Exploring the Usability of Gaze-based Mobile Communication in Ghana

The first Global Report on Assistive Technology (AT) [47] found that 2.5 billion people need AT today, a figure likely to rise to 3.5 billion by 2050, yet in some countries, access is as low as 3% for those who need it. Therefore, many people are still without access to the AT they need to carry out activities of daily life, and this is especially true for the 28-49% of people globally with communication disabilities [30]. In the last decade, digital devices, and especially smartphones with accessible applications, have become increasingly important as AT for the billion of disabled people worldwide, as they offer a variety of tools that enable people to address access barriers experienced in daily life [7, 8, 51, 52, 60, 61]. In contrast to often more costly and less available dedicated assistive devices such as Braille readers or digital communication boards, low-cost Android smartphones are available in most of the Global South through a variety of different providers [49, 70]. However, to date studies looking at the use and impact of smartphone applications to support the needs of people with communication difficulties in the Global South are still relatively scarce [6, 18, 42].

 

Impaired speech makes communication challenging and is compounded by stigma, which can isolate or marginalise people [19, 71]. Often, people who have impaired speech will be understood by and communicate with and through trusted individuals, limiting their speech to others due to the risk of ‘failing’ to communicate within a social exchange, leading to a feeling of inferiority and reduced participation in the moment and cumulatively over time [16]. These issues can also be more pronounced in Ghana and other countries in the Global South where disability stigma and other systemic failures contribute to lack of access to support and subsequent further marginalization [27, 73, 74].

 

People with conditions such as Cerebral Palsy or Stroke can have very limited ability to articulate sounds or may not be able to form any or only some full words. When this is the case, gaze-based communication devices can provide a vital bridge to supporting communication [43]. When used, gaze-based technologies convert purposeful looking behaviours, such as gaze fixations and gaze transfers, to select text or icons on a screen [32, 55, 67], which can then be read aloud by the device.

 

In Ghana and other West African countries, there is a lack of trained Speech and Language Therapy services with trained therapists (SLTs), and poor access to communication-based assistive technologies [6, 29, 42, 74]. However, there is also a fast-changing technology infrastructure; providing new fundamental approaches to support people with communication difficulties in their day-to-day lives [37]. It should be noted that such new technological ecosystem can and should never attempt to replace the work of healthcare professionals, but it can offer the opportunity for cheaper and more flexible access to some ATs, an example being gaze-based AACs. Whilst gaze-based technologies are largely available in high-resource settings, they are rarely found in low-resource settings [42]. The vast majority of gaze-based technologies are, for many, prohibitively expensive. For example, the Tobii PCEye camera costs approximately £2000 and requires additional software and hardware, while ‘all in one’ hardware devices with eye gaze and software can frequently cost £8000 or more ¹. People who require these devices are often those from the most marginalised segments of society and, as a result of systemic injustice, including the unaffordable cost of the AACs they require, the ones with the least met needs [17, 42].

 

For people living with significant physical disability and who can utilise purposeful ‘looking’ behaviours [55], eye-gaze control technology is argued to support increased autonomy by providing access to computers and speech-generating communication software [28]. This technology may also enable increased environmental control and facilitate participation in a variety of activities, including using social media and listening to music, in addition to supporting communication [33]. Eye-Gaze technology normally utilises an infrared camera, which tracks and responds to eye movements in conjunction with specialist software and applications [72]. The technology enables a person to make selections when deliberately fixing their gaze on a target on the screen for a set period of time. Globally, there appears to be limited literature to support the decision for the most suitable candidates for eye gaze, and how it should be implemented [32].

 

In a thematic qualitative analysis of narrative responses from 126 professionals supporting people to use eye-gaze devices in the UK, key recommendations for incorporating eye-gaze control technology included: ensuring optimal seating and positioning, involving a multidisciplinary team, tailoring implementation and content to individual needs, engaging in regular practice sessions, supporting communication partners and consideration of motivation and personal preferences [33]. While the emergence of novel gaze-based applications on low-cost Android smartphones can potentially make such technologies more easier to access for people with severe communication disabilities in the Global South, previous studies have pointed to how infrastructural shortcomings and design which fail to account for contextual factors can hinder the ability of individuals to benefit from assistive applications on smartphone devices [6, 7, 10, 31, 49, 53].

 

Our study sought to evaluate the usability of the free smartphone application Look to Speak, a gaze-based AAC application available for the Android operating system for users with severe communication disabilities in Ghana. We believe that while our study is contextually specific, the problems that it explores have a much broader relevance both in relation to the deployment of traditionally high-tech ATs in the Global South, and more specifically the problem of accessing gaze-based AAC in resource-limited settings. Through training and evaluation sessions with 10 Ghanaian SLTs and 15 clients, we examined what are the barriers and facilitators that influence the effectiveness and impact of the application, to extrapolate implications for adoption of gaze-based smartphone-based AAC in the Global South. Our results show that while participants had positive opinions of Look to Speak, the application often failed to offer significant advantages for many users. These shortcomings were due to a combination of factors including sub-optimal choices in the design of the application, which are partially dictated by technological constraints but also due to inconsistency in interaction modalities, lack of supporting assistive technologies such as adaptive seating which are needed to offer appropriate postural support, and poor familiarity with gaze-based AAC from stakeholders, which made it difficult to evaluate the suitability of the technology compared to potential alternatives. Based on these results we provide recommendation for more context appropriate smartphone-based AAC applications, as well as broader implications around the need to integrate design-level and ecosystem-level considerations to support the adoption of gaze-based smartphone applications in the Global South.