DIGITAL ACCESSIBILITY AND CHRONIC PAIN
Even though I have lived with a chronic pain condition for many years, it wasn’t until recently that I fully realized how my condition influences how I interact with websites, applications, and other digital content, and how there aren’t many resources available that talk about digital accessibility and chronic pain. Today, I will be sharing my tips for creating accessible digital experiences for users with chronic pain and how web accessibility can impact the lives of people with chronic pain.
FIRST, WHY DESIGN FOR CHRONIC PAIN?
Most digital accessibility guidelines are centered around specific disabilities or categories, such as low vision or cognitive disorders. However, designing for chronic pain is just as important as designing for other disabilities for some of the following reasons:
- While the exact number of people with chronic pain is unknown, there are many disabilities and chronic illnesses that have chronic pain as a component of the disorder/condition
- While chronic pain by definition is not a temporary condition, people can experience short-term pain for a variety of reasons including surgery or injury, and benefit from having easy-to-access tools and website.
- Many people who live with chronic pain are unable to have traditional employment opportunities or may receive disability benefits, so it can be difficult for them to upgrade to the latest and greatest technology, purchase assistive technology tools, or even meet with assistive technology specialists
- Designing for chronic pain often intersects with designing for the aging population
- Medications for chronic pain can impact fine motor skills and how the brain processes information
One of the ways that users can design for chronic pain is by including user personas in the design process that have chronic pain conditions. This can take the form of personas who have specific diagnoses as well as personas that may be undiagnosed or that live with chronic pain for a variety of reasons. In each of the sections of this post, I’ll be sharing the experiences of real people who live with chronic pain who are impacted by digital accessibility choices, as well as sharing my own personal experiences.
- Why Everyone Should Design For Chiari Malformation: My Talk At ID24 2020
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HAVE WEBSITES AND APPLICATIONS AVAILABLE ON MULTIPLE PLATFORMS
When accessing digital content, it’s beneficial to have the ability to access the same content across several different platforms or devices so that users can access it regardless of the device they are using. This can look like:
- Having an application available as a web app and as mobile applications so that users can switch to devices with a smaller/larger screen, or access an application when their device is unable to download the mobile app for whatever reason
- Allow users to listen to their digital books or audiobooks on a smart speaker like the Amazon Alexa so that they can access content without looking at a screen or using their hands
- Being able to upload documents from digital storage apps, i.e being able to upload homework to a course website from a cell phone
- Ensure that content is readable across a variety of display sizes
EXAMPLE USE CASES
CASE 1- USER RECOVERING FROM SURGERY
When I was recovering from surgery and had a scar on the back of my head/neck, it was extremely painful and impossible for me to use my cell phone, because I would have to bend my neck significantly so that I could see the phone screen and read text through the bifocal in my glasses. However, I was able to use my tablet because it had an adjustable stand and I could use it hands-free when it was rested on a flat surface, or I could have it closer to eye level and minimize movement of my neck. I could access all the same apps that I had on my phone while on my tablet and use a messaging app connected through my cell phone number to talk to my friends.
CASE 2- AVID READER WITH CHRONIC EYE PAIN
My friend lives with chronic eye pain that can make it difficult for them to focus on lines of text for extended periods of time. However, they love to read and one of their favorite things to do after a long day is relax with a good book. Since they want to minimize looking at a screen as much as possible, they use the Amazon Echo Dot to request audiobooks from their device’s library and use voice controls to navigate the book.
CASE 3- STUDENT WITH ME/CFS DOING THEIR HOMEWORK
A student I worked with was diagnosed with ME/CFS shortly before starting college and often found that they would have high pain levels and low energy levels by the end of the day, which would keep them from being able to do homework at their desk or on the computer due to joint pain. However, they are able to type on their phone with less pain by using autocorrect, keyboard shortcuts, dictation, and other tools. Since they do a lot of their homework on their mobile devices, it is helpful for the college course’s website to support mobile uploads and uploads from cloud services so that the student does not have to move to another device to turn in their homework.
- How I Use My Phone As Assistive Technology In Class
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AVOID AUTO-PLAYING MUSIC OR VIDEO CONTENT
Did you know that lights and sound can aggravate chronic pain for many people? While general accessibility guidelines recommend that users avoid auto-play content or having content with strobe or flashing lights, this is especially important for people who have conditions such as photosensitive migraine. Examples of ways to implement this include:
- Giving users the option to play music, instead of giving users music and having them figure out how to turn it off
- Disabling auto-play for video and gif content on social media
- Avoiding auto-play sidebar videos on websites
- Allowing users to select whether they want content on a given website or in a web browser to auto-play or not
EXAMPLE USE CASES
CASE 1- MAKING DINNER WITH PHOTOSENSITIVE MIGRAINES
I love to cook and bake and frequently browse the internet and social media apps looking for a new recipe that I can try. However, many websites include auto-play video content that can flicker, flash, or even contain strobing lights- all things that can trigger a migraine for me and keep me from being able to even have the strength to eat dinner. In this case, it’s helpful for websites to ensure that videos do not auto-play or there is an option to load websites without video content included.
CASE 2- AVOIDING SENSORY OVERLOAD ON AN EVENT WEBSITE
My friend who lives with a chronic pain disorder is on an event website looking for tickets to a dance performance when loud music suddenly starts to play through their speakers to promote another upcoming concert. My friend describes the loud music as making it feel like their brain is on fire, and they quickly turn off their computer- eventually, they go back on the event website with the speakers muted. Instead of having music auto-play, it would have been better if the website gave the user the option to listen to music while they browse the website and allowed them to preview the music on their own.
CHECK YOUR ANIMATIONS
Vertigo-associated disorders (also known as vestibular disorders) often involve chronic pain and can be further exacerbated by animations, flickering effects, or other movement on the screen. Some ways that designers can ensure that tools are inclusive of people with these disorders is by adding the following items to their product:
- Ensure that the website or application respects animation settings on the device, such as reduce motion or disabling auto-play
- Avoid infinite scroll for content whenever possible, especially parallax effects
- Add content warnings for items with strobe or flashing lights, and avoid having auto-play content that is overly shaky or that has strobe lights
- Allow users to view content in a smaller window instead of in full screen
EXAMPLE USE CASES
CASE 1- “VISUAL EARTHQUAKE”
A young student I worked with sent me a message asking how they could “disable the visual earthquake” that they were experiencing on a video streaming application. I wasn’t sure what this meant at first, until I learned that the application had pinned an auto-play video to the top of the screen that featured a lot of shaking, which would trigger a vertigo attack for them and be extremely painful. I ended up sending feedback to the application asking for the app to respect auto-play settings and to have them avoid having content that can trigger neurological or vestibular issues on their home screen, which is something that they agreed to do.
CASE 2- GETTING NAUSEOUS FROM CLASSWORK
When I was in high school, I tried to use a digital magnifying software to enlarge my classwork for one of my classes. What I didn’t realize at the time was that the screen magnification software could be very jittery and disorienting to look at for people with vertigo issues, and I briefly considered the possibility that I would have to throw up in my backpack because the rapid movements triggered a vertigo attack and made me feel extremely sick. Things like this happened a few more times before I learned that I could use the Lens view of the magnifying software to enlarge a smaller part of the screen, which worked a lot better for me and my vertigo.
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PROVIDE ALTERNATIVES FOR MOVEMENT-INTENSIVE TASKS
Some applications require users to do physical tasks in order to verify their identity, unlock a device, or to interact with another tool. This can be frustrating for users with chronic pain who may have a limited range of motion or who are in less-than-ideal light conditions, so it is critical that digital tools give users alternatives for tasks that would require movement. Some examples of this include:
- Allowing users to type in a password or complete other verification steps instead of using biometric data or movement
- For typing in passwords, give users the option to use an authenticator app instead of typing a password
- Ensure that there is support for dictation on keyboards
- Support auto-complete on forms and for passwords
EXAMPLE USE CASES
CASE 1- DIFFICULTY MOVING HEAD FOR MOVEMENT RECOGNITION
A popular social media app debuted a feature where users can verify that they are not a robot by rotating their head in multiple directions. A user with neck issues from disorders such as Ehlers-Danlos Syndrome, Craniocervical Instability, or Chiari Malformation would likely have trouble with completing this task as these disorders can contribute to a limited range of motion in the neck. In addition to providing this option, the social media app should have a clear way for users to choose another verification option such as answering a text message.
CASE 2- A FRIEND WHO IS TIRED OF TYPING
My friend who lives with Ehlers-Danlos Syndrome tries to limit typing whenever possible as it can aggravate pain in their fingers, wrists, and hands. While this isn’t the case for everyone who lives with this condition, my friend will always look for ways that they can avoid typing on their computer as well as their mobile devices. One of the tools that really helps them is the use of an authenticator app as part of two-factor authentication, as it allows them to be able to simply select an item on their phone screen instead of having to type in a lengthy password. It helps that their email is auto-completed into the username field as well.
CASE 3- USING A VOICE ASSISTANT WHEN TALKING IS TOO PAINFUL
Trigeminal neuralgia is a chronic condition that affects the trigeminal nerve of the face- activities such as eating, talking, or putting on make-up can trigger searing nerve pain that lasts anywhere from a few seconds to several minutes, though the condition can go into remission for long periods of time. When someone is dealing with a trigeminal neuralgia flare that makes it near impossible to talk, it helps to have the option to type in requests for virtual assistant apps instead of having to speak them- Google Assistant, Cortana, Amazon Alexa, and Siri all support these options.
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CONSIDER ALTERNATIVE COLOR SCHEMES
Bright lights can be disorienting for people with chronic pain, and many users will choose to adjust either environmental lighting or lighting on their device to help with this. Another popular tool involves enabling alternative color schemes that are built-in to the device. Ways that designers can consider alternative color schemes include:
- Supporting dark mode for websites and applications
- Examining how digital content looks with a high contrast or inverted color scheme
- Ensuring that graphics are easy to read and that elements such as text have good contrast against the background colors
- For devices, allow users to set screen tints or other filters to help with photosensitivity
EXAMPLE USE CASES
CASE 1- DARK MODE FOR EYE STRAIN
A lot of users with low vision as well as users with migraines will use dark mode as it helps them avoid eyestrain from bright displays, and also makes it easier to browse websites or applications in the dark. Dark mode is also helpful for reading for long periods of time, and many users will gravitate towards it as they do not want to deal with bright lights.
CASE 2- INTERN WHO USES HIGH CONTRAST DISPLAYS
When I interned at a major technology company, I chose to use a high-contrast display theme on my computer as it was easier for me to navigate highly visual applications. Not only did it help keep me from straining my eyes, but I also was able to adjust the angle of my head more easily so that I wasn’t constantly holding my neck at an unnatural angle trying to read a bunch of symbols.
CASE 3- STUDENT WITH GLAUCOMA WHO NEEDS AN INVERTED DISPLAY
One of my best friends has glaucoma and uses inverted colors on their device so that text is easier for them to read. They use an inverted display for almost everything, from social media to reading for class to designing their own website. Designers should ensure that vital information is not communicated by color alone, as my friend would likely be unable to see the different colors when their screen is inverted.
- Black Or White: Choosing Dark Mode For Low Vision
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ALLOW USERS TO READ INFORMATION IN MULTIPLE FORMATS
Chronic pain can contribute to a lot of other conditions including brain fog, processing issues, sensory impairments, and so much more. For this reason, it’s helpful to have information and web content available in multiple formats, which can include:
- Having transcripts and captions for audio and video content
- Writing video and image descriptions for social media
- Using simplified reading displays or text-to-speech to read text
- Giving users the option to save content for later
EXAMPLE USE CASES
CASE 1- FOLLOWING CURRENT EVENTS ON SOCIAL MEDIA
Following current events is very important to me, but there are many cases where I am unable to watch a video or understand what is going on in an image because I do not have a lot of mental energy or because I’m not sure if content contains strobe or flashing lights. I really appreciate it when creators or other users add image or video descriptions to their content that give a summary of important visual information, as this allows me to be informed about what is happening.
CASE 2- ENGAGING WITH A PODCAST
Two siblings have the same genetic condition and very different preferences for interacting with their favorite podcasts. Sibling 1 prefers to listen to their podcast on their phone because they find reading to be challenging, while Sibling 2 finds it difficult to focus when someone is talking and prefers to read whenever possible. By providing a transcript for podcast episodes, both siblings can engage with the podcast in a way that works well for them.
CASE 3- READING THE NEWSPAPER WITH A SIMPLIFIED DISPLAY
Reading the newspaper is a challenge for a family friend who has difficulty holding objects for more than a few seconds at a time, and they find it difficult to read the paper when it is flat on the table since the print is very small. A solution that works well for them is using a simplified reading display like Microsoft’s Immersive Reader, the iOS Reading View, or similar tools to read articles online in large print, or to have the articles read out loud to them.
- Writing Media Descriptions For Current Events: My Talk At Protest Access-A-Thon
- Five Ways To Simplify Reading With Technology
- Ways To Read Webpages Without A Traditional Screen Reader
ADDITIONAL CONSIDERATIONS FOR DIGITAL ACCESSIBILITY AND CHRONIC PAIN
- Make sure that links and buttons have a large target space and are easy to click on so that users don’t have to worry about missing a button
- Avoid having unnecessary countdowns, i.e “you have thirty seconds to enter this password”, as people may type slower
- Provide options for users to attend in-person events or to watch content online so that they can more easily participate
- Have increased spacing between lines so that it is easier to follow along with text