Iterative Design and Field Trial of an Aphasia-Friendly Email Tool
Abdullah Al Mahmud, Jean-Bernard Martens · 2015 · ACM Transactions on Accessible Computing · doi:10.1145/2790305
Summary
This paper presents Amail, an email client specifically designed for people with aphasia—an acquired communication disorder typically caused by stroke that affects language comprehension and expression. Unlike existing AAC (Augmentative and Alternative Communication) tools that focus on immediate needs and short phrases, Amail targets the social communication functions that become increasingly important as people with aphasia move beyond the acute rehabilitation phase: maintaining relationships, sharing stories, and participating in social life. Amail's design addresses known challenges people with aphasia face with conventional email clients: complex menus, multiple windows, pop-ups, and the cognitive demands of composing text from scratch. Key features include a simplified four-button interface, a customizable mini-dictionary with categorized words and sentences (salutations, emotions, invitations, closings), the ability to copy words directly from incoming emails, text-to-speech support, and a photo-based address book. The design process involved iterative feedback from people with aphasia, their caregivers, and speech therapists over three major iterations. The researchers conducted a 3-month field trial with 8 participants with nonfluent (Broca's) aphasia, all post-stroke, ranging from 6 months to 4 years post-onset. Participants had moderate to severe impairments in writing and varying levels of reading, speaking, and comprehension difficulties. The mixed-methods evaluation combined usage logs, questionnaires, interviews, diaries, and analysis of actual email content. Participants were introduced to Amail gradually—starting with only reply functionality before adding composition features—reflecting the need for scaffolded learning with this population.
Key findings
All eight participants successfully learned to use Amail independently, and seven continued using it throughout the 3-month study period. Four participants were still using Amail four months after the study ended. Participants composed messages averaging 14 words in length over approximately 10 minutes of composition time. Critically, 85% of words came from the mini-dictionary, 5% were copied from incoming emails, and only 5% were typed manually—validating the design decision to provide vocabulary support rather than relying on free-form typing. Subjective ratings improved significantly from month 1 to month 3 across multiple dimensions, with the largest effect observed for perceived independence (7 of 8 participants showed improvement). Participants expressed that Amail helped them communicate without relying on partners to compose messages on their behalf. Email partners (24 respondents across the 8 participants) rated their understanding and satisfaction with received messages at 5.4 and 6.0 respectively on 7-point scales, and many noted gradual improvement in their aphasia partners' communication. The study revealed that people with aphasia tend toward passivity and require external stimulation to initiate communication. Self-initiated messages remained rare even after three months; participants were more likely to reply than compose new emails. Social networks expanded during the study—some participants added new email partners and began mutual exchanges with others at their local aphasia center. The asynchronous nature of email proved particularly valuable: it allowed time to compose without the pressure of real-time conversation, letting participants communicate things they couldn't express by phone.
Relevance
This research demonstrates that accessible communication tools can meaningfully improve social participation for people with acquired cognitive-linguistic disabilities. For accessibility practitioners, the study offers several transferable insights: the importance of vocabulary scaffolding over open text entry, the value of asynchronous communication for populations who need extra processing time, and the necessity of gradual feature introduction during training. The finding that dictionary-based composition worked well—with users copying and sometimes editing standard phrases—suggests a design pattern applicable to other populations with language difficulties, including people with intellectual disabilities, dementia, or limited literacy. The study also highlights that adoption success depends heavily on the communication partners: training partners to write simple sentences and ask direct questions was essential. For organizations serving people with aphasia (estimated at 25-40% of stroke survivors), the research validates email as a therapeutic tool that can simultaneously maintain social connections and provide language practice. The request from therapists to install Amail at their rehabilitation center, and the spontaneous adoption by other clients, suggests genuine unmet need. The observation that updating familiar interfaces causes difficulty for this population has implications for any software serving users with cognitive disabilities—stability matters as much as improvement.
Tags: aphasia · augmentative and alternative communication · email · field study · cognitive accessibility · stroke · acquired disability · social communication