Conversational agents are increasingly being introduced in healthcare to enhance access to healthcare and address limited healthcare resources. The aim of this study was to explore experiences of a conversational agent for symptom checking and triage tool assessing the urgency and appropriate level of care implemented in public healthcare from a cognitive accessibility perspective.With a Participatory Action Research approach this study includes: 1) A Participatory Cognitive Barrier Walkthrough in workshops with people with cognitive impairment (n=7), product owner representatives (n=4), and researchers (n=5), followed by a workshop for improvement suggestions; 2) A paired interview with healthcare system specialists (n=2).The data from the study was analysed using reflexive thematic analysis, resulting in five themes: ‘The design of the eHealth service created expectations that were not met during interaction; ‘The eHealth service uses a difficult language’; ‘The eHealth service trigger negative emotions and reactions’; ‘The layout and graphic design of the eHealth service is difficult and sometimes misleading’; and ‘The eHealth service lack in trustworthiness’. The findings show the importance of including people with lived experience of cognitive impairment, to expose and find solutions for cognitive accessibility issues

Background: The adoption of eHealth accelerated during the COVID-19 pandemic. Inequalities in the adoption of eHealth during the COVID-19 pandemic have been reported, but there are few such studies among people with impairment. Objectives: This study aimed to investigate self-reported use and difficulty in the use of eHealth before the COVID-19 pandemic compared to during late social distancing restrictions in Sweden, among people with and without impairment, as well as between different types of impairment. Methods: A cross-sectional survey was distributed twice by snowball sampling to people with self-reported impairment and a general population matched by age, gender, and county. Use and difficulty in the use of six eHealth services were compared between groups using chi-square test and logistic regression with year interaction terms, reported as odds ratio adjusted (aOR) for gender and age with 95% CI. Results: The surveys included 1631 (in 2019) and 1410 (in 2021) participants with impairment, and 1084 (in 2019) and 1223 (in 2021) participants without. Participants with impairment, compared to those without impairment, reported less use and more difficulty in booking health care appointments online, digital identification, and the Swedish national web portal for health information and eHealth services (1177.se), both before and during the pandemic (P = .003 or lower). Video health care appointments were the exception to this disability digital divide in eHealth as video appointment adoption was the most likely among participants with attention, executive, and memory impairments (interaction term aOR 2.10, 95% CI 1.30‐3.39). Nonuse and difficulty in the use of eHealth were consistently associated with language impairments and intellectual impairments. For example, language impairments were inversely associated with use of the logged-in eHealth services in 1177.se in 2021 (aOR 0.49, 95% CI 0.36‐0.67) and were associated with difficulty in the use of 1177.se in 2019 (aOR 2.24, 95% CI 1.50‐3.36) and the logged-in eHealth services in 1177.se in 2021 (aOR 1.89, 95% CI 1.32‐2.70). Intellectual impairments were inversely associated with the use of the logged-in eHealth services in 1177.se in 2021 (aOR 0.19, 95% CI 0.13‐0.27). Conclusions: This repeated cross-sectional survey study, including participants with diverse types of impairment and a control group without impairment, reveals persisting disability digital divides, despite an accelerated adoption of eHealth across the pandemic. eHealth services were not accessible to some groups of people who were identified as being at risk of severe disease during the COVID-19 pandemic. This implies that all people could not use eHealth as a measure of infection protection.

Accessible design enables participation in the digital society for everyone. However, cognitive accessibility is not well established within the field of web design. The International Classification of Functioning, Disability and Health (ICF) provides a descriptive framework that relates health conditions to functioning and participation. ICF Core Sets are purposefully tailored shortlists of ICF categories for describing functioning. The aim of this study was to develop an ICF core set for cognitive web accessibility to be used by web designers. ICF categories with relevance for cognitive accessibility were extracted and linked to the guidelines in the standard for cognitive accessibility: ISO 21801-1, followed by interpretation of the meaning of the ICF categories in relation to cognitive accessibility. The latter was outlined as practical advice for designers on design considerations for cognitive accessibility. The analysis was performed by an iterative back-and-forth process between the lived experiences of persons with cognitive impairments, the ISO-standard and the ICF. The ICF core set comprises 46 ICF categories with design considerations for cognitive accessibility. The ICF core set is suggested to facilitate understanding of the challenges in digital design that users experience and provide strategies to address cognitive accessibility, and thereby improve design outcomes.

“Digital participation” refers to being actively involved in the digital society and using information and communication technology, above all the internet. However, not everyone has access to this global network and the ability to use it. The aim of the study was to explore experiences of using the internet and digital participation among people with aphasia (PWA) in Sweden by analysing data from an online survey undertaken in 2021. Methods & Procedures: The study has a descriptive design using mixed methods. Sixty-four participants with self-reported aphasia and a reference group of 1116 members of the general public answered the same survey with questions related to internet use and the digital society. Answers from both groups to ten multiple-choice questions were analysed statistically, and the PWA’s answers to eleven open-ended questions were analysed using reflexive thematic analysis. Outcomes & Results: Quantitatively, the analysis showed that answers concerning internet use differed statistically significantly between the two groups. Qualitatively, the analysis identified two themes: “The internet imposes heavy demands” and “The internet provides opportunities”, with various sub-themes. Conclusions: PWA described how the internet is very demanding. However, they also reported positive experiences and confidence in the potential of the technology. Even so, the internet can be exclusionary, and it is important to ensure that facilitating factors are considered in the development of technology and technology-mediated communication, so that communication opportunities for PWA and others will be enhanced.

The Web Accessibility Directive (WAD) is part of the European Union’s work for digital inclusion. The WAD obligates that public sector bodies’ websites meet accessibility standards and provide an accessibility statement on the website informing about inaccessible content, and a feedback mechanism for reporting accessibility issues or requesting inaccessible content in an accessible format. The objective of this study was to evaluate how healthcare providers in Sweden have applied accessibility statements on their websites as regulated by law. A descriptive study using a mixed methods approach was conducted, by quantitative descriptive data analysis of the healthcare providers’ accessibility statements compliance to requirements and qualitative data analysis of the written information provided in the accessibility statement. All but one of the 37 evaluated healthcare providers published an accessibility statement. None of the healthcare providers fully met the requirements for accessibility statements, and no one complied with the intention of the law, i.e. to provide accessible health information and eHealth services. There was no or minor progress between the first and the latest published accessibility statement. The possibility to declare no or partial compliance with the law, or claim disproportionate burden, and the lack of enforcement procedures, risk producing symbolic actions e.g., publishing accessibility statements without intention to abide by the law. We suggest that the directives for accessibility statements should be advanced regarding comprehensiveness, understandability, and usefulness. It is suggested that the assessment protocol developed for this study may be used for future evaluations of accessibility statements.

The aim of this study was to describe prerequisites for online collaboration for user participation in co-design of online digital services as perceived by people with impairments and to develop requirements for how online collaboration should be designed to be accessible for all participants. An exploratory study was conducted in parallel to activities in two co-design projects. Researchers, accessibility experts, designers and 31 members of disability organisations participated. All participants had lived experience of impairments. Data was co-analysed by all participants using a qualitative thematic analysis with an inductive approach. Sixty-three requirements for accessible online collaboration were identified pertaining to four themes: digital tools and accessibility; preparation of an online collaboration activity; performing and participating in an online collaboration activity; and documenting and evaluating an online collaboration activity. Conclusion: the co-design process can be strengthened by transition to online collaboration, owing to the possibility of having more frequent interaction, economising the participants’ energy and the design process being more transparent. Using accessible online tools, careful planning, and meeting preparation, and establishing a trustful and convivial atmosphere during each activity, are the cornerstones for accessible online collaboration. People with impairment can participate in online collaboration if the activities meet accessibility requirements.

The aim of this study was to explore how people with impairments perceived the accessibility of information regarding the COVID-19 pandemic in Sweden and what improvements they suggest to ensure accessibility of information in future societal crises. The study had a descriptive design, involving interviews and focus group discussions with people with impairments and their representative organisations, alongside analysis of public crisis information websites. The results showed that while many people with impairments could use their usual information channels, other found that the adapted information they needed was missing and that the government agencies, regional healthcare organisations and local municipalities were unprepared to produce accessible information. In conclusion, society exhibited shortcomings in providing accessible information to people with impairments during the COVID-19 pandemic. The responsible authorities seemed unprepared to provide accessible information. Proactive planning and training are imperative to ensure the provision of accessible information in future crises.

Many services have become digitized in society, including health services. Although there are many advantages to eHealth services, some segments of the population cannot reap those benefits. Objectives: This study aimed to: 1- describe how people with intellectual disability use the internet in Sweden; and 2- understand the nature of the contextual and personal barriers these users face when trying to access eHealth services in particular. Methods: Data from the nationwide survey “Swedes with Impairment and the Internet 2021” (SMFOI-21) were extracted for a subsample of 154 people with self-declared intellectual disability. Results: Findings reveal that people with intellectual disability used the internet predominantly for entertainment purposes. Challenges arose in more complex online activities, like internet searches, logging into eHealth services, booking medical appointments, and financial transactions. Participants relied on support from family, guardians or staff to read, write, create and memorise passwords, understand content, or solve technical problems encountered. They expressed a desire to engage more independently in the digital society but faced barriers due to the cognitive requirements of using apps and the internet as designed by computer scientists, difficulties in navigating complex online processes, such as eHealth services, and a lack of accessible infrastructure. Conclusion: This research underscores the importance of improved accessibility, simplified interfaces, clearer instructions, and a supportive ecosystem to enhance their digital inclusion. It is a matter of people with intellectual disability being afforded equal rights to access health services.

The demand for user participation in design processes is increasing, and there is a need to formulate guidance on how to involve disabled users and their representative organisations. Their participation contributes an extreme user perspective to the design process. The aim of this study was to develop an empirically grounded framework for user participation in co-design processes, involving the users with wide range of characteristics. The study was theoretically grounded in ‘participatory design’ and ‘value sensitive design’ and used an exploratory study design with online workshops to iteratively collect and analyse data. All participants collaborated on an online Miro-board to identify themes and formulate guiding principles for the framework. We propose a framework consisting of three themes: participation fundamentals, participation ethics and participation practicalities, entailing 11 guiding principles. By applying this framework, the premises, methods and activities in the design process will be accessible to all participants, and user participation in design projects will become more transparent, equitable and easier to implement. It will enable all users, people with disabilities and others, to participate and contribute to a design that can be used by the widest range of people.