A Protocol to Assess Usability and Feasibility of e-SpeechT,

a Web-based System Supporting Speech Therapies

Vita Santa Barletta

, Miriana Calvano

, Antonio Curci

and Antonio Piccinno

Computer Science Department, University of Bari Aldo Moro, 70125 Bari, Italy

Keywords:

Speech Therapy, e-Health, Speech Impairment, Gamiﬁcation, Usability Study, Telemedicine, Game-based

Learning.

Abstract:

Speech disorders and impairments are a heterogeneous group of dysfunctions that concern linguistic abilities

and, in the majority of cases, they affect people during their childhood from 4 to 6 years old. Appropriate

treatment should be deﬁned for each patient according to their problems, which can be physical, such as

muscle weakness, brain damage, vocal cord damage, or paralysis, and psychological, such as autism, PTSD

or Down Syndrome. Therefore, considering these aspects, this research work aims at supporting patients in

carrying out therapies to solve speech impairments through gamiﬁcation, game-based learning, e-health, and

telemedicine. A web-based system is proposed to achieve the goals by supporting all stakeholders involved in

speech therapy. The design and plan of a usability and a longitudinal study have been presented, with the goal

of testing the system’s usability and medical efﬁcacy by involving real end-users and domain experts.

1 INTRODUCTION

Speech therapy is the treatment of speech disorders

founded on the application of notions and methods

pertaining primarily to phoniatrics but also to other

disciplines such as glottology, psychology, pedagogy,

and neurology (Law et al., 2003).

Speech disorders refer to the disruption of ”nor-

mal speech”: they affect the vocal cords, muscles,

nerves, and other structures within the throat, due for

example to vocal cord damage, brain damage, mus-

cle weakness, or vocal cord paralysis. So, the ar-

eas of communication involved in this disorder are

phonology, the pattern of sounds used by the child;

grammar, the way that language is constructed; vo-

cabulary, the words that a child can say and under-

stand, morphology, meaningful changes to words to

signal tense, number, etc.; narrative skills, the ability

to relate a sequence of ideas; pragmatic language that

refers to the social language skills in the interaction

with others and in a given situation (Hourcade, 2015;

Law et al., 2003; Adams et al., 2012).

Nowadays, rehabilitation therapies for speech

https://orcid.org/0000-0002-0163-6786

https://orcid.org/0000-0002-9507-9940

https://orcid.org/0000-0001-6863-872X

https://orcid.org/0000-0003-1561-7073

problems are administered by specialists, who are

called speech therapists, and consist in the perfor-

mance of exercises calibrated and chosen with the

aim of solving the speciﬁc problems of each subject.

Assessment of eligibility for intervention includes

a combination of standardized assessment, observa-

tions of linguistic and communicative performance,

and professional judgment (Law et al., 2003). Thanks

to speech therapies, speech disorders can improve: in

order to strengthen the muscles of the face and throat,

a professional therapist guides the patient through dif-

ferent types of exercises (Barletta et al., 2022). It is

important to underline that therapists prescribe chil-

dren to also practice also at home. In some cases,

exercises are perceived as boring, which causes chil-

dren to underperform, to carry them out incorrectly,

or to refuse to perform them. Unfortunately, this as-

pect is not veriﬁable by therapists and it is out of their

control. Thanks to the currently available technology,

these limitations can be overcome and patients can

feel more comfortable.

In speech therapy, three categories of stakeholders

are involved:

1. Speech therapists, who are doctors who have the

goal of resolving problems involving speech im-

pairment and disorders. They usually deﬁne a

personalized treatment program to help solve chil-

dren’s speech difﬁculties and prevent subsequent

546

Barletta, V., Calvano, M., Curci, A. and Piccinno, A.

A Protocol to Assess Usability and Feasibility of e-SpeechT, a Web-based System Supporting Speech Therapies.

DOI: 10.5220/0011893300003414

In Proceedings of the 16th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2023) - Volume 5: HEALTHINF, pages 546-553

ISBN: 978-989-758-631-6; ISSN: 2184-4305

literacy problems.

2. Caregivers, who are parents or anyone who looks

after the children when they have to follow speech

therapies.

3. Patients, who are children from 4 to 6 years old

who are affected by speech disorders.

Currently, limited technological applications sup-

port speech therapists and patients during therapy at

home (Cassano et al., 2022). But at the same time, the

researchers demonstrate that the idea of supporting

this process by using multimedia and smartphone to

make the activity more enjoyable for the target users

is quite widespread (Jesus et al., 2019a; Pentiuc et al.,

2010; Rossano et al., 2020). Thus, considering the

ever-evolving and ever-growing ICT in the medical

ﬁeld, the idea is to develop a system that simpliﬁes

the process of administering therapies to children, be-

cause it enables them to carry out exercises from their

homes, having their caregiver’s supervision and the

therapists’ remote monitoring (Desolda et al., 2021;

Butcher et al., 1987). This can be possible if therapies

are delivered through mobile and ”smart” computing

devices. This results in the development of mobile ap-

plications or, even better, the introduction of systems

that can be accessed from mobile devices, and with

the introduction of new concepts and principles, such

as ”gamiﬁcation” and ”game-based learning” (Saeedi

et al., 2022) for a more effective employement in fol-

lowing the therapies.

The paper presents a web-based system to sup-

port speech therapists in administering and monitor-

ing therapies that aim at solving problems involv-

ing phonology, morphology, content, and structure of

speech. It represents a concrete application of princi-

ples, such as e-health, telemedicine, gamiﬁcation, and

game-based learning. The system targets are children

as patients, from 4 to 6 years old, speech therapists,

and caregivers.

The goals are to help therapists to manage and to

monitor their patients in a quicker and more structured

way; patients carry out the exercises without the need

to physically go to a facility. In addition, the plan of a

usability study and a longitudinal study is presented,

which will be performed in the next future to test the

system’s usability and medical efﬁcacy.

2 SYSTEM DESCRIPTION

e-SpeechT is a system that offers different function-

alities and graphical interfaces for each type of user

will be shown. On the welcome page of e-SpeechT,

users can select their role, log in or create a new ac-

count. Therapists, caregivers, and patients play three

distinctive roles, according to which the system dis-

plays and enables different functionalities. In order to

be consistent with its diverse audience, when children

use the application, the graphical interface becomes

more playful.

2.1 Speech Therapist

The speech therapist’s perspective of e-SpeechT al-

lows to create and to monitor therapies for each child.

More speciﬁcally, as shown in Figure 1, the main

actions that the system allows speech therapists to

perform are listed below: view current and previ-

ous diagnoses; create new therapies and view previ-

ous ones; view the results and their statistics of the

exercises carried out by the patient; check and per-

form corrections on the previously-mentioned exer-

cises; view patients’ personal data.

Figure 1: An example of the patient’s web-page from the

therapists point of view.

The menu section in the upper-central part of Fig-

ure 1 is composed of four sections:

1. add a new patient;

2. monitor and create exercises for therapies;

3. open a calendar where the schedule of appoint-

ments for each patient is shown;

4. receive miscellaneous notiﬁcations.

In addition, speech therapists can create a series,

that is a predeﬁned sequence of exercises that will

be administered each time in the same order. It is

crucial to adapt the level of difﬁculty of exercises

to the patient’s needs, age, and diagnosis in order

to make a balanced and proper evaluation (Pagano

and Marengo, 2021). e-SpeechT allows therapists to

set an error tolerance threshold that plays an impor-

tant role in the automatic correction of exercises per-

formed by the system. This functionality was imple-

mented by training a classiﬁcation model using the

voice recordings of ﬁfteen children. In Figure 2, an

example of threshold setting is shown.

A Protocol to Assess Usability and Feasibility of e-SpeechT, a Web-based System Supporting Speech Therapies

547

Figure 2: Setting of the error tolerance threshold.

The visualization and the automatic exercise cor-

rections provided by the system to the therapist are

shown in Figure 3. However, therapists are allowed

to change these corrections manually.

On the top right, a drop-down menu allows to

change their personal data, view the screening page,

and log out of the system.

Figure 3: Therapy and patient overview.

2.2 Caregiver

Similarly to speech therapists, the ﬁrst page shown

to caregivers is an overview of all the children that

they are associated with, because there might be mul-

tiple patients in the same family. The following

functionalities are offered to the caregiver: accessing

the calendar section where all the appointments and

medical examinations available; accessing the gifts

and rewards section; viewing reports and statistics

of the exercises performed by the child; viewing the

child’s personal information; changing the aspect of

the child’s personal area by setting a playful wallpa-

per, called ”scenario”.

Through their caregiver’s account, children can set

the password to log into their personal area. Since

this system targets children aged from 4 to 6 years

old, their reading and writing skills are at a very early

stage or not present at all, therefore, a graphical pass-

word has been opted for. In order to let children feel

comfortable and welcomed, the graphical password

consists of a cartoon character to be chosen from a

list proposed by the system.

Caregivers are allowed to start or stop the admin-

istration of therapy in order to choose a speciﬁc and

dedicated period of time in which a child has to carry

out the designated exercises. This functionality is

shown in Figure 4.

Figure 4: Therapy options: on the left the button that allows

to start a therapy and on the right the one that allows to stop

a therapy.

On the top right, a drop-down menu can be opened

in which caregivers can view their personal informa-

tion and log out of the system.

2.3 Patient

Patients use the system to carry out exercises pre-

scribed by the therapist by playing serious games. Ex-

amples of exercises are shown, described, and ana-

lyzed in the next section.

3 THE GAME-BASED LEARNING

APPROACH

The e-SpeechT system embodies principles like gam-

iﬁcation and game-based learning. Every aspect of

the system that involves interaction with children is

in the form of games or contains playful aspects

(Di Bitonto et al., 2014). In the following sections,

the patient area will be illustrated.

3.1 Login-Method

The login phase is composed of two steps: speech

therapist choice and password selection; each patient

can access their personal area by choosing among the

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list of speech therapists in the system by recogniz-

ing their proﬁle picture; then, they will need to select

the password image chosen together with her/his care-

giver, as shown in Figure 5.

Figure 5: Child Login page: therapist and password selec-

tion.

Once the child has successfully logged in to the

system, a home screen is shown and both a textual

and audio welcome message is given.

3.2 Exercises

Three categories of exercises can be identiﬁed in e-

SpeechT:

1. Naming images;

2. Minimum pair recognition

3. Repetition of Words.

For the ﬁrst type of exercise, Naming Images, the

system will show on the left the image associated with

the word to pronounce and on the right an orange but-

ton with the icon of a microphone. Under this button,

hints are provided for the execution of the exercise in

the form of buttons representing a loudspeaker; press-

ing on them, the system will reproduce vocally the

selected hint. See, as an example, Figure 6.

Figure 6: Naming Images exercise.

In the Minimum Pair Recognition exercise, the

graphic interface will consist of two images corre-

sponding to the words placed on the sides of the

screen, and a button with a speaker icon between

them: by pressing this button, the system will repro-

duce the name of the correct word. The position of

the correct image will be randomly generated each

time a user accesses the execution of the exercise. To

perform the exercise correctly, the patient must repro-

duce the name of the word, and associate it with one

of the two images by pressing on the possibly correct

one (see, for example, Figure 7).

Figure 7: Minimun Pair Recognition exercise.

For the last type of exercise, Repetition of Words,

two buttons are shown in the center of the screen.

The ﬁrst one represents the icon of a microphone and

the second one that of a speaker; below, one next to

the other, there will be the three words that the child

will have to pronounce. By clicking on them, the im-

age associated with the words will appear as an ad-

ditional hint for the exercise. To carry out the exer-

cise correctly, the child can reproduce the sequence

of words spoken by the system by pressing the button

with the speaker icon and use the hints by pressing

on the words he is uncertain about; in any case, he

needs to press the button with the microphone icon,

pronounce the sequence of words in the correct order,

and press the same button again (see Figure 8).

3.2.1 Exercise Execution

Depending on the type of exercise the child is doing,

the proposed interface changes. Each time the child

completes the execution of an exercise, the system

will show him/her a window with a message, either

written or spoken, congratulating him/her on complet-

ing the exercise, regardless of the outcome. In case

the exercise is performed correctly, the message will

also indicate the earned cookies, which act as a re-

ward.

A Protocol to Assess Usability and Feasibility of e-SpeechT, a Web-based System Supporting Speech Therapies

549

Figure 8: Repetition of Words exercise.

4 EVALUATION PLAN

In order to plan an evaluation of the system’s usability

and medical efﬁciency, we involved two speech ther-

apists from the hospital of Bari ”Papa Giovanni Paolo

XXIII”, with whom we already collaborated in the de-

veloping process of the system. A series of meetings

and discussions were carried out with speech thera-

pists in order to get an insight into the medical aspects

to consider and the appropriate features to evaluate;

their expertise was fundamental during this phase.

Two types of studies have been planned: Usability

and Longitudinal study (Razak et al., 2010; Lazar

et al., 2017). Therefore, the usability study has the

goal of analysing the users’ overall experience with

the system and its features, while the Longitudinal

study is related to the system’s medical effectiveness

and efﬁcacy and the impact on the children’s speech

impairments. Before planning the study, to obtain an

insightful opinion about the system, a pilot study was

conducted involving two speech therapists. The prob-

lems reported in this phase were resolved in advance

to avoid evaluating an already-known faulty system.

This plan involves, in both cases, 10-13 speech

therapists and 20-23 caregivers and 20-23 patients

(because each child is associated with one caregiver).

The group of therapists has also supported the process

of drafting questionnaires, tasks choice, and the dura-

tion of the longitudinal study. In order to guarantee

participants’ privacy, it has been established to assign

to each of them an identiﬁcation code.

4.1 Usability Study

The usability study consists of the execution of tasks

and ﬁlling out questionnaires. This study is planned

to be conducted in a remote way by using the plat-

form ”eGLU-BOX”, a software to support usability

testing based on the eGLU LG 2018.1 protocol (Fed-

erici et al., 2021)

. The tasks have been chosen care-

fully by considering all the main functionalities of the

system and the domain requisites. The creation of the

testers’ accounts on eGLU-BOX will be carried out

before the administration of the test in order to speed

up the process. Two different studies have been cre-

ated: one for speech therapists and one for caregivers,

called respectively “Test iniziale e-SpeechT – Logo-

pedisti” and “Test iniziale e-SpeechT – Caregiver”,

respectively. Each task will be evaluated taking into

account the stress factor that often alters the behavior

of participants. Therefore, two additional steps will

be taken before starting the test. The ﬁrst is an expla-

nation of the study and its goal will have to be carried

out before starting the test. This evaluation plan also

includes an introductory questionnaire in which each

participant is asked to provide personal information

in order to proﬁle them and evaluate their experience

in relation to their age, experience with technology,

and systems supporting health. The second step is

a video demos of e-SpeechT, in which they will be

provided with a ﬁrst overview of the system and its

main functionalities, in order to let them gain comfort

and reduce the stress factor for novice users. The de-

mos at hand bring attention to possible malfunctions

and anomalies that might be encountered, explaining

how to recover from them. The maximum duration

planned for each task is 5 minutes.

4.1.1 Study with Speech Therapists

This study involves 10-13 therapists and the execu-

tion of 6 tasks; for each task, the participant will have

5 minutes to carry it out. The title and the instructions

for each task has a title and instructions are listed be-

low:

1. ”Create a therapy”: ﬁll out the form with the re-

quested information and add some exercises to as-

sign to the patient.

2. ”Monitor statistics”: correct and mark exercises

from the therapies section for a patient.

3. ”Create exercises”: create an exercise for each

category (Naming Images, Repetition of Words,

and Minimum Pair Recognition).

4. ”Create a new word”: create a new word, ﬁll out

the form with the requested information and add

its image.

5. ”Modify thresholds”: change the thresholds and

make some trials to check if the system’s behavior

has actually been affected.

https://egluboxpa.ddns.net/public/

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4.1.2 Study with Caregivers

The designated number for this part of the study is

from 10 to 13 caregivers. Analogously to speech ther-

apists, caregivers will be asked to carry out the follow-

ing tasks:

1. ”Set a password for a new child”: set a password

by choosing among one of the cartoon characters.

2. ”Start a therapy”: start the therapy for a child for

which the button is enabled.

3. ”Monitor statistics”: view the statistics and results

of the exercises carried out by a child.

4. ”Stop a therapy”: Stop a therapy for the child

whose therapy has been previously started.

4.2 Longitudinal Study

The longitudinal study has been planned with the goal

of measuring the effectiveness, the ease of familiar-

ization with the system, and the differences between

the traditional and experimental approaches of the

system. In order to perform a proper evaluation, the

between-subject design technique has been chosen,

which consists in forming a control and an experi-

mental group. The planning phase was carried out

after an accurate literature analysis of the use of di-

aries and data gathering in longitudinal studies (Lazar

et al., 2017); in this case, diaries are in the form of

questionnaires that are ﬁlled out periodically to un-

derstand how the interaction with the system evolves

over time. The recruitment of children and their care-

givers is delegated to the speech therapists, who are

in charge of creating two homogeneous groups in or-

der to balance out potential individual differences that

could ruin the end results. After many meetings and

an in-depth discussion, it was concluded that since

the smallest period of time necessary to obtain med-

ically relevant results and to check the impacts of

therapies on children is 6 weeks, the estimated dura-

tion of the study is 6-8 weeks. The effectiveness and

relevancy of continuous communication with thera-

pists during longitudinal studies can be observed in

the literature, too; an example is the ”Tablet-to-Tablet

(T2T) Speech and Language Therapy Software De-

velopment Roadmap” (Jesus et al., 2019b), in which

the testing phase of systems that support speech ther-

apies focuses on real end-users and lasts around 6

weeks. It is worth to underline that the medical re-

sults of the study will be evaluated by the speech ther-

apists, while computer scientists will take care of only

the technical aspects.

In the following two sections, the activities of each

group will be described in more detail.

4.2.1 Experimental Group

The experimental group will be formed by 10-13 pa-

tients with their caregivers and they will carry out

the therapies with the support of e-SpeechT. The plan

consists of the periodical administration of a ques-

tionnaire, through Google Form, that consists of ques-

tions about the main services that participants avail of,

according to the type of participant. Two question-

naires have been created, and both of them contain

questions about the experience of the patient in order

to get an insight from two different points of view.

The questionnaire for the speech therapists includes

questions that concern the used device, the ease of

use when creating a therapy, the automatic correc-

tion tool for exercises, and a section for possible other

weaknesses or problems that emerged. The question-

naire for caregivers includes questions that concern

the process of starting/stopping the therapy, the expe-

rience while ﬂanking their child while using the sys-

tem, monitoring the statistics, and a section for other

miscellaneous observations.

For caregivers, the questionnaire is administered

right after the child’s completion of the series of ex-

ercises planned for the day, implemented into the sys-

tem.

The section of the questionnaire concerning the

patient’s experience remains unchanged regardless of

whether it is administered to a caregiver or a therapist.

They are asked about the time taken to complete ex-

ercises, the process of logging in their personal area,

the emotions expressed by the child while playing and

how they are adjusting to the system as time passes.

Some questions are:

• ”If the child encountered problems while logging

into e-SpeechT, please specify them”.

• ”Did the child have fun while playing?”

• ”Did the child want to quit the game before its

end?”

The type of response varies among Likert scale,

multi-options, and open text.

Emotional reactions are crucial when it comes to

evaluating children’s experiences because they are of-

ten raw and unﬁltered, letting the most relevant as-

pects emerge. Since the target patients are children,

asking them to ﬁll out a questionnaire would be in-

feasible for two main reasons: the playful atmosphere

would get ruined and some of them are not old enough

to read and comprehend their content. Hence, care-

givers and therapists will have to answer in their

place. Nevertheless, a prototype of a pop-up has been

designed and implemented in order to administer a

rating scale question directly to the patient through a

A Protocol to Assess Usability and Feasibility of e-SpeechT, a Web-based System Supporting Speech Therapies

551

smileyometer, shown in Figure 9, in which the scale

is in the shape of smileys (Bell, 2007; Jesus et al.,

2019b).

Figure 9: Pop-up with smileyometer.

The data obtained through these questionnaires

will be analyzed at the end of the study to understand

its outcomes and results; they will be compared with

those obtained from the control group to draw conclu-

sions.

4.2.2 The Control Group

The control group will be formed by 10-13 patients

with their caregivers and they will carry out the ther-

apies in a traditional way, without the help of e-

SpeechT. They will not have to answer periodic ques-

tionnaires, since traditional protocols and methods do

not need to be further proven as effective. The com-

parison will only involve the results and the impact

that the therapies have had on the children.

5 CONCLUSIONS AND FUTURE

WORKS

Systems that support medicine, health, and well-

being are spreading more and more in today’s world.

Speech therapy is a ﬁeld in which technology can

be extremely helpful since patients’ perseverance and

time consistency is crucial for the successful outcome

of treatments. e-SpeechT is a web-based system de-

signed for speech therapists who oversee young pa-

tients with primary language disorders, followed in

their therapies by a Caregiver, who can be a parent

or a ﬁgure close to the child who assists her/him in

the execution of therapies. Dealing with systems that

are accurately designed and carefully tested is funda-

mental in order for them to be effective, efﬁcient, and

satisfactory.

The initial pilot study with speech therapists

brought up some interesting points that highlighted

the problems and strengths of the system, which re-

sulted to be very useful to plan the usability and lon-

gitudinal studies. This study researched the most con-

venient and appropriate ways to evaluate e-SpeechT

in question by creating an evaluation plan both for

usability and longitudinal studies can be the tool to

portray an analysis of the most relevant aspects of

e-SpeechT. The evaluation plan also involved initial

research of the potential participants to recruit. The

study was not conducted right after the planning phase

because of the COVID-19 pandemic. It resulted that

parents and caregivers were not enticed by the idea of

letting their children follow therapies on digital plat-

forms because of the long period of forced distance

learning that had just passed. Therefore, it is intended

to conduct the planned studies at a later time. Gaining

familiarity with new applications and systems might

be demanding for some; nevertheless, the advantages

that come after that ﬁrst phase are highly beneﬁcial

to all parties involved. In addition, speech therapists

appreciated e-SpeechT during the pilot studies and

seemed to grasp its potential; they have shown interest

to extend the use of the system also to children with

more serious issues, such as Down syndrome.

As future works, it would be interesting to use

the Medical Research Framework (Craig et al., 2008;

Shahsavari et al., 2020) to understand the differences

between assessing feasibility and assessing effective-

ness of the system; this framework emphasizes that

any intervention should be presented to the patients

tailored to the context and culture of the society they

live in, considering political, social, and geographi-

cal aspects (Huang et al., 2021). In conclusion, it is

intended to improve the implementation of the login

method for children by adding a geolocalization fea-

ture, in order to improve the systems’ security and

preserve users’ privacy (Baldassarre et al., 2021).

ACKNOWLEDGEMENTS

The support of University of Bari through grant

“Horizon Europe Seeds 2021” is acknowledged. We

would also thank the student Pier Luigi Laviano

who re-engineered the system during his master the-

sis work, the speech therapists Isabella Roppa and

Roberta Cassano from the “Giovanni XXIII” Pedi-

atric Hospital of Bari for their collaboration in the

system requirements collection, analysis, and study

planning.

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