thethe statementstatement andand response),response), short-termshort-term memorymemory (during(during thethe response),response), visuospatialvisuospatial ability (during the understa understandingnding of of the the structure) structure) [25] [25 ,27[27],], andand associationassociation (during(during thethe reasoning reasoning of of the the options) options) [25 [25][28].,28]. The The areas areas of theof the brain brain responsible responsible for thesefor these functions functions are theare frontalthe frontal lobe, lobe, the temporal the temporal lobe, lobe, the cerebellum the cerebell andum the and parieto-occipital-temporal the parieto-occipital-temporal lobe. Alllobe. of All them of arethem affected are affected in people in people with Down with Down syndrome syndrome [25]. [25].

FormForm DesignDesign TestTest ThereThere werewere fivefive trialstrials onon oneone websitewebsite forfor thisthis test.test. A user who has a deficitdeficit in working memory, inin abstractionabstraction and and in in comprehension, comprehension, is is very very likely likely to haveto have great great difficulty difficulty in filling in filling out aout form. a form. This This test istest designed is designed to determine to determine which which are the are most the understandable most understandable form fields form for usersfields withfor users Down with syndrome. Down Simplesyndrome. questions Simple and questions different and response different methods respon arese offered. methods The are time offered. spent, theThe completion time spent, of thethe testcompletion and the responseof the test offered and the are response valued tooffered know ar whiche valued the optimumto know which form field the optimum is. The aim form is to field verify is. whatThe aim the needsis to verify of a userwhat with the Downneeds of syndrome a user with are whenDown hesyndrome answers are forms. when The he aim answers is to verify forms. what The theaim needs is to verify of a user what with the Down needs syndrome of a user with are when Down he syndrome completes are forms: when he completes forms: •• ClickClick fieldfield 11 cm.cm. ClickClick fieldfield 0.50.5 cm.cm. TestsTests 30–31:30–31: thethe objectiveobjective isis forfor thethe volunteervolunteer toto answeranswer aa questionquestion byby choosingchoosing aa responseresponse fromfrom amongamong aa groupgroup ofof responses.responses. ToTo choosechoose thethe answer,answer, thethe volunteervolunteer mustmust clickclick onon itsits circumferencecircumference (Figure (Figure 27 27).). •• HelpHelp texttext disappears. disappears. Test Test 32: 32: the the objective objective is foris for the the volunteer volunteer to respond to respond freely freely in an in empty an empty field. Anfield. out-of-field An out-of-field instruction instruction is offered is offered and, in and, addition, in addition, a help a text help in text the in same the same field, field, but this but help this texthelp disappears text disappears when when the volunteer the volunteer clicks clicks inside inside it. it. •• Drop-downDrop-down field. field. Test Test 33: 33: the the objective objective is for is thefor volunteerthe volunteer to respond to respond through through a drop-down a drop-down menu. • Emptymenu. field. Test 34: the objective is for the volunteer to respond freely in an empty field. • TheEmpty question field. offersTest 34: the the instruction objective inis for the the same volunteer field, for to example respond “Name”, freely in butan empty that instruction field. The disappearsquestion offers when the the instruction volunteer clicks in the inside same it. field, for example “Name”, but that instruction disappears when the volunteer clicks inside it.

FigureFigure 27.27. ClickClick ﬁeldfield 11 cm.cm. ClickClick ﬁeldfield 0.50.5 cm.cm. TestsTests 30–31.30–31.

ByBy comparingcomparing all all the the form form field field design design trials, trials, some some conclusions conclusions can becan drawn. be drawn. Only Only 19.5% 19.5% of users of successfullyusers successfully hit in click hit in fields click if thefields space if the is lessspace than is 1less cm. than Only 1 16.5%cm. Only of users 16.5% answer of users the questionsanswer the if theyquestions do not if see they the do statement not see the or ifstatement the statement or if disappears.the statement Only disappears. 15.0% of usersOnly 15.0% could notof users hit in could click fieldsnot hit if in the click space fields was if less the thanspace 0.5 was cm. less Only than 13.6% 0.5 cm. of usersOnly use13.6% the of drop-down users use the field drop-down quickly. There field isquickly. a 14.8% There that demands is a 14.8% that that there demands be a preview that there before be aa field. preview For example,before a field. in a configuration For example, form. in a Thereconfiguration is a 12.4% form. of users There who is a read 12.4% all theof users options who offered read all to possiblethe options answers. offered There to possible is 8.2% answers. of users whoThere manage is 8.2% to of answer users who the questions manage to even answer though the their questions statement even disappears though their when statement they click disappears on them (Figurewhen they 28). click on them (Figure 28).

Sensors 2018, 18, 4047 26 of 39

•SensorsWhen 2018, 18 a, userx FOR must PEER clickREVIEW on a circle, he needs precision. The larger the circle, the less the risk26 of of39 failure. A 75.9% of the volunteers correctly clicked the 0.5 cm circle, and 98.5% of the volunteers • When a user must click on a circle, he needs precision. The larger the circle, the less the risk of correctly clicked the 1 cm circle. failure. A 75.9% of the volunteers correctly clicked the 0.5 cm circle, and 98.5% of the volunteers • Fields that include visible instructions and help text offer a temporal gain of 83.3%. correctly clicked the 1 cm circle. • • TheFields forms that withinclude drop-down visible instructions menu have and a highhelp leveltext offer of abstraction a temporal andgain that of 83.3%. makes it difficult • toThe understand. forms with Theredrop-down is a 30.5% menu of have volunteers a high wholevel cannot of abstraction click on and the answerthat makes when it difficult the menu to isunderstand. drop-down. There is a 30.5% of volunteers who cannot click on the answer when the menu is • Androp-down. empty form field that offers instructions inside is an advantage for the user. When these • instructionsAn empty form disappear field that when offers you clickinstructions inside, theinside temporal is an advantage gain is 41.7%. for the user. When these • Ainstructions form with disappear a list of visible when answers you click offers inside, a temporal the temporal gain ofgain 62.5%. is 41.7%. •• NotA form including with a list too of many visible options answers helps offers users a temporal with Downgain of syndrome62.5%. to choose an answer • moreNot including easily. too many options helps users with Down syndrome to choose an answer more • Theeasily. configuration of the form is useful for the user except when the user does not understand the • changesThe configuration that may occur. of the A form preview is useful helps for to the understand user except possible when changes the user and does reduces not understand browsing timethe changes by 74.8%. that may occur. A preview helps to understand possible changes and reduces browsing time by 74.8%.

FigureFigure 28.28. Evaluation 5.5.

3.5.3.5. Color Contrast Evaluation TheThe parieto-occipital-temporalparieto-occipital-temporal lobelobe ofof DownDown syndromesyndrome isis responsibleresponsible forfor visualvisual recognition andand undergoesundergoes alterationsalterations inin thethe microstructuremicrostructure ofof thethe cells.cells. ThisThis problemproblem causescauses bothboth colorscolors andand shapesshapes toto bebe confusingconfusing [[25].25]. This does not mean that the visual problems caused by the profileprofile are serious, butbut visualvisual interpretation interpretation can can be an be inconvenience an inconvenie [6,25nce]. In[25][6]. addition, In Downaddition, syndrome Down is characterizedsyndrome is bycharacterized attention problems. by attention The problems. incomplete The development incomplete of development the cerebellum of affectsthe cerebellum working affects memory, working which focusesmemory, on which attention focuses [20]. on A attention visual misinterpretation [20]. A visual mi cansinterpretation cause failures can and cause result failures in sub-par and result website in browsingsub-par website for people browsing with Down for people syndrome with Down [20,25 ].syndrome [25][20]. Color Contrast Test Color Contrast Test There were four trials on one website for this test. This test offers some websites with several There were four trials on one website for this test. This test offers some websites with several types of background color, button and text. We want to know which the most optimal contrast is and types of background color, button and text. We want to know which the most optimal contrast is and if there are colors that especially distract the attention of volunteers. The test asks the user to find four if there are colors that especially distract the attention of volunteers. The test asks the user to find specific elements within the page. The user must look for the same elements on all the websites. In four specific elements within the page. The user must look for the same elements on all the websites. this way avoiding alteration in the objectivity of the results, because it may be that the user tends to In this way avoiding alteration in the objectivity of the results, because it may be that the user tends look first at one side of the page. Or it may be that the user always traces with the same pattern. The to look first at one side of the page. Or it may be that the user always traces with the same pattern. time spent in finding the button demanded is measured. In addition, this test is performed with rest The time spent in finding the button demanded is measured. In addition, this test is performed with intervals and interspersed in other tests, to prevent the user from remembering the answers. rest intervals and interspersed in other tests, to prevent the user from remembering the answers. Five trials are carried out to test different background colors and button colors (Figures 29–33). The aim is to find out which contrasts are more suitable for users with Down syndrome. Eye tracking technology is used for these tests.

Sensors 2018, 18, 4047 27 of 39

Five trials are carried out to test different background colors and button colors (Figures 29–33). The aim is to ﬁnd out which contrasts are more suitable for users with Down syndrome. Eye tracking technology is used for these tests. Sensors 2018,, 18,, xx FORFOR PEERPEER REVIEWREVIEW 27 of 39

Figure 29. ContrastContrast testtest black. black. TestTest 35. 35.

Figure 30. Blue contrast test. Essay 36.

Figure 31. YellowYellow contrastcontrast test.test. TestTest 37.37. Figure 31. YellowYellow contrast test. Test 37.

Sensors 2018, 18, 4047 28 of 39

Sensors 2018,, 18,, xx FORFOR PEERPEER REVIEWREVIEW 28 of 39

Figure 32. TemporalTemporal resultsresults ofof thethe testtesttest withwithwith blackblackblack backgroundbabackground andand whitewhite letters.letters. Comparison of the timetime spent spent inin ﬁndingfindingfinding eacheach ofof thethe elements.elements. TestTest 35.35.35.

Time to First Fixation 30000 25000 20000 15000 10000 Miliseconds (ms) Miliseconds (ms) 5000 0

Areas of interest

Figure 33. White Contrast test. Test 38. Figure 33. White Contrast test. Test 38.

One can consult the statistics of preferences according to the contrast between background and letters in Figures 34 and 35:

• A blue foreground color # 3B29FA on a white background #FFFFFF (contrast 7.28:1) causes an attention span of 1891 s. • A close-up white color #FFFFFF on a blue background # 3B29FA (contrast 7.28:1) causes an attention span of 2925 s. • A color of foreground cyan # 00FFFF on a black background # 000000 (contrast 16.75:1) causes an attention span of 4270 s. • A close-up cyan color # 00FFFF on white background #FFFFFF (contrast 1.25:1) causes an attention span of 6533 s.

Sensors 2018, 18, 4047 29 of 39

• A black foreground color # 000000 on a yellow background # FFFF00 (contrast 19.56:1) causes an attention span of 7246 s. Sensors 2018, 18, x FOR PEER REVIEW 29 of 39

Sensors 2018, 18, x FOR PEER REVIEW 30 of 39 Figure 34. Evaluation 6.

One can consult the statistics of preferences according to the contrast between background and letters in Figure 34–35: • A blue foreground color # 3B29FA on a white background #FFFFFF (contrast 7.28:1) causes an attention span of 1891 s. • A close-up white color #FFFFFF on a blue background # 3B29FA (contrast 7.28:1) causes an attention span of 2925 s. • A color of foreground cyan # 00FFFF on a black background # 000000 (contrast 16.75:1) causes an attention span of 4270 s. • A close-up cyan color # 00FFFF on white background #FFFFFF (contrast 1.25:1) causes an attention span of 6533 s. • A black foreground color # 000000 on a yellow background # FFFF00 (contrast 19.56:1) causes an attention span of 7246 s.

3.6. Links Evaluation Figure 35. Links. Without Without links. Tracking Tracking buttons without links. Tests 39–41. The Internet demands some autonomy to reduce reaction times [25][29]. As with the color tests, 3.6.attention Links deficit Evaluation and problems during visual interpretation may affect the understanding of text links [16]. TheA text Internet link can demands be interpreted some autonomy as meaningless to reduce by a reaction user with times Down [25 ,syndrome.29]. As with This the would color tests, be a attentiondistraction. deﬁcit and problems during visual interpretation may affect the understanding of text links [16]. A text link can be interpreted as meaningless by a user with Down syndrome. This would beLink a distraction.Test There were four trials on two websites for this test. On the homepage of both websites several Link Test tests are listed. The user must to go to one of the tests. The test that is requested is chosen arbitrarily. In oneThere of the were websites four trials the onuser two is forced websites to forsearch this for test. the On demanded the homepage test in of the both menu websites because several the testsstatement are listed. does Thenot contain user must text to links. go to On one the of other the tests. website The testthere that are is text requested links. The is chosen text link arbitrarily. is found Inin the one statement of the websites of the test, the userso that is forcedthe user to can search click for on the the demanded text link at testthe same in the time menu they because are asked the statementto go to the does test. not The contain test is text concluded links. On when the other the websiteuser arrives there at are the text intended links. The page text (Figure link is found35). The in theobjective statement is to ofdetermine the test, so if thatthe links the user are canpercepti clickble on and the textuseful link for at theusers same with time Down they syndrome, are asked towith go toneurological the test. The and test motor is concluded difficultiesFigure when 36.(Figure the Links. user 36).Without arrives The links. atcerebellum the Tests intended 39–40. of Down page (Figure syndrome 35). Thesubjects objective has ishyperplasia, to determine and if thethis links causes are one perceptible to have orientation and useful difficulties for users with that Down prolong syndrome, your response with neurological time when clicking.It can be concluded that there is a 35.0% of users who do not navigate without text links to the rest of the route options. There is a 26.1% that does not understand its location without breadcrumbs. There is a 15.1% that cannot crawl with the mouse (Figure 37). • According to the surveys, there is a 51.8% of users with Down syndrome with difficulties using the mouse. • It is beneficial for navigation to avoid large movements. Links within the context provide a temporal gain of 64.7%. • That a website shows information about the location offers a temporal gain of 71.8%.

Figure 37. Evaluation 7.

Sensors 2018, 18, x FOR PEER REVIEW 30 of 39 Sensors 2018, 18, x FOR PEER REVIEW 30 of 39

Sensors 2018, 18, 4047 30 of 39

and motor difﬁculties (Figure 36). The cerebellum of Down syndrome subjects has hyperplasia, and this causes oneFigure to have 35. orientation Links. Without difﬁculties links. Tracking that prolong buttons your without response links. Tests time 39–41. when clicking. Figure 35. Links. Without links. Tracking buttons without links. Tests 39–41.

FigureFigure 36. 36. Links.Links. Without Without links. links. Tests Tests 39–40. 39–40. Figure 36. Links. Without links. Tests 39–40. It can be concluded that there is a 35.0% of users who do not navigate without text links to the It can be concluded that there is a 35.0% of users who do not navigate without text links to the rest ofIt thecan routebe concluded options. Therethat there is a 26.1%is a 35.0% that doesof user nots who understand do not navigate its location without without text breadcrumbs. links to the rest of the route options. There is a 26.1% that does not understand its location without breadcrumbs. Thererest of isthe a 15.1%route options. that cannot There crawl is a with26.1% the that mouse does (Figurenot understand 37). its location without breadcrumbs. There is a 15.1% that cannot crawl with the mouse (Figure 37). There is a 15.1% that cannot crawl with the mouse (Figure 37). •• AccordingAccording to to the the surveys, surveys, there there is is a a 51.8% 51.8% of of us usersers with with Down Down syndrome syndrome with with difficulties difﬁculties using using • According to the surveys, there is a 51.8% of users with Down syndrome with difficulties using thethe mouse. mouse. the mouse. •• ItIt is is beneficial beneﬁcial for for navigation navigation to to avoid avoid large movements. Links Links within within the the context context provide provide a a • It is beneficial for navigation to avoid large movements. Links within the context provide a temporaltemporal gain gain of of 64.7%. 64.7%. temporal gain of 64.7%. •• ThatThat a a website website shows shows information information about about the the location location offers offers a temporal gain of 71.8%. • That a website shows information about the location offers a temporal gain of 71.8%.

Figure 37. Evaluation 7. Figure 37. Evaluation 7.

3.7. Temporal Elements Evaluation As with color, visible elements that limit time increase distraction in people with Down syndrome. A chronometer distracts users with Down syndrome because its movement distracts their attention. This is so because the cerebellum causes the action activities to focus on the most prominent visual elements, which may be those that highlight the temporal elements. In addition, the deficit in working memory makes it difficult for navigation actions to end. The deficit of working memory is due to the reduction of the frontal and temporal lobe [25].

Temporal Elements Test There were two trials on two websites for this test. In both there is a simple questionnaire where users must choose several options simply by clicking. In a web this questionnaire is accompanied Sensors 2018, 18, x FOR PEER REVIEW 31 of 39 Sensors 2018, 18, x FOR PEER REVIEW 31 of 39 3.7. Temporal Elements Evaluation 3.7. Temporal Elements Evaluation As with color, visible elements that limit time increase distraction in people with Down syndrome.As with A chronometercolor, visible distracts elements users that with limit Down time syndrome increase becausedistraction its movement in people distracts with Down their syndrome.attention. This A chronometer is so because distracts the cerebellum users with causes Down the syndrome action activities because to focusits movement on the most distracts prominent their attention.visual elements, This is sowhich because may the be cerebellumthose that highlight causes th ethe action temporal activities elements. to focus In on addition, the most the prominent deficit in visualworking elements, memory which makes may it difficult be those for that navigation highlight actionsthe temporal to end. elements. The deficit In addition,of working the memory deficit in is workingdue to the memory reduction makes of the it difficultfrontal and for temporalnavigation lobe actions [25]. to end. The deficit of working memory is due to the reduction of the frontal and temporal lobe [25]. Temporal Elements Test Temporal Elements Test SensorsThere2018, 18 were, 4047 two trials on two websites for this test. In both there is a simple questionnaire 31where of 39 usersThere must were choose two several trials onoptions two websites simply by for clicking. this test. In In a both web therethis questionnaire is a simple questionnaire is accompanied where by usersa countdown must choose (Figure several 38-39). options On the simply other bywebsite clicking. ther Ine is a noweb countdown. this questionnaire The objective is accompanied is to quantify by by a countdown (Figures 38 and 39). On the other website there is no countdown. The objective athe countdown negative impact(Figure of38-39). visible On temporal the other elements.website ther Stopwatches,e is no countdown. countdowns The objective and interruptions is to quantify are is to quantify the negative impact of visible temporal elements. Stopwatches, countdowns and theconsidered negative temporaryimpact of visibleelements. temporal For the elements. test, tw Stopwatches,o websites arecountdowns proposed, and one interruptions with a visible are interruptions are considered temporary elements. For the test, two websites are proposed, one with a consideredchronometer temporary and the other elements. with an For invisible the test, chronome two websitester. The sizeare ofproposed, the visible one timer with occupies a visible 15% visible chronometer and the other with an invisible chronometer. The size of the visible timer occupies chronometerof the form to and ensure the otherthat users with seean invisibleit. The stopwatch chronome haster. a The pause size button. of the visible timer occupies 15% 15% of the form to ensure that users see it. The stopwatch has a pause button. of the form to ensure that users see it. The stopwatch has a pause button.

Figure 38. Visual temporal element. Test 43. Figure 38. Visual temporal element. Test 43.

Figure 39. Without and with a temporal element. Test 43. Figure 39. Without and with a temp temporaloral element. Test 43. There was a 13.3% of users who were able to finish the test with a visible chronometer. However, duringThere the wastest withouta 13.3% of time users limits who who all were were users able able finished. to to finis finish Thereh the the testis test an with with average a a visible visible temporal chronometer. chronometer. gain of 104 However, However, s when duringthe form the does test without not limit time the limitsbrowsing all users time. finished. finished. The reduction There is of an time average of the temporal test fulfilling gain of the 104 criterion s when the2.2.1 formform Timing doesdoes Adjustable, notnot limit limit the the 2.2.3 browsing browsing No Timing, time. time. 2.2.4 The The reductionInterruptions, reduction of timeof 2.2.5time of Re-authenticating the of the test test fulfilling fulfilling the is 52.5% criterion the criterion (Figure 2.2.1 Timing2.2.140). Timing Adjustable, Adjustable, 2.2.3 No2.2.3 Timing, No Timing, 2.2.4 Interruptions,2.2.4 Interruptions, 2.2.5 2.2.5 Re-authenticating Re-authenticating is 52.5% is 52.5% (Figure (Figure 40). 40).

FigureFigure 40.40. EvaluationEvaluation 8.8. Figure 40. Evaluation 8. By comparing all the results, several conclusions can be drawn. There is a 40% of users who cannot finish a task if there is a stopwatch that does not allow pausing. There is a 37.6% of users who do not finish the task if they cannot prolong the time. There is a 21.9% of users who do not finish the test if there is a temporary element visible (Figure 40).

• Without visible temporary elements, volunteers gain 52.5% of the time. • There is 97% of the volunteers who press the PAUSE button, stating they need to stop the stopwatch. • In trials where you cannot stop the time, 90% of users did not ﬁnish. Sensors 2018, 18, 4047 32 of 39

4. Conclusions and Recommendations

4.1. Recommendations From the results of the user tests, a series of useful recommendations for web developers is presented. These recommendations are divided into:

- Recommendations for playing multimedia elements - Recommendations for audio ﬁles - Recommendations for presenting the content - Recommendations for the design of forms - Recommendations based on color contrasts - Recommendations for links

These recommendations are based on user tests performed with people with Down syndrome. However, it is important to note that these recommendations are also applicable to other user profiles. People with Down syndrome have a set of symptoms that are also present in other users. For example, the explanation of unusual words in the text itself is useful for people with Down syndrome and for any other user with learning problems, or for users who do not know the language, or even people with low vision who use a screen magnifier [30]. In [30] W3C includes a list of possible beneficiaries for each of the success criteria.

4.2. Multimedia Elements Recommendations (1) During the tests of reproduction of multimedia files, it is concluded that it is preferable to use visual elements instead of auditory ones. This is due to the auditory attention deficit of the subject profile. It is recommended to avoid sign language or iconic language. This recommendation may contradict accessibility guidelines 1.2.3, 1.2.5 and 1.2.7 because the reproduction of auditory content may be abstract for users with Down syndrome. In the subtitle tests, we observed that subtitles and audio are more efficient at the same time. When there is more than one form of communication, it can confuse the user. This recommendation may contradict accessibility guideline 1.2.2 and 1.2.4 because the reproduction of audio and text at the same time may confuse a user with attention deficit and with short-term memory alterations. However, when an audio file does not include a visible narrator, it may be useful to include subtitles. (2) It is not recommended to play very long audios. It is also not advisable to add additional visual information to the audios, when said information is complementary and does not describe the main message. This recommendation may contradict criterion 1.2.7 because it is not advisable to offer two types of messages at the same time to people with short-term memory deficits (3) We observe that it is not recommendable that the multimedia files are reproduced automatically without the consent of the user. When this happens, users lose concentration and his deficit in short-term memory does not allow them to retain the content of the audio that was reproduced without warning (4) It is recommended to incorporate pause and restart buttons. During the navigation tests on the accessible website, users used these buttons. During the inaccessible website browsing, users clicked on the screen waiting for the audio to stop.

4.3. Sounds Recommendations (1) It is recommended to play audio files with a volume between 20 dB and 50 dB. A person with auditory deficit hardly listens to volumes below 20 dB and needs a lot of concentration to understand the message. A volume greater than 50 dB is a considerable auditive distraction and is not effective for the transmission of a message. Sensors 2018, 18, x FOR PEER REVIEW 33 of 39 Sensors 2018, 18, x FOR PEER REVIEW 33 of 39 4.3. Sounds Recommendations 4.3. Sounds Recommendations (1) It is recommended to play audio files with a volume between 20 dB and 50 dB. A person with Sensors(1) auditoryIt2018 is recommended, 18, 4047deficit hardly to play listens audio to files volumes with abelo volumew 20 betweendB and 20needs dB anda lot 50 of dB. concentration A person33 with of to 39 understandauditory deficit the message. hardly listens A volume to volumes greater than belo 50w dB20 isdB a considerableand needs a auditivelot of concentration distraction and to isunderstand not effective the for message. the transmission A volume ofgreater a message. than 50 dB is a considerable auditive distraction and (2) It is recommended that background sounds be four times quieter than the main one. It is observed (2) Itis notis recommended effective for the that transmission background of asounds message. be four times quieter than the main one. It is that if this is not fulfilled, there is a greater possibility that the message goes unnoticed. (2) observedIt is recommended that if this isthat not backgroundfulfilled, there sounds is a greater be four possibility times quieter that the than message the goesmain unnoticed. one. It is (3) It is recommended to add “pause” and “restart” buttons. During the navigation tests on the (3) Itobserved is recommended that if this tois notadd fulfilled, “pause” there and is“restart a greater” buttons. possibility During that ththee message navigation goes tests unnoticed. on the accessible website, users used these buttons. During the inaccessible website browsing, users (3) accessibleIt is recommended website, usersto add used “pause” these andbuttons. “restart Du”ring buttons. the inaccessible During the website navigation browsing, tests on users the clicked on the screen waiting for the audio to stop. clickedaccessible on website,the screen users waiting used for these the audiobuttons. to stop.During the inaccessible website browsing, users (4) ItclickedIt is is recommended recommended on the screen that that waiting the the content content for the of of audio the the messages messages to stop. be be understandable understandable and forceful. (4) It is recommended that the content of the messages be understandable and forceful. 4.4. Textual Content Recommendations 4.4. Textual Content Recommendations (1)4.4. TextualThe level Content of language Recommendations used is important for both comprehension and motivation. In the broadcasts (1) The level of language used is important for both comprehension and motivation. In the where we use complex words, abbreviations or technicalities, the volunteers dislike the broadcast. (1) broadcastsThe level ofwhere language we use used complex is important words, abbrevia for bothtions comprehension or technicalities, and the motivation. volunteers dislikeIn the It is recommended to avoid unusual, complex or technical words. thebroadcasts broadcast. where It is we recommended use complex to words, avoid abbreviaunusual,tions complex or technicalities, or technical words.the volunteers dislike (2) IntheIn the thebroadcast. case case of of using usingIt is recommended unusual unusual words, words, to it itavoi is is recommended recommendedd unusual, complex to to provide provide or technical a a textual textual words. definition definition within the (2) sameInsame the web webcase page. page.of using This This unusual definition definition words, can can itbe be is linkedlinked recommended to to a a text text link, link,to provide within within a the the textual same same definition text. text. within the (3) ItsameIt is is further further web page. recommended recommended This definition that that canthe the bedefinition definition linked to be a textdisplayed link, within while the the same meaning text. of the unusual (3) wordItword is further is is required required recommended (Figure 41).41 ).that the definition be displayed while the meaning of the unusual word is required (Figure 41).

Figure 41. TextualTextual content recommendation 3. Figure 41. Textual content recommendation 3. (1) It is recommended to avoid abbreviations as much as possible. (1) It is recommended to avoid abbreviations as much as possible. (2)(1) IfIt isabbreviations recommended are to used, avoid it abbr is recommendedeviations as much to provideas possible. a textual definition through a link (2) If abbreviations are used, it is recommended to provide a textual deﬁnition through a link (2) incorporatedIf abbreviations within are theused, same it isweb recommended page (Figure to42). provide a textual definition through a link incorporatedincorporated within within the the same same web web page page (Figure (Figure 42).42).

Figure 42. Textual content recommendation 5. Figure 42. TextualTextual content recommendation 5. (1) For the same reason it is recommended to use a Secondary Education reading level, with short (1) For the same reason it is recommended to use a Secondary Education reading level, with short (1) andFor consistent the same reason sentences it is of recommended less than 25 words. to use It a is Secondary recommended Education to avoid reading jargon, level, abstract with terms short and consistent sentences of less than 25 words. It is recommended to avoid jargon, abstract terms andand redundancies. consistent sentences of less than 25 words. It is recommended to avoid jargon, abstract terms and redundancies. (2) Itand is recommended redundancies. to avoid literary resources that can be confusing for the user. To generate this (2) It is recommended to avoid literary resources that can be confusing for the user. To generate this (2) recommendation,It is recommended we to used avoid metaphors literary resources in one of that the can tests. be The confusing volunteers for the did user. not Tounderstand generate thisthe recommendation, we used metaphors in one of the tests. The volunteers did not understand the metaphor,recommendation, so it is concluded we used metaphors that a literal in onelanguage of the is tests. preferable. The volunteers did not understand the metaphor, so it is concluded that a literal language is preferable. (3) Inmetaphor, the iconicity so it istest, concluded the volunteers that a literal were languageinterested is in preferable. the illustrations, however, they did not (3) showIn the muchiconicity understanding test, the volunteers of them. were Their interested results varied in the depending illustrations, on thehowever, degree they of iconicity, did not (3) In the iconicity test, the volunteers were interested in the illustrations, however, they did not show beingshow muchthe icons understanding with low level of them. of iconicity Their results and the varied recurring depending icons onor withthe degree descriptive of iconicity, labels much understanding of them. Their results varied depending on the degree of iconicity, being being the icons with low level of iconicity and the recurring icons or with descriptive labels the icons with low level of iconicity and the recurring icons or with descriptive labels simpler. It is recommended to include illustrations with low level of iconicity. This recommendation may contradict the usability criterion that indicates that the use of images increases speed during Sensors 2018, 18, 4047 34 of 39

navigation. It can also contradict the usability criterion that indicates that it is favorable to use standardized icons that replace the text, such as error, success and warning notiﬁcations. (4) In all the tests two fonts were offered: one textured and one monochromatic. All the results obtained were considered. It is recommended to use black text on a white background. (5) Several tests on subtitles were carried out. It is recommended to use a background color that highlights the text. In dialogues between several people it is recommended to use different colors with sufﬁcient contrast.

4.5. Form Design Recommendations (1) The proof of forms was very enlightening, since the effectiveness of the design of the ﬁeld of a form serves in the same way from a menu or for other functions. The most effective response ﬁelds are, in order of preference:

• Elements to click • Empty ﬁelds with visible instructions • Expansion menus • Empty ﬁelds with visible instructions until clicked

This recommendation may contradict the usability criterion which indicates that it is preferable to limit the initial explanations in the forms. It also contradicts the recommendation that if the explanation is necessary, it could be added using a link. For users with Down syndrome it is recommended that the ﬁelds of the form include initial explanations. In addition, it contradicts the usability criterion that indicates that the information requested must be limited, for example, by hiding optional parts or using expandable forms. For a user with Down syndrome with motor and neurological limitations, it is recommended not to use expandable menus or hidden options that may go unnoticed.

(2) It is recommended that the configuration forms include a list of predisposed options. For example, a menu to change the background color with various color combinations. That series of options cannot have more than five options. (3) It is recommended to offer previsualized configuration forms. It is recommended to use two previsualized, one previewed with the same button (for example a button with red background and white letters to change the colors of the web to red and white) and a second one previewed in the webpage itself so that the user understands what the change consists of. (4) It is recommended to try the changes at the request of the user do not imply a change of context. (5) It is recommended that the options of the forms have a size proportional to the visible space of the web page to avoid the use of scroll bars.

4.6. Contrast Recommendations (1) The color contrast test was performed using eye tracking technology. For this, it was necessary to offer different pages of the test website and wait for the retina of each volunteer to indicate the most striking aspects. This test is interesting, because Down syndrome is considered a proﬁle with an acute attention deﬁcit. The results of this test show those contrasts that kept your attention longer. The most effective color contrasts are, in order of effectiveness: blue button # 3B29FA on a white background #FFFFFF, white button #FFFFFF on blue background # 3B29FA, cyan button # 00FFFF on black background # 000000, cyan button # 00FFFF on white background # FFFFFF, black button # 000000 on yellow background # FFFF00. Sensors 2018, 18, 4047 35 of 39 Sensors 2018, 18, x FOR PEER REVIEW 35 of 39

4.7.Sensors Link 2018 Recommendations, 18, x FOR PEER REVIEW 35 of 39

(1)4.7.(1) LinkForFor Recommendationsthe the test test of links, different texts were offere offeredd with tests that invited users to access different pagespages related to the content of the text. It is recommended to incorporate the links within the (1) For the test of links, different texts were offered with tests that invited users to access different contextcontext and and include include their their purpose purpose (Figure 43).43). pages related to the content of the text. It is recommended to incorporate the links within the context and include their purpose (Figure 43).

Figure 43. Link recommendation 1. Figure 43. Link recommendation 1. This recommendation may contradict the usability criterioncriterion that states that if the content is too long, text links should be included. For example, with a link that says, “keep reading”. This type of long,This text recommendation links should be included. may contradict For example, the usability with a cr linkiterion that that says, states “keep that reading”. if the content This type is too of additional information may be abstract for a user with Down syndrome. It is recommended that the additionallong, text links information should be may included. be abstract For forexample, a user with Downa link that syndrome. says, “keep It is recommendedreading”. This thattype the of texts do not contain extended information because attention deficit and short-term memory make textsadditional do not information contain extended may be informationabstract for a because user with attention Down syndrome. deficit and It short-term is recommended memory that make the comprehension difficult. Text links are useful when their purpose is to help the user in their location, comprehensiontexts do not contain difficult. extended Text links information are useful becaus whene theirattention purpose deficit is to and help short-term the user in memory their location, make for example by clicking the “Cart” button. It is also recommended to avoid having an additional forcomprehension example by difficult. clicking theText “Cart” links are button. useful It when is also their recommended purpose is to to help avoid the havinguser in their an additional location, information redirect to a different page. informationfor example redirectby clicking to a differentthe “Cart” page. button. It is also recommended to avoid having an additional information(2) It is recommended redirect to a differentto add linkspage. to navigate to related web pages. This recommendation (2) It is recommended to add links to navigate to related web pages. This recommendation guarantees guarantees that users know how to get to where the page invites them to arrive. During one of (2) Itthat is usersrecommended know how to to add get tolinks where to navigate the page invitesto related them web to arrive.pages. DuringThis recommendation one of the tests, the tests, additional information was offered to complex texts. In the accessible web, they were guaranteesadditional informationthat users know was how offered to get to complexto where texts.the page In the invites accessible them to web, arrive. they During were offered one of offered a link that led to a page that explained the definition of the complex world, or the thea link tests, that additional led to a page information that explained was offered the definition to complex of thetexts. complex In the accessible world, or theweb, explanation they were explanation of the purpose of the page (according to the test). It was shown that these additional offeredof the purpose a link that of the led page to a (according page that toexplained the test). the It was definition shown of that the these complex additional world, links or the are links are useful as long as their usefulness is explained. explanationuseful as long of the as their purpose usefulness of the page is explained. (according to the test). It was shown that these additional (3) It is recommended to use breadcrumbs to offer information about the user’s location. This test links are useful as long as their usefulness is explained. (3) wasIt is like recommended the previous to one, use breadcrumbsbut the text statement to offer informationinvited the user about to thechange user’s the location. page to a This specific test (3) It is recommended to use breadcrumbs to offer information about the user’s location. This test pagewas like(Figure the previous44). one, but the text statement invited the user to change the page to a specific waspage like (Figure the previous 44). one, but the text statement invited the user to change the page to a specific page (Figure 44).

Figure 44. Link recommendation 3.

4.8. Temporal Elements RecommendationsFigure 44. Link recommendation 3.

4.8.(1) Temporal In this test, Elements a visible Recommendations temporal element was placed in one of the test websites. A high percentage of volunteers could not finish the test due to the level of distraction offered. It is recommended (1) InIn this this test, test, a a visible visible temporal temporal element element was was placed placed in one of the test websites. A A high high percentage to avoid unnecessary temporary elements. ofof volunteers volunteers could not ﬁnishfinish thethe testtest duedue to to the the level level of of distraction distraction offered. offered. It It is is recommended recommended to (2) It is recommended to offer the option to pause or prolong the time. The volunteers try to stop toavoid avoid unnecessary unnecessary temporary temporary elements. elements. the chronometer by pressing the page, so it is concluded that a button that allows the pause or (2) ItIt is is recommended recommended to to offer offer the the option to pause or prolong the time. The volunteers try to stop prolongation of time would be effective. thethe chronometer chronometer by by pressing pressing the the page, page, so so it it is is concluded that a button that allows the pause or (3) It is recommended to offer the option to deactivate or postpone interruptions, except those that prolongationprolongation of of time time would be effective. imply an emergency. (3) ItIt is is recommended recommended to to offer offer the the option option to to deactivate or postpone interruptions, except those that (4) It is recommended that the user loses data when his session expires. implyimply an an emergency. emergency. (4) It is recommended that the user loses data when his session expires. (4)4.9. LabelsIt is recommended Recommendations that the user loses data when his session expires.

4.9.(1) Labels The descriptions Recommendations were useful in all the tests, because the volunteers on multiple occasions need help to understand the tasks or the functions of a web. It is recommended to incorporate labels (1) TheThe descriptions descriptions were were useful useful in in all all the tests, because the volunteers on multiple occasions need to the icons. helphelp to to understand the taskstasks oror thethe functionsfunctions of of a a web. web. It It is is recommended recommended to to incorporate incorporate labels labels to (2) It is recommended to add descriptive headers. tothe the icons. icons. (3) It is recommended to add descriptive labels (Figure 45). (2) It is recommended to add descriptive headers. (3) It is recommended to add descriptive labels (Figure 45).

Sensors 2018, 18, 4047 36 of 39

(2) It is recommended to add descriptive headers. (3) It is recommended to add descriptive labels (Figure 45). Sensors 2018, 18, x FOR PEER REVIEW 36 of 39

Figure 45. Labels recommendation 3.

5. Conclusions For website accessibility to be effective, it is recommended to analyze the user profileprofile to which the web is directed. For this, their physical and neurological characteristics must be studied, relating each of them with the recommendations on accessibilityaccessibility and usability to verify their effectiveness. There are manymany studies that analyze through surveys the existing web needs of users with Down syndrome and and users users with with cognitive cognitive disabilities. disabilities. These These surveys surveys are are usually usually directed directed to a to very a very wide wide age agerange. range. This This type type of study of study is very is very useful useful to torais raisee awareness awareness in in society society and and about about the the importance importance of inserting thesethese peoplepeople in in activities activities that that require require the th usee use of computers.of computers. However, However, this this type type of study of study may havemay have limitations. limitations. The first The limitation first limitation is the ageis the range age thatrange is usuallythat is usually proposed. proposed. When theyWhen are they studies are directedstudies directed to students to students as they begin as they to analyzebegin to the anal useyze needs the ofuse 4 yearsneeds old. of 4 At years this old. age manyAt this people age many with cognitivepeople with disabilities cognitive have disabilities not yet have acquired not yet reading acqu andired writingreading skills,and writing necessary skills, during necessary navigation. during navigation.The second limitation is to try to meet these needs without having proposed a test of them. Users withThe cognitive second disabilities limitation areis to not try alwaysto meet aware these n ofeeds their without limitations having or proposed their needs. a test It is of possible them. Users that somewith cognitive of the questions disabilities answered are not by always people aware with Down of their syndrome limitations offered or their a non-objective needs. It is orpossible unrealistic that response.some of the For questions example, theanswered study carried by people out for wi thisth Down research syndrome shows that offered 42% ofa thenon-objective volunteers door notunrealistic present response. attention problems.For example, This the response study carried is not objective out for this considering research the shows attention that 42% deficit of thatthe characterizesvolunteers do the not profile. present This attention is demonstrated problems. inThis several response of the is tests not objective carried out considering in which a the considerable attention numberdeficit that of volunteerscharacterizes leave the theprofile. test unfinishedThis is demons becausetrated there in several is a visual of the element tests carried that distracts out in which their attention,a considerable but there number are questionsof volunteers that leave can be the very test usefulunfinished in terms because of opinion. there is For a visual example, element we were that interesteddistracts their to know attention, if users but with there Down are syndromequestions oftenthat can modify be very the configurationuseful in terms of theirof opinion. computers, For orexample, if they we use were the helpinterested button, to orknow if they if users feel isolatedwith Down in activitiessyndrome that often require modify a computer.the configuration In this research,of their computers, a survey was or conductedif they use thatthe help sought button, to obtain or if these they data,feel isolated in addition in activities to others that related require to the a needscomputer. that usersIn this have research, consciously a survey or believe was conducted they have. th Theat sought survey to had obtain no age these limit data, because in addition one of the to objectivesothers related was to to the know needs which that age users range have is moreconsci interestedously or believe in new they technologies, have. The which survey was had deduced no age tolimit be thatbecause between one 15–35of the years objectives old. was to know which age range is more interested in new technologies,On the other which hand, was deduced there are to also be that accessibility between and15–35 web years usability old. guidelines aimed at people withOn cognitive the other disabilities. hand, there However, are also accessibility there is currently and web no usability research guidelines that tests aimed and evaluates at people these with guidelines.cognitive disabilities. This was the However, number one there priority is current in thely research, no research since it that is considered tests and necessary evaluates to knowthese ifguidelines. the guidelines This was that the currently number exist one priority are effective. in the research, During the since tests it is we considered found some necessary contradictions to know betweenif the guidelines accessibility that andcurrently usability exist guidelines are effectiv ande. theDuring results the of tests our we tests. found For example,some contradictions we found a contradictionbetween accessibility between and criterion usability 1.2.3 guidelines “Description and ofth pre-recordede results of our audio”, tests. 1.2.5For example, “Audio description”we found a andcontradiction 1.2.7 “Extended between description” criterion 1.2.3 and “Description the results of of the pre-recorded tests on multimedia audio”, reproductions.1.2.5 “Audio description” Our results indicateand 1.2.7 that “Extended audio reproduction description” can and be abstractthe results and of difficult the tests to understand,on multimedia so any reproductions. auditory allusive Our informationresults indicate would that beaudio ineffective. reproduction It is concluded can be abst thatract including and difficult a visible to understand, narrator to so an any audio auditory file is 86.1%allusive faster information than a single would audio be ineffective. file. An audio It is concluded file below that 20 dB including or above a visible 50 dB causesnarrator a timeto an loss audio of 82.7%file is 86.1% compared faster to than an audio a single reproduced audio file. in An that audio interval. file below 20 dB or above 50 dB causes a time loss ofGuideline 82.7% compared 1.2.2 and to 1.2.4 an audio “Subtitles” reproduced also contradict in that interval. each other, since our results conclude that the projectionGuideline of1.2.2 a moving and 1.2.4 text “Subtitles” can be confusing also contradict for people each withother, attention since our deficit results and conclude short-term that memorythe projection problems. of a moving On the other text can hand, be itconfusing should be for noted people that with a text attention message deficit is more and useful short-term than an memory problems. On the other hand, it should be noted that a text message is more useful than an auditory one, as long as the text is short and direct. It is demonstrated that by eliminating audio and conserving subtitles, navigation is 2.1% faster than if audio and subtitles are played at the same time. In usability the guideline that states that the use of images can be useful for the speed of performance is contradicted, since we verify that the icons are difficult to understand. In the same way, the criterion that indicates that the information must be limited by means of expandable forms or by links

Sensors 2018, 18, 4047 37 of 39 auditory one, as long as the text is short and direct. It is demonstrated that by eliminating audio and conserving subtitles, navigation is 2.1% faster than if audio and subtitles are played at the same time. In usability the guideline that states that the use of images can be useful for the speed of performance is contradicted, since we verify that the icons are difficult to understand. In the same way, the criterion that indicates that the information must be limited by means of expandable forms or by links to other pages is contradicted. In the research it has been verified that this type of fields is confused and not very perceptible for users with Down syndrome. Regarding text links, they must be incorporated into the text itself. It is determined that in a drop-down field requires greater concentration because you need to display the hidden menu and click on one of the answers. There is a 68.6% of the volunteers that displays the menu and does not click on any answer. It is also determined that adding labels to the icons reduces the reaction time by 40%. In this research, contradictions have been observed between the WCAG 2.0 guideline and the usability guidelines and the results of the study tests. That is, not all existing guidelines are effective for users with Down syndrome. In addition, a series of useful accessibility and usability recommendations for people with Down syndrome are extracted. All tests, including surveys, were conducted with people with Down syndrome. The volunteers did not receive personal assistance during the tests or during the surveys. For this purpose, previous tests were carried out that determined the design, the wording and the level of difficulty most appropriate to the profile. The environment for the user tests was made based on the needs in the results obtained in the surveys. WCAG 2.1 has incorporated new guideline. Although the approval of the new guidelines is after our study, some approach our conclusions. For example, guideline 1.3.5 that suggests the possible benefits of a simpler webpage structure resembles our conclusions regarding the comparison of the two websites proposed for the study. Criterion 1.4.10 that aims to dispense with the scroll bar matches our results in terms of the content structure. The criterion 1.4.11, in contrast, that can be verified in our tests with eye tracking technology. Criterion 1.4.13 regarding hidden information can be linked to our tests with form fields. In Figure 46 we can see the time in seconds spent on the tests. These results are an average of all the trials. Each trial contained several tests to determine if the results were useful. The result of each of the trials is found in the paper itself. The longer time spent was less effective. One can compare the time spent on the two websites, the accessible website A and the inaccessible website B. A considerable temporary gain is observed in all the tests that are intended to be accessible. Time is important during website browsing, so we can conclude that following these proposed recommendations will offer an advantage to users with Down syndrome. Disability is a term that evolves, that depends on the context and that does not imply perpetuity. It is a relative term, so it depends on the web developers that there is a digital context in which there is no lack of capacity. This research has helped us understand the importance of knowing users well to meet their needs. All the tests have been designed specifically for this profile and the results have been favorable. Many of these tests are present in daily activities, such as filling out a form to request a medical consultation. For future work we would like to try the same tests but with daily activities. For example, analyzing websites of the administration, social networks or leisure. Knowing how our trials positively affect daily activities would be important for our research. Sensors 2018, 18, x FOR PEER REVIEW 37 of 39 to other pages is contradicted. In the research it has been verified that this type of fields is confused and not very perceptible for users with Down syndrome. Regarding text links, they must be incorporated into the text itself. It is determined that in a drop-down field requires greater concentration because you need to display the hidden menu and click on one of the answers. There is a 68.6% of the volunteers that displays the menu and does not click on any answer. It is also determined that adding labels to the icons reduces the reaction time by 40%. In this research, contradictions have been observed between the WCAG 2.0 guideline and the usability guidelines and the results of the study tests. That is, not all existing guidelines are effective for users with Down syndrome. In addition, a series of useful accessibility and usability recommendations for people with Down syndrome are extracted. All tests, including surveys, were conducted with people with Down syndrome. The volunteers did not receive personal assistance during the tests or during the surveys. For this purpose, previous tests were carried out that determined the design, the wording and the level of difficulty most appropriate to the profile. The environment for the user tests was made based on the needs in the results obtained in the surveys. WCAG 2.1 has incorporated new guideline. Although the approval of the new guidelines is after our study, some approach our conclusions. For example, guideline 1.3.5 that suggests the possible benefits of a simpler webpage structure resembles our conclusions regarding the comparison of the two websites proposed for the study. Criterion 1.4.10 that aims to dispense with the scroll bar matches our results in terms of the content structure. The criterion 1.4.11, in contrast, that can be verified in our tests with eye tracking technology. Criterion 1.4.13 regarding hidden information can be linked to our tests with form fields. In Figure 46 we can see the time in seconds spent on the tests. These results are an average of all the trials. Each trial contained several tests to determine if the results were useful. The result of each of the trials is found in the paper itself. The longer time spent was less effective. One can compare the time spent on the two websites, the accessible website A and the inaccessible website B. A considerable temporary gain is observed in all the tests that are intended to be accessible. Time is important during website browsing, so we can conclude that following these proposed recommendations will offer an advantage to users with Down syndrome. Disability is a term that Sensorsevolves,2018 that, 18, 4047depends on the context and that does not imply perpetuity. It is a relative term,38 so of 39it depends on the web developers that there is a digital context in which there is no lack of capacity.

Figure 46. Spent time.

This research has helped us understand the importance of knowing users well to meet their Author Contributions: needs. All the tests L.R.B.have workedbeen designed on the methodological specifically part.for this J.P.E. profile worked and on the the implementation. results have L.A.-V.been worked in the development and ﬁeld tests. R.G.C. worked on the global and methodological review of the paper. favorable. Many of these tests are present in daily activities, such as filling out a form to request a Funding: This research received no external funding.

Conﬂicts of Interest: The authors declare no conﬂict of interest.

References

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