Social media has played a growing role in patient education efforts. [13] Although many low vision individuals use social media, they likely encounter accessibility challenges. To the authors’ knowledge, this study is the first to analyze compliance to WCAG for ophthalmology social media posts and found no evidence that posts that were intended for a visually impaired audience met guidelines compared to those that were not. Our findings showed that 49% of overall ratings for ophthalmology social media posts did not meet any WCAG standards, which is consistent with other studies examining general WCAG compliance among web pages. A 2023 study by Utah State University tested the top one million web homepages and found that 96.3% were not compliant. [14] Another study found that the majority of e-government websites in India did not meet Level A standard with WCAG 2.1. [15] Our findings suggest that more ophthalmology posts than non-ophthalmology posts did not adhere to any WCAG guidelines, with contrast issues being the most common reason for failure. Similarly, a study examining web accessibility of the library webpages of top-ranking United States post-secondary institutions found that approximately half of errors were categorized as contrast errors, directly impacted those with visual impairments. [5] Based on these findings, enhancing contrast either at the content creator or consumer’s level may significantly improve the accessibility and educational impact of these ophthalmology posts to the intended audience.
This overall poor WCAG compliance among ophthalmology posts may be explained by several factors. First, content creators may not be aware of WCAG standards. Despite the growing availability of accessibility information over the past two decades, website accessibility has not improved appreciably. An analysis by Swallow et al. contributed some of these findings to external factors, such as client and organizational attitudes to web accessibility or difficulty in enforcing accessibility legislation. [16] Moreover, creators may experience difficulties in utilizing the accessibility information provided by tools, guidelines, and resources. One study analyzing 17 students taking part in a web accessibility course concluded that WCAG is “far from testable for beginners” due to difficulty in comprehending the language used in guidelines. [17]
Tools such as the WebAIM WCAG 2 checklist were created to simplify the official WCAG 2.1 specifications into a more usable checklist for web creators; however, this study highlighted several limitations of the checklist. Many of the WebAIM criteria are subjective, such as “descriptive and informative post title,” which reviewers may grade differently. In our study, designers attempted to decrease subjectivity and bias by having multiple reviewers grade posts; however, there was low inter-rater reliability, suggesting that grading of posts still varied despite using a controlled, stepwise evaluation algorithm. Additionally, the WebAIM WCAG 2 checklist may not be the most suited for content addressing a visually impaired audience. For instance, there are no criteria on the checklist referring to type of font used, as some fonts may appear more obscured or difficult to read than others. This may impact accessibility of the post for a visually impaired individual. Finally, the checklist was not the most suitable for analyzing social media posts, as many criteria from the original checklist needed to be omitted because they were not relevant for social media posts. For example, several original criteria specify keyboard function requirements, but keyboard functionality is a feature controlled by Instagram rather than post-creators. [7] Study creators concluded that this criterion and other criteria not applicable to singular social media posts should be omitted in the adapted WebAIM WCAG checklist that was used for this study.
This study has several limitations. We had assumed that the content creators aimed to educate the public, while the main incentive for for-profit content creation is typically to exert and widen one’s digital influence. Hence, there may not be sufficient incentives for WCAG compliance as this may or may not increase the number of “views,” “shares,” or “likes” that signifies a post’s popularity. Also, this cross-sectional study does not speak toward the overall trend of WCAG compliance, nor can we generalize on the variability of WCAG compliance using our modestly-sized sample against the vast web content that currently exists on the Internet. Future studies could amend study design to see if WCAG compliance influences a post’s popularity, while a subsequent study may create and validate a new tool for analysis of social media posts to WCAG guidelines, since the original WebAIM WCAG checklist is tailored specifically to online websites. Finally, increasing the number of posts examined in a future study may provide greater insight to determine generalizability.