J2 - GAO NLS Report - April 2016 - pp. 41.pdf

LIBRARY SERVICES

FOR THOSE WITH

DISABILITIES

Additional Steps Needed to Ease Access to Services and Modernize Technology

Report to Congressional Committees

April 2016

GAO-16-355

United States Government Accountability Office

United States Government Accountability Office

Highlights of GAO-16-355, a report to congressional committees

April 2016

LIBRARY SERVICES FOR THOSE WITH

DISABILITIES

Additional Steps Needed to Ease Access to Services and Modernize Technology

Why GAO Did This Study NLS, within the Library of Congress (LOC), provides free audio and braille materials for U.S. citizens and residents who cannot read standard print due to visual and other disabilities. In fiscal year 2016, the NLS program received about $50 million in federal funds to provide these materials through a national network of libraries. The House report accompanying the fiscal year 2016 legislative branch appropriations bill included a provision for GAO to review NLS’s users and the technology it employs to meet their needs.

GAO examined (1) the characteristics of NLS users and the steps NLS is taking to ensure eligible individuals’ access and awareness, and (2) how NLS provides materials and the extent to which it is considering emerging trends in technology. GAO reviewed relevant federal laws and regulations, NLS documents, and administrative data; interviewed NLS officials, librarians from 8 of the 101 network libraries selected for geographic diversity and a range in the number of users, and officials from research and advocacy groups and assistive technology companies; and reviewed literature on NLS-eligible populations and trends in assistive technologies.

What GAO Recommends Congress should consider authorizing NLS to provide its users devices for reading electronic braille files. In addition, GAO recommends that NLS re-examine its eligibility certification requirements, evaluate its outreach, and assess alternative approaches to delivering audio content. LOC generally agreed with these recommendations.

What GAO Found The National Library Service for the Blind and Physically Handicapped (NLS) is primarily used by older adults with visual disabilities, and NLS has taken some steps to ensure eligible users’ access to and awareness of available services. In fiscal year 2014, about 70 percent of the program’s 430,000 users were age 60 and older and almost 85 percent had visual disabilities, according to the most recent NLS data available at the time of GAO’s review. Federal regulations establish eligibility for NLS services for people with a range of disabilities.

However, medical doctors must certify eligibility for people with reading disabilities such as dyslexia, which is not required for those with visual or physical disabilities. According to officials from network libraries and other stakeholder groups, the requirement for a doctor’s certification is an obstacle to accessing services because of additional steps and costs to the individual. These officials and stakeholders said other professionals, such as special education teachers, are also positioned to certify eligibility for applicants with reading disabilities. GAO has previously noted the importance of disability programs keeping pace with scientific and medical advances. However, the certification requirement has remained largely unchanged for more than 40 years. NLS has taken steps to inform eligible groups about its services, such as partnering with other organizations that serve these groups, developing a new website, and distributing an outreach toolkit to network libraries. However, NLS has no plans to evaluate which outreach efforts have resulted in new users in order to ensure resources are used effectively—a key practice identified previously by GAO.

NLS offers materials to its users in a range of formats, but its efforts to adopt new, potentially cost-saving technologies are hampered by limitations in both its statutory authority and its analyses of alternatives. Users may choose to receive, through the mail, audio materials on digital cartridges or hard copy braille documents. Users may also choose to download audio and braille files from an NLS-supported website. During fiscal year 2014, 86 percent of users chose to receive audio materials on digital cartridges, according to NLS data. NLS officials said they would like to provide users with devices for reading electronic braille files, a faster and less bulky approach than braille documents, and per the agency’s July 2015 analysis, could become more cost effective with technological advances. However, federal statute does not authorize NLS to use program funds to acquire and provide braille devices as it does for audio devices, which prevents the agency from taking advantage of technology that has the potential to reduce costs. NLS is also examining new technologies for audio materials but has not fully assessed available alternatives. For example, NLS is considering supplementing its collection of human-narrated audio materials with text-to-speech (i.e., synthetic speech) materials, which some evidence suggests could be produced more quickly and at a lower cost. However, NLS has not comprehensively compared the text-to-speech option to its current approach in order to make a decision on whether to move forward, as called for by GAO best practices for alternatives analysis. Without this analysis, NLS may miss an opportunity to meet its users’ needs more efficiently and cost effectively. View GAO-16-355. For more information, contact Daniel Bertoni at (202) 512-7215 or bertonid@gao.gov.

http://www.gao.gov/products/GAO-16-355 http://www.gao.gov/products/GAO-16-355

Page i GAO-16-355 Library Services for Those with Disabilities

Letter 1

Background 3 NLS Users Are Primarily Older Adults with Visual Disabilities, but

NLS Efforts Are Not Ensuring Full Access and Awareness 8 NLS Offers Materials in a Range of Formats, but Statutory and

Other Limitations Impede Adoption of Potentially Cost-Saving Technologies 15

Conclusions 28 Matter for Congressional Consideration 28 Recommendations for Executive Action 29 Agency Comments and Our Evaluation 29

Appendix I Comments from the Library of Congress 31

Appendix II GAO Contact and Staff Acknowledgments 35

Related GAO Products 36

Figures

Figure 1: Organizational Structure of the Library of Congress 5 Figure 2: Age of NLS Users, on September 30, 2014 10 Figure 3: Distribution of Disabilities among NLS Users, on

September 30, 2014 11 Figure 4: Percentage of NLS Users Accessing Reading Materials, by Format, Fiscal Year 2014 17 Figure 5: Number of NLS Reading Materials Circulated to Users, by Format, Fiscal Years 2010-2014 18 Figure 6: NLS Specialized Audio Players and a Commercially

Available Audio Device 19 Figure 7: Hard Copy Braille Book and a Refreshable Braille

Device 22

Contents

Page ii GAO-16-355 Library Services for Those with Disabilities

Abbreviations

ACS American Community Survey BARD Braille and Audio Reading Download system IDEA Individuals with Disabilities Education Act LOC Library of Congress NCLD National Center for Learning Disabilities NFB National Federation of the Blind NHIS National Health Interview Survey NLS National Library Service for the Blind and Physically

Handicapped USPS United States Postal Service

This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately.

Page 1 GAO-16-355 Library Services for Those with Disabilities

441 G St. N.W.

Washington, DC 20548

April 4, 2016

The Honorable Shelley Moore Capito Chairman The Honorable Brian Schatz Ranking Member Subcommittee on Legislative Branch Committee on Appropriations United States Senate

The Honorable Tom Graves Chairman The Honorable Debbie Wasserman Schultz Ranking Member Subcommittee on Legislative Branch Committee on Appropriations House of Representatives

The National Library Service for the Blind and Physically Handicapped (NLS), within the Library of Congress (LOC), provides free, accessible reading materials for those who cannot read standard print. A substantial number of Americans have difficulty reading standard printed material due to visual and other types of disabilities. For example, according to one estimate, nearly 21 million Americans are blind or have visual disabilities.1 Others may have trouble holding or handling a book due to conditions such as quadriplegia or paper allergies. The inability to read can have a significant impact on an individual’s education, work capacity, and full integration in society. The program was authorized in 19312, and it received about $50 million in federal funding in fiscal year 2016. U.S.

citizens and residents with sufficiently severe visual or physical disabilities or reading disabilities resulting from organic dysfunction such as dyslexia and other learning disabilities are eligible for the NLS program.

Headquartered in Washington, D.C., NLS operates in conjunction with a national network of state and local libraries that conduct outreach, 1Centers for Disease Control and Prevention, Summary Health Statistics for U.S. Adults:

National Health Interview Survey, 2012 (Hyattsville, MD: February 2014).

2Pub. L. No. 71-787, 46 Stat. 1487.

Letter

Page 2 GAO-16-355 Library Services for Those with Disabilities determine eligibility, and distribute reading materials. In addition, the United States Postal Service (USPS) receives funds to cover the costs of mailing these materials. The House report accompanying the fiscal year 2016 legislative branch appropriations bill included a provision for GAO to review NLS’s services, including its user base and the technologies it has in place to meet users’ needs.3

We examined: (1) the characteristics of NLS’s users and the steps NLS is taking to ensure those eligible are aware of and have access to its services, and (2) how NLS provides materials to users and the extent to which it is considering emerging trends in technology.

To address these objectives, we reviewed relevant federal laws and regulations, as well as NLS documents including procedures, strategic planning documents, studies by external contractors on NLS’s outreach and its braille program, and assessments of network library performance.

We reviewed NLS administrative data for fiscal years 2010 through 2014, the most recent available at the time of our review, on the number of users, user demographics, and formats in which materials were provided.

We assessed the reliability of these data by interviewing cognizant NLS officials and reviewing related documentation, and found the data to be sufficiently reliable for our reporting objectives. Additionally, we interviewed officials from NLS, LOC, and USPS. We also interviewed staff at 8 of NLS’s 101 network libraries about topics including user demographics and NLS technologies. We interviewed librarians in the District of Columbia, Georgia, Illinois (two libraries), Massachusetts (two libraries), Oklahoma, and Washington state. We selected these libraries to achieve diversity in geographic location, number of users, and outreach practices. For example, we included some libraries that had piloted new outreach materials from NLS or changed their organizational structure in recent years. We also interviewed officials from a number of external stakeholder groups, including research and advocacy organizations for relevant disabled populations; other organizations that provide accessible reading materials; private companies that produce assistive technology for those with visual disabilities; and the CNIB Library, a private non-profit

3See H.R. Rep. No. 114-110 (2015), which accompanied H.R. 2250, 114th Cong.

Page 3 GAO-16-355 Library Services for Those with Disabilities library in Canada for those with visual and other disabilities.4 Finally, we reviewed select articles and reports on the demographics of NLS-eligible populations and trends in assistive technologies for these populations. To assess NLS’s efforts to ensure access to its services and consider technological trends, we used criteria previously identified by GAO in the areas of disability evaluation, outreach, and alternatives analysis, as well as criteria for internal controls in the federal government.

We conducted this performance audit from June 2015 through April 2016 in accordance with generally accepted government auditing standards.

Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

NLS operates a program that provides free reading materials for residents and citizens of the United States and its territories as well as U.S. citizens residing abroad who are generally unable to read standard print because of a visual or physical disability. Under its authorizing statute, the program may provide reading materials in braille, audio, and other formats, and since the 1940s, may provide devices for reproducing audio recordings.5 The types of materials that NLS provides include books, magazines, music scores and materials for music instruction. In addition, NLS users have access to over 400 state, national, and international audio and braille newspapers through Newsline, a telephone and internet-based

4 Specifically, we interviewed officials from these research and advocacy organizations:

American Council of the Blind, American Foundation for the Blind, National Federation of the Blind (NFB), Blinded Veterans Association, National Center for Learning Disabilities (NCLD), and the Center for Applied Special Technology. We also interviewed officials from these organizations that provide accessible reading materials: American Printing House for the Blind, Bookshare, Learning Ally, and National Braille Press. We also interviewed officials from the private sector technology companies HIMS, Inc. and HumanWare.

5Under federal law, it is not an infringement of copyright for authorized entities, including NLS, to reproduce and distribute certain published literary works in specialized formats for the use of blind and other persons with disabilities. 17 U.S.C. § 121.

Background

Page 4 GAO-16-355 Library Services for Those with Disabilities service.6 The Free Matter for the Blind and Other Physically Handicapped Persons program, administered by USPS, assists NLS in circulating materials to its users. In fiscal year 2016, USPS had a budget of approximately $55.1 million for free delivery of mail in the NLS program and certain other purposes. USPS delivered 43.9 million pieces of mail through the program during fiscal year 2015.

NLS is within the LOC’s Office of National and International Outreach, under LOC’s organizational structure effective Oct. 1, 2015 (see fig. 1).

NLS receives its own congressional appropriation; however, LOC oversees the budget and activities of NLS and approves its budgeting decisions. For instance, if NLS’s budgetary plan includes investing in a new technology initiative, it must submit a proposal for approval by LOC’s Information Technology Steering Committee. LOC also oversees NLS’s strategic planning process. NLS is currently in the process of developing its first comprehensive strategic plan, which NLS officials stated will be completed in fiscal year 2016.7 LOC will review this plan to ensure it aligns with LOC’s overall strategic plan. In addition, LOC has oversight of NLS through processes such as monitoring, checks of internal control procedures, and performance management.

6In fiscal year 2016, the Library of Congress (LOC) received federal funding of approximately $50.2 million for the program operated by NLS, which included $650,000 that was specified to support a free newspaper service to blind and physically disabled residents. Regarding this latter amount, LOC has contracted with NFB, which operates Newsline with a combination of federal and state funds, to have NFB utilize those funds.

According to NLS officials, NLS users qualify for the Newsline service because the qualification standards for both NLS and Newsline are identical, and eligible users can sign up for both services simultaneously.

7In the draft of this strategic plan, several broad priorities have already been identified, including increasing public awareness of the NLS program, increasing the quantity and variety of the materials available to users, and making options for the delivery of NLS reading materials more timely and user-friendly.

NLS’s Structure and Administration

Page 5 GAO-16-355 Library Services for Those with Disabilities

Figure 1: Organizational Structure of the Library of Congress

Note: This figure is a simplified depiction of the relevant components of the Library of Congress’s organizational chart.

Administration of the NLS program is shared between NLS headquarters and a national network of libraries and outreach centers. Headquarters is located in Washington, D.C., and its staff’s functions and responsibilities include selection and production of reading materials, procurement of playback equipment, establishment of standards and assurance of quality products and services, and development, maintenance, and circulation of the specialized music collection. In addition, NLS relies on a network of 101 regional and sub-regional libraries and outreach centers to implement the program. Most states have one regional library participating in the network that is operated by the state or other entity. Some states also have sub-regional libraries that coordinate with the regional libraries to serve a specific geographical area, and are generally operated by public libraries. NLS network libraries conduct outreach to potential users;

screen applicants for eligibility; provide customer service to users such as assistance with selecting an appropriate NLS device and identifying

Page 6 GAO-16-355 Library Services for Those with Disabilities preferred reading materials; store, maintain, and circulate NLS books and machines; and report to NLS on equipment, books, and users.8 The operating costs for these activities and services are not funded by NLS but rather by state, local, and other sources.

Under LOC regulations, the following four categories of individuals are eligible to access the NLS program:9

• Blind This refers to persons whose visual acuity is 20/200 or less in the better eye with correcting glasses or who have a restricted field of vision.10

• Visual Disability This refers to persons whose visual disability with correction prevents the reading of standard printed material.

• Physical Limitation This refers to persons who are unable to read or unable to use standard printed material because of physical limitations.11

• Reading Disability Resulting From Organic Dysfunction This refers to persons who have a reading disability resulting from organic dysfunction that is severe enough to prevent them from reading printed material in a normal manner. An NLS factsheet states

8Additionally, there are Advisory and Outreach Centers that assist with outreach efforts on behalf of NLS and provide connectivity to the NLS automated circulation system;

independent machine-lending agencies designated by NLS to circulate NLS devices; and two multistate centers that store and distribute playback equipment and supplies, specialized collections of materials, and back-up copies of the NLS collection.

936 C.F.R. § 701.6.

10This category includes people whose wide diameter of visual field subtends an angular distance no greater than 20 degrees.

11The term “physical limitation” is used in LOC’s regulatory language. For the remainder of this report, all the disabilities in this category will be referred to as “physical disability.”

Populations Eligible for

NLS

Page 7 GAO-16-355 Library Services for Those with Disabilities such reading disabilities may include dyslexia, attention deficit disorder, autism, or developmental disabilities.12

Under the LOC regulations, a competent authority is required to determine the eligibility of all potential users. In cases of blindness, or visual or physical disabilities, a variety of professionals are permitted to certify an individual’s eligibility, including doctors of medicine, registered nurses, therapists, social workers, and certain hospital staff, among others. In the absence of any of the competent authorities listed in the regulation, a professional librarian may approve eligibility. By contrast, in the case of those with a reading disability, the competent authority must be a doctor of medicine who may consult with colleagues in associated disciplines.

Estimates of the blind and visually disabled population vary widely, and the precise number who may be eligible for NLS is unknown. Estimates for this population are often based on self-reported information and rely on different definitions of blindness and visual disability. For example, according to the National Health Interview Survey (NHIS), in 2012 there were approximately 21 million adults ages 18 and older who reported that they had “trouble seeing.”13 However, according to the American Community Survey (ACS), in 2013 there were approximately 7 million adults ages 18 and older who reported that they were blind or experienced “serious difficulty seeing.”14

It is also difficult to estimate the number of people who would potentially qualify for the NLS program based on reading and physical disabilities.

With regard to reading disabilities, a National Center for Learning Disabilities (NCLD) report estimated that in 2012 there were approximately 2.4 million public school students who qualified for special education programs under the Individuals with Disabilities Education Act

12The term “reading disability resulting from organic dysfunction” is used in LOC’s regulatory language. For the remainder of this report, all the disabilities in this category will be referred to as “reading disability.”

13Centers for Disease Control and Prevention, National Health Interview Survey, 2012.

14U.S. Census Bureau. American Community Survey 2013, 1-Year Estimates (figure C18103). (Washington D.C.: 2015). Both the NHIS and ACS estimates report only numbers for non-institutionalized civilian adults and exclude those in long-term care facilities or prisons.

Page 8 GAO-16-355 Library Services for Those with Disabilities

(IDEA) based on learning disabilities, and many of these students had reading disabilities specifically.15 In addition, according to the Survey of Income and Program Participation in 2010, there were at least 3.5 million adults ages 18 and older with learning disabilities, including reading disabilities such as dyslexia.16 Regarding physical disabilities, NLS officials said that the wide range in the types and severity of potentially qualifying conditions and the lack of centralized data make it difficult to estimate the population of potentially eligible users of the NLS program.

15Candace Cortiella and Sheldon Horowitz, The State of Learning Disabilities Report:

Facts, Trends and Emerging Issues (New York: National Center for Learning Disabilities, 2014).

16NCLD officials estimate that a much larger number of Americans—20 percent of adults and children—may have a learning disability. This estimate is based on a review of a number of research studies on this population.

NLS Users Are Primarily Older Adults with Visual Disabilities, but NLS Efforts Are Not Ensuring Full Access and Awareness

Page 9 GAO-16-355 Library Services for Those with Disabilities

In fiscal year 2014, about 430,000 individuals used the NLS program, with the majority being older individuals who were blind or had other visual disabilities.17 The majority of NLS users were aged 60 and over (about 70 percent), with almost 20 percent at least 90 years of age (see fig. 2). In addition, almost 85 percent of NLS users were either blind or had other visual disabilities resulting in their inability to read standard print (see fig.

3).18 NLS officials told us that the majority of users have age-related vision loss and therefore did not qualify for services until later in life.

About 6 percent of NLS users had physical disabilities, which include multiple sclerosis and Parkinson’s disease, according to officials we spoke with from network libraries. Another nearly 6 percent of users had reading disabilities. NLS guidance explains, and network library officials corroborated, that users’ reading disabilities generally include dyslexia, autism, and traumatic brain injuries. In part because of their older age, many users have physical dexterity issues which compound their other disabilities, according to NLS officials. Although NLS does not track users’ mobility or dexterity limitations as part of its annual data collection efforts, a survey of users and non-users NLS contracted for in 2013 indicated that almost half of users had limited mobility, and about a third had problems with manual dexterity.19

17NLS officials estimate that almost 200,000 additional people used the NLS program in fiscal year 2014 through loans to institutions such as nursing homes, schools, and hospitals.

18The specific types of disabilities that made users eligible for the NLS program remained consistent, with no type fluctuating more than 2 percent across the five fiscal years we reviewed (2010 through 2014).

19NLS contracted with ICF International to conduct a survey of current NLS users, former NLS users, and eligible non-users. The survey was conducted from March 11th to May 10th, 2013 and was offered in both web and telephone modes. Sample users were selected using a stratified random sampling approach and ICF determined that the results were generalizable to the full NLS user population. Completed responses were obtained from 2,517 individuals and the response rate for the sample of current NLS users was

28.9 percent (response rates could not be calculated for the other groups). See ICF Incorporated, L.L.C., National Library Service for the Blind and Physically Handicapped (NLS) Talking Book and Braille Program Evaluation and Recommendations for Increased Patronage (Virginia: June 28, 2013).

Older Adults with Visual Disabilities Make Up the Majority of Users, though an Eligibility Requirement May Limit Access of Potential Users with Reading Disabilities

Page 10 GAO-16-355 Library Services for Those with Disabilities

Figure 2: Age of NLS Users, on September 30, 2014

Note: These data are based on the number of users on Sept. 30, 2014, rather than a cumulative total for fiscal year 2014.

Page 11 GAO-16-355 Library Services for Those with Disabilities

Figure 3: Distribution of Disabilities among NLS Users, on September 30, 2014

Note: These data are based on the number of users on Sept. 30, 2014, rather than a cumulative total for fiscal year 2014.

NLS’s 2013 survey of users and non-users indicated that NLS users generally have retired from employment or are unemployed, have low or fixed incomes, and are more likely to live alone than non-users. In addition, 13 percent of the user respondents reported having served in the military.20

The number of NLS users remained stable from fiscal year 2010 through fiscal year 2014, according to NLS data. NLS officials said they estimated about 10 percent turnover in their users each year. While they recruit new users, they said the number of older users who die each year generally results in the number of users staying about the same. Although NLS does not project user estimates for future years, the proportion of the U.S.

population age 65 and older is expected to increase from 13 percent in

20These data are not available over time as NLS does not conduct user surveys regularly.

Although NLS inquires if applicants are veterans of U.S. military service, they do not track this data. Under LOC regulation, preference in providing reading materials and equipment must be given to the needs of the blind and other persons with disabilities who have been honorably discharged from the Armed Forces of the United States. 36 C.F.R. § 701.6(g).

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2010 to more than 20 percent in 2050, which may increase the number of NLS’s older users.21

While NLS serves individuals with a range of disabilities, an eligibility requirement specific to individuals with reading disabilities may hinder this group of potentially eligible users from accessing services. Specifically, the regulatory requirement that only doctors of medicine may certify a reading disability was cited as a barrier to services by staff with whom we spoke at 5 of the 8 network libraries, 2 organizations that provide similar services to NLS, and 2 organizations specializing in learning disabilities.22 This eligibility requirement, which originated in 1974 and has remained largely unchanged since, creates additional steps and costs for applicants with reading disabilities in comparison to other groups, and may hinder some individuals’ access to services. For example, officials we spoke with from a network library said that many of their potential users have little money and live in rural areas that are far from doctors, which limits their ability to get the necessary certification.

Furthermore, a medical diagnosis is not necessary to determine if an individual has a reading disability, according to a number of groups we interviewed and the policies of other organizations that support people with these disabilities. According to staff we spoke with at two organizations specializing in learning disabilities, and 6 of the 8 network libraries, special education teachers and school staff are typically also knowledgeable about reading disabilities. Recognizing this, certification of reading disabilities is conducted by non-medical personnel for other disability services. For example, under IDEA educational services are provided to eligible children with disabilities, including learning disabilities, which may affect reading. However, IDEA does not require a doctor’s certification of eligibility; this determination is instead made by the child’s parents and a special education team generally comprised of the child’s teacher and at least one other person qualified to conduct diagnostic examinations of children, such as a school psychologist or remedial reading teacher. In addition, two private organizations that, similar to NLS, provide individuals with alternatives to standard print materials, use

21GAO, Older Adults: Federal Strategy Needed to Help Ensure Efficient and Effective Delivery of Home and Community-Based Services and Supports, GAO-15-190 (Washington, D.C.: May 20, 2015).

22See 36 C.F.R. § 701.6(b)(2)(ii).

http://www.gao.gov/products/GAO-15-190

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LOC regulations as guidance to determine the eligibility of individuals with disabilities except for reading disabilities. These organizations instead allow individuals who are deemed competent authorities for the other LOC eligibility categories by the organizations to certify for reading disabilities.

Although the eligibility requirement for those with reading disabilities may be inconsistent with other federal policies and with some entities’ current practices, and potentially hinder access to services, NLS does not plan any modifications. Network libraries have formally recommended to NLS that it re-visit the requirement that a doctor certify the eligibility of those with reading disabilities. This is also consistent with our previous recommendations that agencies providing disability benefits and services should ensure they use up-to-date medical criteria, which reflect advances in medicine and technology and include consideration of non-medical evidence.23 NLS officials said that changing the eligibility requirement for reading disabilities may lead to more users and increased costs. Two other organizations that provide similar services saw an increase in the number of users after they changed their certification requirements so non-medical personnel could certify eligibility. NLS has not estimated the potential demand for its services by those with reading disabilities, and so the actual effect on NLS services from revising the eligibility requirement is unknown.

NLS’s current users likely represent a small percentage of those eligible, but NLS has initiated new efforts to increase awareness and usage of its services. In 2014, NLS developed a plan for improving and expanding its outreach efforts. This plan is based, at least in part, on the recommendations from the 2013 survey of NLS users and non-users.24 The efforts may help address outreach challenges reported to us by staff at the eight network libraries, including limited nationwide awareness, a lack of information in accessible formats, difficulty reaching the wide variety of potentially eligible populations, and a lack of guidance provided network libraries. NLS’s efforts to improve outreach include:

23GAO, High Risk Series: An Update, GAO-15-290 (Washington, D.C.: Feb. 11, 2015).

24ICF Incorporated, L.L.C., Talking Book and Braille Program Evaluation and Recommendations for Increased Patronage.

NLS Is Initiating New Outreach Efforts, but Does Not Collect Information Needed to Evaluate Their Effectiveness http://www.gao.gov/products/GAO-15-290

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• Increasing electronic recruitment methods: NLS has established additional electronic resources, including website announcements and advertisements through social media. For example, NLS developed a Facebook page and is developing a new website. These changes may increase nationwide awareness of services, which staff at 5 of the 8 libraries told us was needed.

• Producing more information in accessible formats: NLS is developing videos for its website as well as talking guides on how to use its services. These guides are being developed specifically for older individuals to explain processes step by step. Previously, information on services was mostly provided via brochures and posters.

• Fostering more partnerships: NLS is increasing communications with other organizations that serve its eligible populations. In October 2014, NLS sent e-mails to 300 organizations identified as serving people who may be eligible for its services, with the goal of partnering with these organizations and conducting outreach through them.

According to officials, 150 organizations responded to this email and agreed to work with NLS. For example, veterans service organizations agreed to ensure veterans are informed about the program and encouraged to take advantage of its services.

• Providing an outreach toolkit for network libraries: NLS recently released a toolkit providing guidance and materials such as customized posters and a webinar for librarians on how to effectively conduct outreach through partnerships, media, social media, and events. Staff at 6 of the 8 network libraries told us they wanted more guidance and assistance from NLS on outreach efforts such as these.

While NLS is making efforts to improve outreach, it has not collected information necessary to evaluate these efforts. NLS’s plan and ongoing efforts to improve outreach address a number of best practices for outreach that we have previously identified, such as researching the target audience, identifying stakeholders, obtaining feedback, and using multiple approaches.25 However, NLS has not developed a plan for assessing its outreach efforts, also a best practice we previously

25GAO, Social Security Disability: Additional Outreach and Collaboration on Sharing Medical Records Would Improve Wounded Warriors’ Access to Benefits, GAO-09-762 (Washington, D.C.: Sept. 16, 2009).

http://www.gao.gov/products/GAO-09-762

Page 15 GAO-16-355 Library Services for Those with Disabilities identified.26 Generally, NLS officials told us they will judge the success of these new outreach efforts by determining whether there have been increases in the overall number of users, the number of users in particular target categories, and the number of visits to their website. However, these measures will not inform NLS as to which efforts directly resulted in new NLS users, which would help NLS allocate resources to those that are most cost-effective. Although staff we interviewed at 3 of the 8 network libraries said they have tracked how users heard about their services for this purpose, NLS does not obtain such data centrally.

NLS offers its users several options for receiving both audio and braille reading materials, and the vast majority of NLS users choose to receive audio materials, primarily in the form of digital cartridges sent through the mail. NLS users may receive audio materials through the mail on digital cartridges or cassettes, download audio files from the Internet, receive hard copy braille documents through the mail, or download braille files from the Internet. According to NLS administrative data, almost 90 percent of NLS users received digital cartridges during fiscal year 2014, with the majority playing these cartridges on specialized audio devices provided by NLS, and a much smaller number using other, commercially-available devices.27 (See fig. 4.) About a third of NLS users continued to

26Such a plan would be consistent with best practices and communication strategies recommended to NLS as part of a market research study issued in 2014.

27NLS only provides users its own specialized players, not commercially-available devices, according to agency officials.

NLS Offers Materials in a Range of Formats, but Statutory and Other Limitations Impede Adoption of Potentially Cost- Saving Technologies NLS Provides a Range of Reading Formats, but Most Users Choose to Receive Audio Materials Through the Mail

Page 16 GAO-16-355 Library Services for Those with Disabilities receive cassettes through the mail, although this format is being phased out.28 Downloading from the Internet was less popular than receiving materials through the mail, with only about 10 percent of NLS users downloading audio materials through NLS’s online Braille and Audio Reading Download (BARD) system.29 BARD enables eligible users to search for and select audio files for immediate download rather than wait to receive materials through the mail. These files may be transferred to a digital cartridge and played on NLS’s specialized device, or downloaded directly to and played on a variety of commercially available devices, such as smartphones. A much smaller proportion of NLS users chose to receive braille materials, whether in hard copy or downloaded from BARD and read on a refreshable braille device that converts an electronic text file into braille characters.30

28Before moving to its digital cartridges and players starting in 2009, NLS provided analog cassettes and cassette players. NLS is phasing out this technology and converting analog recordings to digital, but some users still listen to cassettes for certain content that is not yet available digitally.

29BARD was introduced in 2007, and was upgraded in 2013 to consolidate two separate systems for downloading braille and audio materials. We do not report data for fiscal years prior to 2014 due to a change in how NLS reports data on downloads. According to NLS officials, prior to fiscal year 2014, NLS’s data for audio downloads through BARD represented the number of users with BARD accounts who could potentially download materials. Starting with fiscal year 2014, according to NLS officials, the agency reported the number of users who actually downloaded audio materials. As a result of this change, trend data on the percentage of NLS users downloading materials through BARD are misleading.

30Refreshable braille devices, currently available commercially, rely on piezoelectric technology, meaning electric currents raise and lower plastic pins that form braille characters. After one line has been read, the display is refreshed to provide the next line of characters. As discussed later in this report, NLS does not provide its users with such devices.

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Figure 4: Percentage of NLS Users Accessing Reading Materials, by Format, Fiscal Year 2014

Note: Percentages do not add to 100 because NLS users may access reading materials through multiple formats during a fiscal year. This figure includes only users who were served in the United States by regional and sub-regional libraries. It excludes miscellaneous services, musical materials, and any materials sent to U.S. citizens living in another country.

Over the last 5 years, the majority of materials circulated to NLS users each year have been either digital cartridges or cassettes, although the number of items downloaded through BARD has been gradually increasing (see fig. 5). The number of digital cartridges has increased substantially since they were introduced in 2009, while the number of cassettes has declined as they are phased out. Meanwhile, the number of

Page 18 GAO-16-355 Library Services for Those with Disabilities audio files downloaded annually from BARD more than doubled between fiscal years 2010 and 2014. Among braille materials, there has been a shift away from hard copy to electronic braille.

Figure 5: Number of NLS Reading Materials Circulated to Users, by Format, Fiscal Years 2010-2014

Note: This figure includes only users who were served in the United States by regional and sub-regional libraries. It excludes miscellaneous services, musical materials, and any materials sent to U.S. citizens living in another country. Also, this figure does not include analog discs, as fewer than 100 discs were circulated annually to users in recent years.

Most users’ preference for receiving materials through the mail and playing them on an NLS-provided specialized audio device appears to be linked to their level of comfort with technology and their access to the Internet, according to interviews and survey data. NLS designed the digital cartridges and players that provide users with audio books and magazines to be easy to see and handle for those with visual and other

Page 19 GAO-16-355 Library Services for Those with Disabilities disabilities.31 The program’s mainly older users feel comfortable with NLS’s specialized audio player because it is user friendly, according to staff at all 8 network libraries we contacted. For example, librarians in one state said many users like NLS’s player because it is durable and easy to use, and many—especially those who lost their vision later in life—do not feel as comfortable using commercially available audio devices. At the same time, younger NLS users—a minority of the customer base—may prefer to use other devices, such as smartphones, to access NLS audio materials, according to staff we spoke with at 6 of the 8 network libraries.

Staff in one library said younger users tend to be more sophisticated in their use of technology, and prefer to use smaller, mainstream devices rather than the NLS player. (See fig. 6 for an image of NLS’s standard and advanced players and the commercial audio device which as of August 2015 had more registered NLS users than any other commercially available device.)

Figure 6: NLS Specialized Audio Players and a Commercially Available Audio Device

31For example, the NLS player has no functions other than playing digital cartridges and has built-in audio instructions. NLS offers both a standard and an advanced version of the device; the advanced version has some additional features, such as bookmarking and navigating, which allow users to skip to different parts of an audio book.

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Furthermore, some users lack Internet access or do not feel comfortable downloading files from the Internet. According to NLS’s 2013 user survey, about 40 percent of those not using BARD cited lack of Internet access as a reason. Staff at all 8 network libraries told us that many of their NLS users lack access either to the Internet or a computer. For example, staff in one library told us many of their NLS users have low incomes, or are older with fixed incomes, and many, especially in more rural areas, lack the high-speed Internet connection needed for BARD. According to NLS’s 2013 user survey, about 50 percent of sampled users who do not use BARD said they lacked the computer skills to do so. Similarly, staff in all 8 network libraries we contacted said the process of downloading files from BARD onto a computer, and then transferring them to a cartridge that can be played on an audio device, is challenging for some users. For example, staff in one library said users have difficulty figuring out which folder to save downloaded files into on their computers. Recognizing this, NLS officials told us they expect in summer 2016 to introduce a new software application known as Media Manager intended to simplify the process of downloading from BARD onto a computer by handling a number of the steps automatically.

Meanwhile, the much lower use of braille compared to audio among NLS’s customer base may, in part, reflect the rate of braille use among blind people in the United States overall as well as characteristics of NLS users. The precise number of blind and visually impaired people who use braille in the United States is not known, according to a study on braille by LOC’s Federal Research Division32, as well as officials from two national organizations that produce braille materials and an assistive technology company we contacted. However, according to the LOC study, several estimates suggest that the proportion of blind and visually impaired Americans who use braille may be about 10 percent.33 According to a research and advocacy group for the blind and an organization that produces braille materials, braille use declined after many blind students were moved from specialized schools for the blind, which are more likely

32LOC Federal Research Division, The Current State of Braille Literacy and Electronic Assistive Braille Technologies (Washington, D.C: September 2014).

33The study cites, for example, data indicating that approximately 14 percent of visually impaired students used braille as their primary or secondary form of reading during fiscal year 2014, and a study from the 1990s that found less than 10 percent of blind and visually impaired adults used braille.

Page 21 GAO-16-355 Library Services for Those with Disabilities to teach braille, into public schools.34 Another factor that has impeded the wider use of braille, according to an organization that provides braille materials and an assistive technology company we contacted, has been the high cost of refreshable braille devices, which sell for $1,000 to $2,000 at a minimum. Beyond reflecting braille use in the wider population, NLS users’ low use of braille may also reflect the specific demographics of the NLS population. Individuals who lose their vision later in life may be less likely to learn braille than those who were blind at an early age, according to staff from one library we contacted and a 2012 NLS report.35

NLS is considering whether to adopt several new technologies for delivering braille and audio content to its users which have the potential to improve services and reduce costs. However, in one case—providing refreshable braille devices to its users—NLS’s efforts are hampered by limitations in its authorizing statute, among other factors. In two other cases—developing an audio player with Internet connectivity and adding synthetic speech materials to its audio collection—the agency has not taken steps to assess the potential cost savings resulting from alternative approaches.

Promoting braille is one of the broad goals included in NLS’s draft strategic plan for 2016 to 2020, and the agency believes providing braille electronically will help achieve that goal. According to a 2012 NLS report,36 braille is the literacy medium for those who are blind and visually impaired, as unlike audio, it is a direct corollary to print and displays features of print, such as capitalization and punctuation. This view is consistent with those of several other organizations we contacted, including a research and advocacy organization serving people who are blind. There is also some evidence suggesting that blind people have

34According to the U.S. Department of Education, as a result of IDEA—the precursor to which was enacted in 1970—the majority of children with disabilities are now educated in neighborhood classrooms with peers who do not have disabilities.

35Library of Congress, Report of the National Library Service for the Blind and Physically Handicapped (Washington, D.C.: September 2012).

36LOC, Report of the National Library Service for the Blind and Physically Handicapped.

NLS’s Efforts to Adopt New Technologies Are Hampered by Limitations in Its Statutory Authority and Analyses of Alternative Approaches

Refreshable Braille Devices

Page 22 GAO-16-355 Library Services for Those with Disabilities better employment outcomes if they use braille.37 NLS officials told us they believe that the ability to loan refreshable braille devices could attract more users to NLS. The agency has cited several advantages of this technology compared to hard copy braille, including that it is less bulky to store and transport and can be delivered more quickly to users.38 (See fig.7 for images of a 13-volume hard copy braille book in NLS’s collection and an example of a refreshable braille device.)

Figure 7: Hard Copy Braille Book and a Refreshable Braille Device

37LOC Federal Research Division, The Current State of…