Early Adopters of a Low Vision Head-Mounted Assistive TechnologyAnnuska Zolyomi, Information School, University of Washington, email@example.com
Jaime Snyder, Information School, University of Washington, firstname.lastname@example.org
AbstractEarly adopters of emerging technology offer unique insights into the benefits and hurdles of using technology in daily life. We interviewed early adopters of a head-mounted assistive device for low vision called eSight 2.0 and client-facing employees of the company that produced the device in order to better understand the ways that daily use of the technology can help us understand social implications of digitally enhanced vision. These interviews probed personal and professional experiences for social and emotional impacts associated with adoption of this type of low-vision assistive technology. From our interviews, four themes emerged: 1) assessing the value of assistive technology in real life, 2) negotiating social engagement, 3) boundaries of sight, and 4) attitudes toward and expectations of technology. We introduce the concept of multiplicities of vision to highlight that sight is not one thing for all people in all situations. We argue that individuals with low vision who use assistive technology have skilled vision that is neither fully-human nor fully-digital, but rather, assembled through a combination of social and technical affordances. We propose that instead of seeing low-vision users through a deficit model of sight, human-computer interaction designers have more to gain by viewing people with low vision as individuals with expertise in skilled vision that is both socially and technologically mediated.
Globally, 246 million people have "low vision," an umbrella term for moderate to severe visual impairments . While much of this population is completely blind, a larger portion has partial vision. These individuals can experience acuity loss, high sensitivity to light, blind spots, and other disruptions of the visual field. A growing number of assistive technologies (AT) for people with low vision are emerging that take advantage of recent developments in computer vision, wearable technologies, and battery life. In contrast to permanent and invasive treatment like surgery, these devices provide a temporary, relatively low risk option for those with vision loss. However, users of low vision head mounted displays (HMDs) such as the eSight eyewear (Figure 1) are still in the minority among the population of people with low vision. In adopting this technology, trade-offs are often made between social, emotional, and biological factors.
To better understand these trade-offs, our study asks:
- What is the emergent, social, and emotional nature of visual experience made available to low vision users through AT, specifically the eSight HMD?
- How is this experience of vision assembled via a combination of social and technical affordances?
- What are the implications of these experiences for the design of assistive and augmentative technologies in the future?
Our study contributes rich, qualitative descriptions of users’ psychological and social experiences when integrating technology-mediated sight into their daily lives.
2.1 The experience of low vision
Vision is typically described in terms of three characteristics: visual acuity, contrast sensitivity, and visual field perception [2,3]. People with low vision have some functioning sight that is obscured in one or more of these characteristics. For example, macular degeneration is the gradual deterioration of the retina, which results in blind spots. A person is considered to have low vision if refractive errors cannot be corrected (even wearing lenses) and/or reduced field of view of 20 degrees or less. Visual impairments, including low vision, "cause a number of disabilities including difficulty with reading, writing, recognizing faces, watching television, orientation and mobility, and completing activities of daily living" [3:495].
There are currently multiple technologies available to help people with low vision accomplish daily tasks [4,5]. Many of these tools provide access to digital devices such as desktop computers, laptops, mobile phones, and public kiosks [6,7] through screen magnification, text-to-speech, and speech-to-text (dictation and command-and-control) software and hardware. Applications integrated within operating systems also enable users to enlarge the size of text and elements on the screen using font and zoom settings. Many of these technologies require text to be in a readable format through Optical Character Recognition (OCR) . Audio books and video camera-based magnifiers, including closed circuit televisions (CCTVs), are common tools for people with low vision to access print media.
2.2 Challenges to Assistive Technology Acceptance
Despite the array of available low vision technology, potential users can have limited awareness of emerging or established technologies that could meet their needs . Further, devices like eSight are expensive and financial support is not always available through federal programs or private health insurance . Social dynamics can also influence the acceptance of assistive technology. While some users of AT report that mastering their AT gave them an increased sense of independence and productivity , social stigma has been highlighted as a key deterrent to use [10,11,12]. Some individuals felt that using non-mainstream technology brought attention to their disability and increased the perceived "otherness" of having a disability.
2.2.1 Head-Mounted Displays and eSight 2.0
As mainstream technology has moved toward mobile and wearable devices, so has the low vision field. A recent trend has been portable HMD, like the eSight device, that provide magnification and contrast enhancements using optoelectronics and video technology. The eSight 2.0 device was released in 2013 in the United States and Canada. It has been the subject of a study conducted by the Canadian National Institute for the Blind (CNIB) which established that it "offers a statistically significant improvement in visual acuity and contrast sensitivity for users" .
The eSight device is a head-mounted camera system that captures live video sent through a small portable computer (about the size of a paperback book) that is carried by the user. The user wears an eyeglass frame that holds high-resolution organic-LED (OLED) screens. A real-time image is displayed on the OLED screens, and the user can adjust features such as contrast and zoom.
3. Our Research Approach
We conducted semi-structured interviews with 13 users of eSight 2.0 (six female, seven male). All the participants had a minimum of 5 years with vision loss, had used eSight for over one year, and were over the age of 25 (average age of 52). The participants were trained or employed in, or retired from, occupations such as information technology support, nursing, marine engineering, teaching, electrician, office administration, kitchen design, and visual art. They had low vision conditions such as Stargardt disease, Macular degeneration, and Usher’s Syndrome. Participants reported using a variety of low vision aids (LVAs) and AT over time, typically spurred by changes in their visual condition and evolving needs. LVAs included hand held magnifiers, binoculars, CCTVs, large print books, audio books, canes, and guide dogs. For digital access, many reported using a screen magnifier and text-to-speech functions of software such as ZoomText and Kurzweil.
One-hour interviews deployed the critical incident technique of eliciting and documenting participant narratives . This technique asks participants to recall a specific, significant activity and recount what they "saw, heard or felt" [14, p. 329] during the unfolding of that event. Early transitional experiences with the eSight eyewear were positioned as critical incidents in long-term adaptation to technology-mediated sight.
We supplemented the eSight user interviews with semi-structured interviews with three eSight employees who are involved in demonstrating eSight to potential users as well as fitting and training new users. These activities have given these individuals insight into non-use, barriers to adoption, and typical challenges faced by new users.
After analyzing our interview data, we identified four themes that reflected the concerns and perspectives of our participants: 1) assessing value of AT in real life, 2) negotiating social engagement, 3) boundaries of sight, and 4) attitudes & expectations of technology.
Theme 1: Assessing the Value of AT in Real Life
This theme described participants’ rationale for using AT, which we found changes over a lifetime. Their sense of agency in their lives and their emotional readiness influenced their desire to experiment with AT and the perceived value of the AT. Experimentation with AT use was primarily driven by a need for mobility and to be able to see things at different focal planes. For example, Participant 05 (P05) explained: "Using binoculars were not flexible enough. Constantly having to adjust them for different distances. I’m better off to stand next to [the] presentation screen." Participants described using more traditional AT, such as walking canes or guide dogs, with mixed feelings about inclusion and stigma. For instance, P02 relied on his cane, saying, "I don’t go anywhere without it," whereas P02 said "I’m embarrassed to use my white cane."
With regards to the decision to start using the eSight eyewear, our participants expressed a strong, hopeful reaction when they first learned about the device on TV, online, or at a vision trade show. In the initial screening to try the eSight device, our participants vividly described their first experiences using eSight, many tearing up as they talked about the "night and day difference" (P03) in their vision and feeling "blown away" (P06) and overwhelmed (P11). These were emotional experiences since the success of eSight, or lack of success, was usually evident upon initial use.
Theme 2: Negotiating social engagement
Participants directly associated technology-mediated sight with social engagement. While sharing a range of stories about how they were active, social, and adventurous, many participants described situations in which their visual impairments constrained the ways they contributed to their families, communities and work environments. In contrast to research focused on barriers to social acceptance, our research surfaced descriptions of technology-mediated sight as explicitly connected to a sense of self-worth and societal value. For example, one participant described what it was like to try to do the family grocery shopping before eSight:
"He won’t let me do the grocery shopping because I don’t buy any of the right stuff that everybody likes...I would never come home with anything that anybody liked. I thought I was picking the, you know, this jar of peanut butter looks like this jar of peanut butter." (P01)
This person went on to explain that with eSight, she is now able to see small differences in labels, making her better able to respond to her family’s preferences. This increased acuity also made her keenly aware of all the things she missed without the device, contributing to feelings of inadequacy and, at times, depression. Here we see evidence of technology-mediated sight being used to negotiate ongoing attempts to balance inconveniences, even stigmas, associated with head-mounted AT with desires for more robust social practices in spite of differences in visual abilities.
Related aspects of social engagement included experiencing degrees of inclusion and independence through use of the eSight eyewear. Having the ability to observe and use non-verbal communication through eye contact, facial expressions and proximity were considered a strong benefit of the device. However, many of the stories shared by participants highlighted challenges to achieving true parity and equity to those without visual impairment. They described a social reality that was distinct from unmediated interactions, such as:
"...when I first met a client, I would not wear my eSight because part of my job with sales was selling the kitchen design and if a person can’t see your eyes they have a hard time trusting you.... I’m used to not seeing anyone’s eyes, I’m used to using other points, but most people are not, so when they’re talking to you they want to see your eyes." (P10)
The eSight device (and similar technology) is not a cure-all for challenges of inclusion, independence, and social integration faced by individuals with low vision. The social reality created using these devices for interpersonal communication and engagement is distinct, valued, and not entirely similar to unmediated interactions.
Theme 3: Boundaries of Sight
Our participants described their visual experiences not solely in terms of the traditional characteristics of vision – acuity, contrast, and field of view – but also in relation to space and distance. In talking about how navigating their physical surroundings changed through use of the eSight eyewear, most people placed a particularly high value on the ability to see at a distance. For many, especially those with degenerative conditions, visual experience of the world became increasingly shallow in depth as their eyesight deteriorated. One participant described the challenge of having such shallow depth of field: "To be able to see my wife’s face what I would call clearly without the eSight, she has to be within a few inches of my face" (P06). Another participant told us that while she could see her son’s nose and eyelashes if she held him close, she longed to be able to watch him play: "I don’t see far away, I see stuff but it’s super blurry and ... I’d love to be able to sit on my deck and watch my son play in the sandbox." (P09)
Participants also spoke about the ways in which using the eSight device increased their awareness of differences between their own experience of sight and those of fully sighted friends and loved ones. They developed skills to reconcile their mental models of space and distance with models of sighted individuals. For example, where a sighted companion might think of the path to a favorite coffee shop as a series of left and right turns, for someone with low vision, this path might be described in terms of a sound and temperature scape.
Over half of the participants referred at one point or another to being aware that the device gave them "super powers," or the ability to see in more detail, at greater distance or under dimmer lighting conditions than fully sighted individuals could. One participant described herself as appearing to look like "a super hero" or a "cyborg mom" (P01) when she wore the device to pick up her son at school. Another participant described working in a warehouse using eSight to magnify product information:
"I’ll be like Robocop and just read everything... They would say, ‘What was that part number?’ and I’d be like, ‘1234567 and the serial number ABCD,’ and I’d just read it off and it was like they were talking to a walking computer." (P11)
These examples demonstrate their self-awareness about their mental models and abilities with and without technology-mediated sight.
Theme 4: Attitudes and Expectations Toward Technology
Our interviews revealed tensions between an individual’s desire to enhance their visual experiences, their confidence in their skills using technology, and their expectations of what technology can deliver. Although our participants exhibited a baseline trait of being comfortable with technology, that is not the case of all potential users. During the screening process, eSight assesses the potential customer’s familiarity with technology by asking about their use with everyday technology such as TV remote controls and cell phones. As mentioned previously, participants described sensing a gap between their own mediated encounters with the visual world and what those with more fully functioning sight experience. Few participants expected technology alone to bridge that gap, at least in their lifetime, but many expressed hope for future generations, with at least six of the thirteen referencing their own children or grandchildren in their hopes for the future. Twelve explicitly stated that they actively and enthusiastically shared information about eSight with others, with P06 referring to himself as a kind of "Johnny Appleseed." Many simply wanted others to share in the experience of sight offered by eSight. Others had a more global vision of the possible impact of the technology: "...My thought was if this works, this is like, this is a historical moment." (P01)
We drew two key concepts from our findings: multiplicities of vision and low vision as skilled vision.
Multiplicities of Vision
These narratives highlight that sight is not just one thing for all people in all situations. Individual variations in sight occur on a yearly, monthly, daily and even hourly basis. Technology mediated sight is assembled from hardware, software, experiences of sight, physiology, and social engagement. Rather than describing a stable, static, or standardized experience, many participants instead referred to visual experiences they had with eSight as a different, a new type of sight that provided them with an experience of the visual, if not the singular notion of "vision" that they might have held when they first heard about the device. The participants in our study explicitly stated that the eSight device did not "cure" them of their visual impairment, was not a replacement for more fully functional sight, and was not appropriate for all situations.
We learned that not just seeing but understanding the personal value of what is being seen was an important aspect of how and why technology-mediated sight is integrated into someone’s life. The value that eSight users placed on what was being seen (e.g., the face of a loved one, paperwork involved in a desk job that enabled someone to support a family, the panorama of the Grand Canyon), was entangled with their assessment of the technology, the concessions they were willing to make to use the device (including cost), and ultimately what they came to describe as "adequate" or "enough" sight.
These observations have implications for more holistic, situated, and longitudinal evaluation of HMD like the eSight eyewear. Replication of normative vision is just one possible outcome. Some devices might be far better positioned to introduce entirely new types of visual experiences for low vision users. Technology designers can strive to create rich social or task supports using modalities other than vision to enhance a person’s holistic experience, based on personal and social goals.
Low Vision as Skilled Vision
This study of eSight provides evidence of the daily practices of people to adapt and develop specialized visual skills. They learned this "vernacular" skilled vision  through trial and error as they assessed how to make the best use of the visual input they received. Similar to how astronomers and microbiologists develop expertise in gathering and interpreting visual information from telescopes and microscopes, eSight users are learning how to make sense of the visual information provided by the eSight device. For most of our participants, their visual experience with eSight is the first time (or the first time since the onset of a visual condition), that they had access to a particular visual ability. For instance, eSight enabled participants who have a radically shortened depth of view (e.g., only being able to see things that are inches away from their eyes) the ability to navigate depth of field.
Along with exercising new or improved visual abilities, the eSight device provided users with a more fluid ability to make seamless transitions through foreground, middle ground, and background. The capability of the eSight to simultaneously pan, zoom, and focus makes it distinct from other ATs like magnifiers or smartphone apps. This functionality enables users to see through space. Therefore, the visual experience afforded by the eSight device is not just a series of interactions with flat planes but a seamless experience.
We encourage new avenues of investigation and innovation in other visual and multi-modality domains. Designers can gain a deeper understanding of the choices these skilled users make in adopting and operating vision technologies, and therefore, design technologies that are more compatible and usable based on people’s specialized sensory abilities.
We conducted an analysis of technology-mediated sight based on interviews with early adopters of eSight eyewear for low vision users. Our findings describe 1) sociotechnical experiences of vision offered through this device, and 2) the ways in which these experiences are assembled through a combination of social and technical affordances. In doing so, we argue that the narratives of eSight users are not just about the adoption of ATs but also help us to better understand the way in which they develop expertise in skilled vision. The concept of multiplicities of vision can be instrumental to designing nuanced and situated assistive and augmentative reality technologies.
We thank Rob Hilkes and the eSight users and employees who participated in our research.
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