People with aphasia help design a browser extension to break down web barriers

People with post-stroke aphasia struggle to use the web for healthcare, information, and support, and a new Australian study has documented exactly where the digital world shuts them out. The research, published in BMC Digital Health, is the first stage of a project called Bridging the Digital Divide, which aims to co-design a web accessibility browser extension with and for people with aphasia. Rather than relying on automated audits, the team gathered direct accounts from people living with the condition, their family members, and the health professionals who support them, then mapped those experiences onto concrete design priorities for the technology they intend to build.

Aphasia is a communication disability caused most often by stroke, affecting speaking, understanding, reading, and writing. Stroke is a leading cause of death and disability globally, and one third of stroke survivors experience aphasia. For more than 60 percent of these individuals, the condition becomes chronic and requires long-term management. Because effective self-management of chronic conditions increasingly depends on digital access to health information, online services, and support resources, persistent barriers to web accessibility can undermine independent healthcare navigation. Compared with other disability groups, people with aphasia and communication disabilities are more likely to report feeling digitally excluded, with negative consequences for self-management, information seeking, service access, and social connection. The reduced ability to access online information can also cause discouragement and damage self-esteem.

The study used experience-based co-design and human-centred design approaches. Focus groups were held online with nine people with aphasia, eight family members, and ten health professionals; a tenth person with aphasia consented but withdrew due to illness. Each group met for three hours in two sequential phases: an experience-gathering discussion followed by a structured prioritisation activity using the nominal group technique. Participants shared experiences of accessing healthcare, information, and support services online, described one positive and one negative web experience, and named an associated emotion. The discussions were transcribed verbatim and analysed with reflexive thematic analysis, while the prioritisation data were pooled across groups and analysed with qualitative content analysis. Two people with post-stroke aphasia served as consumer investigators throughout, contributing to research design, co-facilitating focus groups, and shaping analysis and interpretation.

The experience data produced six themes. The first, aphasia-aware design, captured the consensus that awareness of aphasia is a prerequisite for usable technology. Participants with aphasia and family members described frustration, anger, and stress when communication breakdowns occurred because others did not understand the condition. Aphasia-friendly websites with increased white space, bolded text, icons, and text-to-speech were considered helpful, and one participant praised a news site that simplifies and summarises items to improve readability. Health professionals stressed that aphasia is heterogeneous, so flexibility matters: some people found pictures and icons supportive, while others found symbols difficult or a total distraction. Text-to-speech technology helped many participants, but only when the speech rate could be slowed without disrupting naturalness and the underlying language was not too complex.

The second theme, confidence building through support and practice, showed that confidence with technology before a stroke shapes motivation to return online. Frequent pre-stroke users described fewer challenges getting back on the web, while less confident users relied on family members to manage online activities. Some participants initially avoided the web after their stroke; one said she remembered nothing and was frightened of it. Repeated opportunities to practise fostered independence, and family members emphasised taking things step-by-step and celebrating small victories. Yet needing help carried emotional costs. One family member described how his wife, a very capable person, found it demeaning and frustrating to ask for help with tasks that were obviously simple for people without aphasia. Health professionals noted that time constraints in therapy sessions made supporting clients online difficult and time-consuming, sometimes leading clinicians to take over tasks such as completing registration forms.

The third theme, challenges to online service access, identified registration forms, password management, and telehealth setup as key barriers. Passwords and authentication processes were viewed as terrible by participants across groups, and two-factor authentication caused additional stress when there was a time limit to input information. Alternate log-in methods that avoided remembering and typing alphanumeric passwords facilitated access; suggestions included biometrics, shape-drawing, and one-click links sent by email. Online forms demanded so much information input that they blocked people from initiating service access, and having to complete the same form repeatedly for the same services was described as annoying. Telehealth drew mixed opinions: it made attending appointments more convenient for people in remote areas, but setting up a telehealth appointment required prerequisite activities such as establishing an email address, plus confidence with technology and troubleshooting ability. Family members also reported feeling left on their own after hospital discharge, navigating what one called a minefield and a treasure trove of online information about stroke, aphasia, and support services.

The fourth theme, searching is hard when you can’t find the right words, placed word retrieval and spelling difficulties at the centre of online information seeking. Many participants with aphasia abandoned search attempts after feeling overwhelmed, frustrated, and hopeless. They used strategies including dictionaries and thesauruses for synonyms, circumlocution, asking another person, or using chatbots, and bookmarking websites helped them revisit frequent searches. Assistive technology offered mixed success. Speech-to-text systems and voice assistants often misunderstood unclear speech or non-words; one participant described saying something at the beginning of a sentence only for the system to end up totally confused. Predictive text helped only when the user already knew the word and could type the first few letters, and one health professional warned it could make things worse by presenting too much information at once. Many participants were unfamiliar with artificial intelligence tools, and reluctance to try them may reflect fear that non-typical speech will be misunderstood or inadequate knowledge of how the tools work.

The fifth theme, written information online is overwhelming, reflected the difficulty of reading and understanding large volumes of text with complex language and dense page layouts. Facilitators included simple language with minimal jargon, summaries, large font sizes, increased white spacing, and information presented in different modalities. A few participants said bold words were amazing, although most did not express a preference for keyword bolding, and health professionals reported no consistent approach to selecting which words to emphasise. The sixth theme, finding new ways to connect with peers, showed participants turning to social media and video platforms as alternate sources of information and support. Facebook and Instagram were perceived as easier to use because of reduced text, more images, and endless scrolling, and Facebook groups served as spaces for posting questions to peers. Instant messaging apps offered communication beyond words through emojis. YouTube videos about stroke and aphasia aided understanding through multimodal presentation, though lengthy videos could be overwhelming, and several family members described university research opportunities as the best source of information they had found.

When the prioritisation data were pooled, 201 ideas had been generated across all groups, with people with aphasia prioritising 36 ideas, family members 24, and health professionals 29. The top five priorities for improving web accessibility were greater access to learning and support resources, new technology and tools, communication-accessible design, inclusive and tailored technology, and help from a real person. These priorities were mapped to four design principles intended to guide the browser extension: simple language, simple interface, user customisation, and development of training materials and resources. The mapping drew on the W3C Web Content Accessibility Guidelines, usability heuristics, and the Principles of Universal Design. The findings were also synthesised into a generalised experience map organised around six components of Internet use: motivation for use, getting online, navigation, finding information, accessing online healthcare, and finding support.

The study’s context sharpens the stakes. In Australia, all government agencies are required to comply with the Web Content Accessibility Guidelines version 2.2 at Level AA, but there is no governing body to administer the legislation, creating heavy reliance on self-reporting. A high proportion of Australian health service webpages, including government websites, were found to contain at least one accessibility violation, with common errors including empty links or buttons, missing alternative text, and missing labels for form controls. For people with aphasia who depend on text-to-speech functions or screen readers, such violations can render web content inaccessible. Low readability compounds the problem: many websites present written content above a grade 6 reading level, the maximum recommended by aphasia accessibility guidelines, and even many stroke and aphasia websites do not comply. The authors note limitations: the sample excluded people with aphasia from non-stroke causes, was predominantly metropolitan, and the health professionals were mostly speech pathologists, so perspectives may not generalise fully to rural and remote communities or other disciplines. Participants’ suggestions were also shaped by familiarity with existing technologies. The experiences and priorities documented here will now feed into co-design workshops, where people with aphasia, family members, and health professionals will work with the research team to develop the browser extension and training materials, with iterative prototyping guided by the principles of simple interface, simple language, and user customisation.

Subject of Research: Experience-based co-design research identifying web accessibility barriers and design priorities for people with post-stroke aphasia

Article Title: Co-design of a web accessibility browser extension for people with post-stroke aphasia: Understanding experiences and priorities in the first stage of an experience-based co-design study

Article References: Lee, J., Worthy, P., Deslandes, R., Burton, B., Copland, D. A., Jamieson, P., Barron, K., Shrubsole, K., Togher, L., Hill, A. J., Wiles, J., Haslam, S. A., & Wallace, S. J. (2026). Co-design of a web accessibility browser extension for people with post-stroke aphasia: Understanding experiences and priorities in the first stage of an experience-based co-design study. BMC Digital Health, 4(1), Article 59. https://doi.org/10.1186/s44247-026-00289-2

Image Credits: AI Generated

DOI: 10.1186/s44247-026-00289-2

Keywords: aphasia, stroke, web accessibility, co-design, browser extension, digital exclusion, human-centred design, telehealth, nominal group technique, healthcare access, assistive technology, BMC Digital Health