On Christmas Day, Brian Switzer thought he and his partner had been exposed to Covid-19. Switzer is a deafblind assistive technology instructor, so when he took a Covid test at home, he had to rely on his sighted partner for the entire procedure. “Even just unwrapping it, figuring out what the different features are, the directions, how to use it, all of that required being able to read the text on the box,” he told me on a recent video call.
Switzer’s experience reveals a glaring design flaw in the healthcare system: instead of being an integrated feature from the start, accessibility is an afterthought. If Covid tests were designed to be accessible for low-vision people, these designs wouldn’t just be relevant for this pandemic. They could also be replicated in other diagnostic devices like pulse-oximeters, glucose monitors, and pregnancy tests—all of which currently deliver results through visual cues. Not only would it make healthcare products more inclusive, but it would also bring more paying customers through the door.
Covid has made it all too clear that the most vulnerable people are even more at risk during the pandemic. “I’m a firm believer that you can tell a lot about a society looking at the groups that are least cared for,” says Bon Ku, the author of Health Design Thinking and the head of an innovative research lab at Thomas Jefferson University, where he created the first design thinking program at a medical school.
While this pandemic is far from over, Ku is already thinking about the next one. He and other experts say that the way we have currently designed Covid tests is reflective of the “reactive system” of American healthcare. But it doesn’t have to be that way.
Lost in translation
According to the National Federation of the Blind, more than 7 million Americans are visually impaired. Many have underlying conditions that make them more vulnerable and at risk of getting Covid, including cancer, diabetes, and other genetic diseases. Most people don’t have a testing site within walking distance, so at-home testing is often all that’s available. But nothing about the way at-home tests are designed is accessible.
A standard rapid test comes with several individually packaged items that are hard to distinguish from one another. The instructions are displayed in fine print. A precise number of droplets have to be squeezed into a tiny hole on the test stick. And to top it all off, the results come in the shape of a faint, pink line that can be impossible to distinguish against the white backdrop.
Some people have been using video apps like Be My Eyes and Aira, which connect low-vision users with sighted people who can see through their cameras and guide them through the process. At the end of January, Aira even announced a partnership with the National Federation for the Blind to provide a visual interpretation of COVID tests.
Arguably, though, these visual interpretation apps are nothing but a band-aid; they exist because someone designed a product that only works for non-disabled, sighted people, leaving low-vision individuals at the margins. Switzer, who works at the Perkins School for the Blind in Watertown, Massachusetts, says video apps are a necessary tool, but they don’t offer much privacy. “Ideally, we’d like for people with disabilities to open and use a product from beginning to end without relying on assistance from other people,” he says. “That would boost their confidence, make them more self-reliant, allow them more flexibility.”
Switzer describes deafblindness — a combination of sight and hearing loss — as a spectrum. He says he has a little white perception, which allows him to see bright lights when they are right in front of him. He uses a screen-reader and a braille display to communicate on the computer and a combination of hearing aids and a headset when we speak. As an assistive technology instructor, he is well acquainted with solutions that can help people with blindness or low-vision achieve independence in their career, but when it comes to his own personal health, these solutions still don’t exist.
For low-vision people to use a rapid test unassisted, every step needs to be rethought. According to Michael Wordingham, a policy officer at the Royal National Institute for the Blind in the UK, instructions would need to be available in alternative formats like braille, large text, and audio-led explainer videos. Packaging would also come with tactile markings and symbols to help people figure out which end to open first. (He notes tactile markers would be more efficient because over 80% of blind people don’t know how to read braille.)
Since the summer of 2020, Covid tests in the UK have been available with instructions in braille, audio, or large print. (This is not the case for U.S. test kits.) But when the time comes to deliver a precise number of droplets into the hole and interpret the results, the obstacles remain the same.
This isn’t a new challenge. Pregnancy tests are also lateral flow tests. Both use a strip of paper that absorbs a liquid and then translates the results into a visual pattern: in most cases, one line means negative, two lines means positive. Either way, the results can only be deciphered by sighted individuals.
In 2019, however, the RNIB collaborated with product designer Josh Wasserman to develop a pregnancy test prototype for low-vision people. The device uses a battery-operated motor that is activated by a chemical change and pushes up a bump on the surface of the product. If you’re not pregnant, you would feel nothing on the surface; if you are pregnant, you would feel a bump. (The product was designed so the cost would be the same as a regular pregnancy test.)
According to Martin Wingfield, RNIB’s head of brand, the same kind of technology could be used in the rapid Covid tests. In fact, Wingfield says the RNIB is currently in conversations with manufacturers to create a tactile Covid test. It’s an exciting promise, but if the pregnancy test prototype is any indication, taking the product to the market will prove challenging. It’s been three years since the prototype was unveiled, and the product has yet to be manufactured.
For Wingfield, manufacturers and healthcare companies that don’t invest in inclusive products are missing a huge business opportunity: “Blind and partially sighted people have a gigantic spending power,” he says. Designing more inclusive products could open the door for more customers. According to a 2020 report, people with disabilities worldwide control over $13 trillion in annual disposable income, giving healthcare companies a significant opportunity to expand their customer base.
However, bringing an accessible test to market could take a long time. In the meantime, instead of redesigning the actual test, designers could rework how results are translated. David Janka is a designer and lecturer at Stanford’s d.School. He suggests there may be a way to tap into our smartphones’ accessibility menu, which comes with a host of sensory elements like vibrations and sounds. In this case, the rapid test would remain the same flat stick, and low-vision people would use a separate device, most likely their phone, to interpret the results.
Once a medical student, Janka was part of a team that redesigned the bulky catheter into a discreet, portable product that gives those with urinary incontinence, including teenagers and young adults, a lot more independence and a higher quality of life. “There’s an interesting intersection with pregnancy testing or Covid testing,” says Janka. “It doesn’t always need to be private, but people should have a choice.” Janka admits that using the smartphone isn’t an ideal solution, as it can exclude some people. But it would give low-vision people the ability to interpret their results without having to rely on someone else.
To some extent, this technology already exists. Seeing AI is an app that uses the phone’s camera and AI vision to identify objects and colors, then audibly describe them for low-vision people. Switzer at Perkins says he uses it to differentiate between dollar bills, but the app can also interpret colors. He says the algorithm could be trained to read a Covid test the way it was trained to understand objects and colors. The concept could then be applied across a wide spectrum of testing and monitoring devices like CGM monitors and blood sugar tests, pulse oximeters, and, of course, standard pregnancy tests.
The fact of the matter is, healthcare products across the board need to be made more inclusive. And for this to happen on a consistent basis, accessibility needs to be baked in from the start of any public health project. For Mike Wordingham, the RNIB’s policy offer, this extends to the way we communicate about public health on social media to the way we design products. “This experience has shown how important it is that we need to get a design right for all those tests.”