Large Print
Increasing the size of the object is most commonly put into practice in the form of ‘large print’, when it may be used alone, or in addition to another form of magnification such as a hand-held plus lens.
The size of print used varies between sources, but is approximately 18- to 24-point. Print of 16-point size may be called ‘enlarged’ and ‘giant’ print is 24-point or greater. As well as the increase in size of approximately 1.5× to 2.5× provided by large print in comparison to ‘standard’ print (which is typically 10- or 12-point), the typeface, letter spacing, and line length and spacing, may all differ. These features, along with the colour of the text and background, and the print contrast, could be changed in order to increase legibility. There is no standard for large print, and publishers seem to select print characteristics for aesthetic reasons, so not all large print books will be read equally easily by a particular individual.
There is an extensive research literature on the topic of typeface legibility in reading ( ), including some studies of readers who are visually impaired. One very noticeable characteristic of a font is whether it is proportionally spaced, (a thin letter like l takes up less space than a wide letter like m) or fixed-width (monospaced: all letters take up the same space). Nowadays most fonts are the former, although the latter makes it easier to estimate word length (important when planning eye movements for reading) and may be better for those with central vision loss who may experience more crowding ( ). Kerning can also be added to software fonts. This is an increase in the spacing between certain letter pairs to avoid confusion: so, for example, cl is not mistaken for d, or nn is not read as m.
Sans-serif fonts are thought to be easier to read than seriffed letters, and feature in texts aimed at those with learning disabilities. The Tiresias and the American Printing House for the Blind fonts (APHont) for visually impaired readers also use that rationale. Gary Rubin and colleagues found that people with low vision read Tiresias more quickly than three other fonts (Helvetica, Foundry Form Sans and Time New Roman), but that this was because at each font size, Tiresias is slightly larger than the other fonts ( ). When x-height was equalised, there was no difference in reading speed between these typefaces by people with low vision. tested two other specially designed fonts—Eido and Maxular—against Courier, Helvetica and Times Roman ( Fig. 6.1 ) ( ). They found that Courier allowed those with macular degeneration to read text with a significantly smaller x-height (i.e. better reading acuity), but Courier (and the other fonts with wider spacing) led to slightly lower reading speed.
People with macular disease read more quickly and with fewer errors when line spacing and word spacing are increased ( ) although this effect is quite small and is suggested only for those with very slow reading speed ( ). Increased spacing on printed text requires considerably more paper and is not always practical to implement.
Large Print Books and Other Publications
Previously only produced by specialist publishers, large print books are now also in the catalogues of mainstream publishers, and available from online suppliers. They are also commonly available through local public libraries, although the range of titles available varies considerably. A number of religious publishers produce large print versions of the Bible, and devotional literature for a number of denominations is available. Technically, there is no limitation to how printed material could be formatted, but there are extensive copyright restrictions, which limit the ability to modify or distribute a published work.
A ‘Big Print’ TV and radio guide is available from Royal National Institute of Blind People (RNIB) on subscription. Both RNIB and the Partially Sighted Society sell crossword and puzzle books, diaries and calendars in their online shops; RNIB also offer recipe books. CustomEyes produces about 4000 children’s titles (both educational and fiction) as books with a user-selected format ( .). The typeface, weight (bold or normal), font size, line spacing, paper colour and binding (e.g. spiral, so the pages lie flat) can all be customised. Specialist centres such as the Joseph Clarke Service in London can produce books in specific formats, although it may take some time for these books to be made. It will often be easier for students to obtain books electronically and to read them on a tablet computer or e-reader. Alternatively, the RNIB library provides textbooks in electronic formats which can be printed out in the font, colour and spacing chosen by the person with low vision.
Other Large Print Documents
It is a requirement of the Equality Act 2010 that service providers do not treat the users of their services less favourably because of their disability. Providers are required to make reasonable adjustments, and one very simple option which is offered is the provision of large print information (other accessible formats are also usually offered such as Braille or audio). Banks, utility companies and local councils, should therefore, on request, provide any correspondence or information leaflets in the preferred format.
From July 2016, the Health and Social Care Act 2012 required that organisations providing NHS health and adult social care must follow the Accessible Information Standard. This requires that individuals with a disability or sensory loss are asked if they have any information or communication needs, and how those needs should be met. They must then receive information in a format they can access, and large print would be an important option. Accessing information about their medication, and reading pharmacy labels, are acknowledged concerns of patients with visual impairment ( ). These issues should be addressed by the Accessibility Standard, but there was poor awareness of its existence amongst patients ( ) and of the needs of visually impaired patients amongst pharmacists ( ). Patients should therefore be encouraged to be proactive if they are experiencing problems managing their medications, or indeed in receiving any health information in an inaccessible format. The RNIB have published a ‘toolkit’ giving guidance on how to proceed ( ).
There are a number of commercial transcription services which specialise in producing documents in Braille, and a number of them are also equipped to provide large print. There is obviously some expense and delay inherent in having items produced this way. Large print material can, however, be produced by enlargement on a photocopier, and this could be suggested to a patient for, for example, a favourite knitting pattern or recipe. Local public libraries and high-street stationery shops often have such equipment, and charges should be modest. If copying is done repeatedly to increase print size still further, the print contrast will diminish rapidly. It should be noted that smaller font sizes have proportionally greater letter spacing, so text magnified by photocopying (or indeed by viewing it through any magnifying device) will have greater spacing than when printing the document using a larger font size.
Large print music is available which is produced in a slightly different format to standard musical scores. If the standard score is simply enlarged overall, then the spacing between notes becomes excessive, and there is increased risk of the reader losing the line. Modified Stave Notation (MSN) is used, where the symbols are enlarged (and can be repositioned and/or explained by words), and redundant spaces are eliminated: typically any text is 24-point bold. Music notation software, available in the form of an app, has made the production of MSN much easier, and users can customise and store their preferred layout.
Advantages and Disadvantages of Large Print as a Rehabilitation Strategy
Using large print as a method of magnification has the following advantages and disadvantages:
Advantages
- 1.
The patient’s habitual reading posture can still be used; the object is viewed binocularly at a ‘normal’ reading distance.
- 2.
No special instruction or training in use is required, whereas this would be necessary to benefit fully from the use of an optical aid.
- 3.
There is no unusual cosmetic appearance, nor any of the restrictions apparent with optical aids (such as aberrations, or a reduced field-of-view). Some school students may, however, be sensitive to being seen by peers with very large-scale worksheets or examination papers when they have requested large print.
- 4.
No eye examination or professional advice is required: the patient can take the initiative and try the method out for themselves.
Disadvantages
- 1.
In the case of a printed book, as the print size has increased, the book itself must also increase proportionately in physical size. This can make it difficult to handle, and to carry home from the library! In some very thick books (such as the Bible), the publishers may use very thin paper to moderate the size of the book, and this can be difficult to read because of shadows partially seen through from the reverse of the page.
- 2.
As most books are in portrait format, enlarged print can mean very few words per line, which can make navigating around the page more challenging: the reader has to make more return sweep eye movements from the end of one line to the beginning of the next line.
- 3.
There is often only a standard, limited amount of magnification available, rarely exceeding 2×. Nonetheless, the RNIB survey ( ) found that 58% of blind and 75% of partially sighted individuals could comfortably read a print sample of bold 16-point type, thus suggesting that this strategy may be more widely applicable than previously thought.
- 4.
Only a limited range of book titles is available (probably <1% of the titles available in print), with the publishers concentrating on fiction likely to appeal to a wide readership. There are almost no technical or reference books, although some dictionaries are available. When diagrams or tables are enlarged, the captions may remain in a smaller font. There are also relatively few children’s fiction books, particularly for those in their teens.
- 5.
If enlarged print is prepared by photocopying, the print contrast and quality will suffer and pictures will usually be black-and-white. All material must be organised and prepared well in advance (which may be a disadvantage for vocational or educational use).
There is some controversy about whether children should invariably be encouraged to use large print, rather than using ‘normal’ print and gaining magnification with an optical device. There are further criticisms in using large print in the educational setting: it does not provide the child with a means of access to general print sources outside school, and it does not remove the need for other aids to cope with magnification needs for intermediate and distant tasks (e.g. art and craft work, or mobility). found that children using optical aids and normal print continued to show an increase in reading speed and ability throughout their school career, whereas the performance of those who used large print appeared to plateau. describe an objective procedure for determining a child’s reading performance under these different circumstances to decide which method is ‘best’: in general, however, large print did not increase reading speed, accuracy or the working distance. , however, suggests that optical aids provide a slower reading speed for children, and that in fast-moving interactive classroom sessions, the large print option will prove much more practical ( ). For adult readers, found no difference between reading performance using relative size or relative distance magnification.
E-Books
Electronic books, or e-books, are publications which are made available digitally and which can be accessed via reading from the screen of a computer or smartphone or from a dedicated e-reader ( Fig. 6.2 ).
