What Has Been Done To Increase Accessibility For Mental Health Services?

Introduction

The number of mental health apps continues to rise. Estimates suggest that over ten,000 mental health apps are now available to the public (1). The types of mental health apps vary widely; some provide self-help resources grounded in evidence-based practices such as Cognitive Behavioral Therapy (CBT), others provide pathways to virtual care either from professional providers or lay peers, whereas yet others are designed to augment therapy and increment the efficiency or efficacy of clinical care. As a subset of the broader digital mental health movement, apps are often seen as a span to accessing care, providing an easy and cost-effective way for consumers to get assistance through devices they may already use (2, 3). In short, to make mental health intendance more "attainable".

However, this potential to expand access to mental wellness care to those in need is predicated on whether such products are truly attainable for various, underserved, and vulnerable populations. Many believe that accessibility means "making products usable by people in a broad range of situations— circumstances, environments, and conditions" (4), and that attainable design ultimately benefits everyone. While accessibility in digital mental health has often been considered in terms of expanding access to various populations including ethnic, racial, sexual and gender minorities (3, 5, half-dozen), individuals across the lifespan (7), individuals experiencing homelessness, or rural populations (3), it has rarely been considered in terms of people with physical, sensory, and cognitive disabilities (8, nine). This is a missed opportunity in digital mental wellness, where researchers and developers could be leading the way in incorporating agreement of affective, behavioral, and cognitive aspects to create mental health technologies that might truly bridge the gap between those who are able to access and receive services and those who cannot.

In this newspaper we will a) define accessibility, especially every bit it pertains to mental health apps, b) present existing work around models of accessibility equally it relates to technology and digital health, c) identify considerations specific to mental health apps, and d) recommend future directions in digital mental health to better incorporate accessibility. While digital mental health is a broad field which includes many cutting-edge technologies (eastward.g., virtual reality, wearables), we focus this paper on mental wellness software which run on commonly available platforms (e.1000., personal computers, tablets, and smartphones). By acknowledging all facets of accessibility in design and use, digital mental health can amend meet its promise to expand admission and benefit broader audiences, including those who are most vulnerable and those most in need of mental wellness intendance.

To amend empathise the lens of the authors of this work, we disclose that some of the authors have personal experience with disabilities including navigating attention-related challenges as a person with Attending Deficit/Hyperactivity Disorder. Much of our involvement in writing this piece came from our experience with reviewing mental health apps and noticing a lack of apps that answer to arrangement-level accessibility tools (e.k., captions, screen readers, etc.), our piece of work in evaluating the implementation of digital mental health in various service settings, and enquiry studying and designing assistive technologies for people with disabilities. We besides consulted colleagues who are mental health providers with mobility/dexterity and visual impairments.

Defining Accessibility

For a resource to be near accessible, it must exist able to be used by a person with a disability for the same purpose, the same effectiveness, and with a similar corporeality of time and effort as someone who is non-disabled (10). In the context of the physical world, this tin can have the course of ramps or braille signs. In the context of the digital earth, accessibility means that a website or tool is built with content and blueprint that is understandable and navigable with or without assistive technologies. It also means that a digital resource includes back-end technical or coding considerations, such every bit compatibility with assistive technologies to allow for greater admission for those with disabilities.

The Web Accessibility Initiative (WAI) provides an example of guidelines to define what constitutes an attainable digital resource. The POUR guidelines highlight considerations such that people with disabilities tin can perceive, understand, navigate, collaborate with, and contribute to the web (11). Considerations within Pour include: P erceivable data and user interface; O perable user interface and navigation; U nderstandable information and user interface; and R obust content and reliable interpretation (12).

One claiming with defining accessibility with regards to apps, and with developing accessible mental wellness apps, is that accessibility needs vary dependent on a person's disabilities. People, for instance, who are D/deaf or hard of hearing, or those with learning disabilities may do good from captioning. People who take vision impairments or those with Attention Deficit/Hyperactivity Disorder (ADHD) may do good from text customization options such as text size, scaling, contrast, and reflow. People with colour incomprehension may benefit from images that use additional formatting or annotations to help brandish information. Others who accept motor impairments or people with cognitive disabilities may do good from tools such as voice dictation and eye-tracking to help interface with technology. More examples are provided in Figure i.

Effigy 1. Applying the Spider web Accessibility Initiative (WAI) POUR guidelines to digital mental health.

Accessibility for mental wellness apps requires making similar considerations as one would in the broader digital globe. For example, a meditation app designed with accessibility for diverse needs in mind would include captions for audio-based meditations and sound indicators for visual cues such every bit breathing. The importance of such considerations is magnified for a population that is already dealing with layers of challenges to accessing the care they demand. To meliorate understand accessibility every bit information technology relates to digital mental health, we tin beginning by looking at existing work in digital accessibility and in digital health.

Existing Work Focusing on Digital Accessibility and Digital Health

In general, accessibility within the digital space has taken steps toward standardization through organizations and protocols such every bit WAI and its related efforts (thirteen, 14). Researchers, organizations, and major tech companies such every bit Microsoft and Mozilla, have contributed to the creation of accessibility standards and the creation of guidelines for assessing the accessibility of websites and apps such as WAI's Cascade guidelines (12, 15–18). Mobile platforms such equally iOS and Android are also designing with physical and sensory accessibility in heed. To encourage app developers to lawmaking their apps to work with assistive technologies, Apple tree (iOS) and Google (Android) accept been actively integrating assistive technology such as screen readers into their operating systems (nineteen, 20). Apple tree, Google, and several other organizations have besides created automated tools that tin can assess an app and check if it has integrated accessibility features or met certain guidelines (21). This helps to standardize and ease the brunt of checking for accessibility in engineering science (although human review is still warranted). Despite all these efforts, accessibility in the digital world is still poor, including in digital health (22). However, every bit researchers and designers in this space, we should be leading the ways in terms of accessibility because everyone experiences mental health challenges at some betoken in their lives – ranging from acute to serious mental health discomfort or distress. Every bit such, making more mental health resources available to everyone should exist a common goal.

Inquiry on accessibility remains limited in the digital mental health space. Piece of work on accessibility in digital health more broadly is more than developed (23–26) and offers some insights on how to amend consider and increase accessibility in mental health apps. A number of studies in digital health take found that principles of co-blueprint or including those with lived experience in developing an app can assistance place and address accessibility bug for an app'due south target audience such every bit customization and personalization, inclusive language, or better measurements based on differing abilities (27–33).

One study looking at the use of digital health apps for vision impaired individuals plant that past applying accessibility focused user feel (UX) guidelines to an app'due south blueprint, information recognition and uptake increased for both those who are vision impaired, and those who are without vision harm (27). The study's researchers also found both depression-quality data presented in an app, also every bit poor presentation and organisation of valid information beyond other apps. Researchers point out that this can exist especially troubling especially for low-vision consumers, for whom data may already exist difficult to access.

I arroyo in research is to include feedback from caregivers or professionals, in addition to feedback from disabled consumers (28). Done accordingly, which means including caregiver and professionals to provide additional, diverse viewpoints and triangulation with consumer voices, this tin exist useful to add context and insights (29, 34). Nevertheless, professionals may have worked with other people with similar disabilities but differing accessibility needs. Thus, although work in digital health has demonstrated potential usefulness of triangulation with caregivers and professionals, it needs to exist washed in a mode that does not diminish the involvement and voice of disabled people.

Unfortunately, accessibility research in digital mental wellness itself is limited. Once again, there is an opportunity hither to understand and address accessibility barriers for those who might use mental health apps. In the post-obit section nosotros expect at accessibility considerations for mental health apps every bit they relate to a disabled person's ability to use mental health apps for the same purpose, effectiveness, and with a similar corporeality of time and effort as someone who is without inability.

Accessibility Considerations in Mental Health Apps

A mental health app may not fulfill its intended purpose without weighing accessibility in design. Mental wellness apps are a solution for receiving treatment for those unable to access traditional forms of therapy or an opportunity to heighten treatment for those who are already receiving therapy. Accessibility considerations for mental health apps should help ensure that a mental health app can perform the same functions, achieve the aforementioned outcomes, and require the aforementioned amount of time and effort for those with or without disabilities. This includes consideration of physical, sensory, and cognitive disabilities, as well every bit the intersection of such disabilities with mental health concerns (35).

Mental health apps should aim to perform the same function regardless of the accessibility needs of those using them. Given that major functions of mental health apps are often around providing psychoeducation through didactic material, reinforcing skills through interactive exercises, and supporting tracking of things such as mood, symptoms, triggers, or medication, apps should attempt to ensure that functions can be performed by all. Various issues, nevertheless, may interfere with consumers using these functions. For example, those who are D/deafened or hard of hearing may profoundly benefit from captioning in sound-heavy meditation apps. Alternatively, those who are vision dumb may require resizable or customizable text when navigating text-heavy content. It is estimated that almost 33% of adults with physical disabilities in the U.S. (nigh 17.4 million people) feel mental health bug, and those with disabilities should be afforded the same benefits from digital tools equally those who are non-disabled (36).

Those with temporary disabilities must also be able to perform the advisable tasks inside a mental health app. Those experiencing common side effects of psychotropic medications such as blurry vision, tremors, or memory impairments, may have problem reading text-heavy content that is non resizable or customizable; an accessibility feature commonly needed by those who are vision impaired. In another instance, over-animated or dumbo app designs may make information technology challenging to complete and retain didactic material for those with poor working memory, a symptom found within a variety of mental health challenges (37). Concrete, sensory, and cerebral disabilities oft co-occur with mental health conditions (38–40), adding layers of digital accessibility concerns for individuals. Creating attainable content should serve to benefit a mental health app's reach, while maintaining or even improving the app's effectiveness at delivering information.

For a mental health app to be of the same benefit to people with disabilities, they must be able to use the app for the same or similar corporeality of time and attempt. In addition to the examples outlined above, poor adherence to accessibility guidelines tin also impact the amount of time and effort required to apply and trust a mental health app (41, 42). Failing to apply accessibility guidelines to privacy policies may result in overwhelmingly complex policies written at higher-level reading levels requiring boosted fourth dimension and effort to empathize (29, 43, 44). This is specially critical for those using a mental health app, who might need clear assurances that sensitive personal information such as what is shared in a mental health app volition exist treated with respect.

Futurity Directions: Making Mental Wellness Apps More Accessible

Work on accessibility on mental health apps is sparse. Prioritizing such work, however, could provide an opportunity to expand the accomplish of mental health apps, especially to those who face many barriers to traditional mental wellness care. We annotation three fundamental areas where we should work to improve the consideration of accessibility for mental health apps – standards, research, and recognition.

Various standards and evaluation frameworks accept evolved for mental wellness apps [e.thou., APA Framework (45), Enlight (46), I Heed PsyberGuide (47)] which have consensus around cardinal areas of evaluation including prove-base, user experience, and data security and privacy. Even so, none of these standards and frameworks consider accessibility. The closest aspect would be user experience, merely although accessibility impacts user experience, they are non equivalent and assessing user experience may non identify accessibility problems. Accessibility should be a core area of evaluation for mental health apps. This could include accessibility as discussed in this paper, besides equally other components contributing to access, such as language or arrangement requirements, but its inclusion in evaluation would go a long way to assistance promote inclusion. It is beyond the scope of this paper to define specific, measurable items that define whether a mental health app is accessible or non, however, the examples provided in Effigy 1 outline some considerations that might be incorporated in such items. A recent synthesis of various evaluation frameworks identified 11 distinct questions related to accessibility covering areas of availability, offline modes, and vulnerable populations as the target audition (48). Another review has recommended the Matching Person to Technology (MPT) model equally one framework to use when considering health apps for people with intellectual disabilities (xxx).

Accessibility research needs to be collaborative, by including those with lived experience and accessibility needs in the blueprint and iteration of mental wellness apps. Although every bit discussed earlier, providers and caregivers can provide boosted data, this should be done in a way that empowers rather than diminishes the voices of those with lived feel. Iterative research is central because the diverse accessibility needs of consumers are unlikely to exist addressed or incorporated in just a few focus groups or studies. Furthermore, accessibility considerations made during various stages of iterative research should be well described and contextualized to allow other research groups to iteratively build off each other's findings. Collaboration is also required between diverse stakeholders including industry partners to brand employ of advances in attainable technologies more than broadly in research designs and considerations.

Qualitative research and interviewing geared toward understanding accessibility in mental wellness apps can brainstorm to inform specific needs in the space. Similar work has been done past Bernard and colleagues, just that was focused more on how mental illness tin affect accessibility of apps and websites (29). Research pattern that is mindful of participants' conditions is too important. Beaton and colleagues, for case, demonstrated consideration of how the temporary disabilities acquired by concussion symptoms, might bear on their findings (28). Rather than limiting findings to information collected during the interview, they encouraged participants to follow upwards with whatever boosted thoughts after the interview to provide time for think and processing.

Consumer surveys, particularly those washed early in the process of research or design, tin provide valuable agreement of potential areas to explore including needs and opportunities. Nevertheless, when using surveys, recruitment needs to ensure proper representation to consider accessibility. If survey samples are small or targeted toward specific populations, that population should exist well-contextualized to ensure that findings are interpreted appropriately. If survey samples are large, and intended for wide-spread generalization, an eye toward proper representation of diverse accessibility needs should be a consideration in recruitment.

Elevating accessibility to a critical consideration in the digital mental wellness space requires making sure information technology is not brushed aside by just stating that it is already included in electric current evaluations. Furthermore, professional organizations and journals could do a ameliorate task of raising accessibility issues, first by making these spaces more accessible, and 2d by ensuring that accessibility issues are included in the dialogue.

Furthermore, while this paper focused on mental health apps, information technology is every bit of import to consider accessibility in the broader digital mental health space, as many digital mental health tools are being made available across various device class factors. Finally, while we centered around accessibility in the context of inability, it would be wrong to ignore the importance of usability and inclusion. Usability refers to considerations for efficient and satisfying design, while inclusivity includes considerations for elements such as culture, education, and digital literacy in the evolution of technologies (49). Both are likewise of import to consider in digital mental wellness, and they often overlap with each other and with accessibility. Without being mindful of "usable" blueprint, we risk neglecting attainable pattern, and without creating "inclusive" content, we are limiting others' ability to access the content.

Conclusion

Technology has facilitated the creation of a multitude of mental health apps. Over the by few years, accessibility has been a growing consideration in applied science mostly. The time is overdue for these areas to come together and promote accessibility within mental health apps. A get-go footstep to promoting accessibility would be the adoption of standards in mental health apps which follow principles from established accessibility guidelines. Second, research should explore whether mental health apps are usable for the same purpose, with the aforementioned effectiveness, and with the same time, across people. Third, the field needs to recognize that accessibility for some-merely-not-all is counter to the goal of digital mental health to make resources broadly bachelor and will only serve to entrench rather than overcome inequalities in care. Keeping the status quo and failing to prioritize the accessibility needs of consumers of mental health apps limits the quantity and quality of available treatment options. Furthermore, prioritizing accessibility may not merely do good individuals with disabilities but create better mental health apps for all users. With careful consideration and implementation of accessibility work inside the field of digital mental health, nosotros tin make even bigger strides to deliver on the goals of digital mental wellness to increase admission for all.

Information Availability Argument

The original contributions presented in the study are included in the article/supplementary cloth, farther inquiries can be directed to the corresponding author/s.

Author Contributions

JB wrote the first typhoon of the manuscript. JB, KER, and SMS wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.

Funding

SMS received funding from Ane Listen for the functioning and direction of One Mind PsyberGuide. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.

Conflict of Interest

SMS has received consulting payments from Otsuka Pharmaceuticals for work unrelated to this manuscript and is on the Scientific Advisory Board for Headspace, for which he receives bounty.

The remaining authors declare that the enquiry was conducted in the absenteeism of whatsoever commercial or financial relationships that could exist construed every bit a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and exercise not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Whatever product that may be evaluated in this commodity, or merits that may be fabricated by its manufacturer, is not guaranteed or endorsed past the publisher.

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