Mark M. Uslan

Analysis: Including Visually Impaired Participants in Validation Design Studies of Diabetes Technology

In an article in this issue of Journal of Diabetes Science and Technology, Sherwyn Schwartz, M.D., presents a study to validate the design of the ClikSTAR® insulin pen from sanofi-aventis and demonstrates that the device can be used correctly by participants with diabetes. Concern with this article lies with the selection of participants, which was meant to reflect the intended audience for the insulin pen device but does not address the inclusion of visually impaired individuals, who comprise over 20% of the adult diabetes population. Visually impaired individuals need to be included as part of the intended audience for insulin administration technology, and manufacturers of these devices need to design their products for safe use by all people, including those who are visually impaired. The study demonstrated successful use of the ClikSTAR insulin pen in a population that did not include subjects with severe visual impairment. We believe that future validation studies for insulin administration technology should also include samples of visually impaired users and that visually impaired patients will embrace the use of insulin pens designed with their needs in mind.

Accessibility of blood glucose monitoring systems for blind and visually impaired people.

Blindness and visual impairment are prevalent among people with diabetes. Blood glucose monitoring systems (BGMSs) have revolutionized diabetes care, but none of the 30 or so commercially available monitoring systems was designed to be fully accessible to blind and visually impaired persons. Seventeen BGMSs were evaluated for accessible use by people who are blind or visually impaired. Features and functionalities (e.g., operating procedures, user interface design, device specifications, and computer interface capabilities) were examined and tabulated, as was usability and accessibility. A subset of these systems with the highest degree of accessibility was selected and thoroughly examined and tested. Additionally, 12 people who are blind or visually impaired and who were issued BGMSs by their physician or diabetes educator were interviewed and videotaped using their meters. Of the 17 BGMSs, only four had voice output capability, an essential component of accessibility for blind and visually impaired persons. The six BGMSs without voice output that had the largest display fonts were found to have few accessibility features for visually impaired persons. Users indicated that voice output and portability were desired attributes of an accessible BGMS. None of the BGMSs evaluated had all of the required accessibility attributes, including the four systems that had voice output capability. The four systems with voice output were much bulkier and heavier than those that did not have this capability. Recommendations are made for design and development of BGMSs that would increase effective usage by blind and visually impaired persons, including integrating text to speech and streamlining the blood glucose monitoring process.

Are Current Insulin Pumps Accessible to Blind and Visually Impaired People

Background: In 2004, Uslan and colleagues determined that insulin pumps (IPs) on the market were largely inaccessible to blind and visually impaired persons. The objective of this study is to determine if accessibility status changed in the ensuing 4 years. Methods: Five IPs on the market in 2008 were acquired and analyzed for key accessibility traits such as speech and other audio output, tactual nature of control buttons, and the quality of visual displays. It was also determined whether or not a blind or visually impaired person could independently complete tasks such as programming the IP for insulin delivery, replacing batteries, and reading manuals and other documentation. Results: It was found that IPs have not improved in accessibility since 2004. None have speech output, and with the exception of the Animas IR 2020, no significantly improved visual display characteristics were found. Documentation is still not completely accessible. Conclusion: Insulin pumps are relatively complex devices, with serious health consequences resulting from improper use. For IPs to be used safely and independently by blind and visually impaired patients, they must include voice output to communicate all the information presented on their display screens. Enhancing display contrast and the size of the displayed information would also improve accessibility for visually impaired users. The IPs must also come with accessible user documentation in alternate formats.

Blood Glucose Meters That Are Accessible to Blind and Visually Impaired Persons

Blood glucose meters (BGMs) that can be used nonvisually or with a visual limitation were introduced in the mid-1990s, but it was not until 2006 and 2007 that a new set of meters with accessibility features were introduced: Prodigy, Prodigy Autocode, and Prodigy Voice (Diagnostic Devices, Charlotte, NC), and Advocate and Advocate Redi-Code (TaiDoc, Taiwan). Accessibility attributes of the newly introduced BGMs were tabulated, and product design features were examined and documented. The Prodigy Voice was found to be the only one of these new BGMs that is fully usable by blind and visually impaired persons.

Accessibility Attributes of Blood Glucose Meter and Home Blood Pressure Monitor Displays for Visually Impaired Persons

The vast majority of diabetes-related self-management technology utilizes small visual displays (SVDs) that often produce a low level of contrast and suffer from high levels of reflection (glare). This is a major accessibility issue for the 3.5 million Americans with diabetes who have reduced vision. The purpose of this article is to gather comparative data on the key display attributes of the SVDs used in blood glucose meters (BGMs) and home blood pressure monitors (HBPMs) on the market today and determine which displays offer the best prospect for being accessible to people with reduced vision. Nine BGMs and eight HBPMs were identified for this study on the basis of amount of devices sold, full-functionality speech output, and advanced display technologies. An optical instrumentation system obtained contrast, reflection (glare), and font height measurements for all 17 displays. The contrast, reflection, and font-height values for the BGMs and HBPMs varied greatly between models. The Michelson contrast values for the BGMs ranged from 11% to 98% and font heights ranged 0.39–1.00 in. for the measurement results. The HBPMs had Michelson contrast values ranging 55–96% and font height ranging 0.28–0.94 in. for the measurement results. Due largely to the lack of display design standards for the technical requirements of SVDs, there is tremendous variability in the quality and readability of BGM and HBPM displays. There were two BGMs and one HBPM that exhibited high-contrast values and large font heights, but most of the devices exhibited either poor contrast or exceptionally high reflection.

Accessibility of Insulin Pump Displays to People With Low Vision

This letter serves as an update to the work performed in 2009 by Burton et al1 in determining the accessibility of available insulin pumps with a specific emphasis placed on the performance of the displays for individuals with low vision.

Accessibility of Blood Glucose Monitoring Systems for Blind and Visually Impadred People

In the U.S., there are about 17 million people with diabetes. Blindness and visual impairment is prevalent among people with diabetes. Blood Glucose Monitoring Systems (BGMSs) have revolutionized diabetes self care, but none of the 30 or so commercially available monitoring systems was designed to be fully accessible to blind and visually impaired persons. Seventeen (17) BGMSs were evaluated for accessible use by people who are blind or visually impaired. Features and functionalities — e.g., operating procedures, user interface design, device specifications, and computer interface capabilities — were examined and tabulated as was usability and accessibility. Additionally, twelve (12) people who are blind or visually impaired and who were issued BGMSs by their physician or diabetes educator were interviewed and videotaped using their meters. Of seventeen (17) BGMSs, only four (4) had voice output capability, an essential component of accessibility for blind and visually impaired persons. The six (6) BGMSs without voice output that had the largest display fonts were found to have few accessibility features for visually impaired persons. Users indicated that voice-output and portability were desired attributes of an accessible Blood Glucose Monitoring System. None of the BGMSs evaluated had all the required accessibility attributes, including the four systems that had voice output capability. The four systems with voice-output were much bulkier, heavier, and expensive than those that did not have this capability. Recommendations were made for development of BGMSs that would increase effective usage by blind and visually impaired persons, including integrating Text to Speech (TTS), streamlining the blood glucose monitoring process, and applying a “Universal Design” concept for future development so that BGMSs are usable by the widest possible array of users.

Blood Glucose Meter Usability for the Blind and Visually Impaired

Very few meters satisfy the needs of users with limited or no vision, a growing population among diabetics.