Accessibility Testing of European Health-Related Websites

The current development of the Internet and its growing use make it necessary to meet the needs of those disabled people who experience accessibility problems, be it related to visual, motor, mobility, auditory, cognitive or intellectual skills. Most software engineering companies have not been developing for users with special needs because they do not see a potential market in these users [1]. However, figures have proved that at least 10% of the world’s population has some kind of impairment (http://​www.​disabled-world.​com/​disability/​statistics/​). This number is estimated to reach 14% in the USA, and 65% of the population older than 65 years is likely to develop a handicap of some kind. Disabilities correlate with age. In developed societies, more and more people turning older than 75 are likely to have some kind of impairment. This group will comprise 14.4% of the population by 2040, compared to 7.5% in 2003. It is almost a twofold increase [2].

Another factor is that by 2020 25% of the EU’s population will be over 65 years. Money spent on pension, health and long-term care is expected to increase by 4–8% of the GDP in the forthcoming decades. These expenditures will triple by 2050. It is not negligible either that the combined wealth of older Europeans is estimated more than €3000 billion [3]. If companies do not respond to the demand of producing barrier-free websites, they are likely to lose a considerable number of potential customers/users. New solutions are needed for those elderly people who might not be able to leave their homes and for healthcare monitoring [3, 4]. Barrier-free Internet and software are an essential part of this process. Figure 1 shows elderly populations in the countries of the European Union (EU-28) in the period of 2004–2014.

Table 1 shows the GDP, total population, region and percentage of the population in the countries included in this study from Central-Eastern Europe (the so-called V4 countries) and from West Europe (W-E) and North Europe (N-E). The size of the elderly population is increasing everywhere in Europe.

Table 2 shows the GNI data and the region by each country in this study.

Providing a barrier-free Internet, software and VR applications is a challenging task. Already existing principles and standards of universal design/design for all cannot guarantee accessibility, per se [11, 12], and the fact that providers overlook these regulations further delays the introduction of a barrier-free Internet [13]. In 1999, the World Wide Web Consortium published the Web Content Accessibility Guidelines WCAG 1.0 [14]. Web Content Accessibility Guidelines, WCAG 2.0, was released in 2008 [15]. To complete WCAG 2.0, the researchers recorded the number of known problems identified for A, AA and AAA level guidelines. While WCAG 1.0 contains 14 guidelines with 62 checkpoints at three priority levels, the WCAG 2.0 has only four principles with 12 guidelines. Both have three levels of conformance: A, AA and AAA. Both provide technical advice.

The main principles and structure of WCAG 2.0:

Several other guidelines based on WCAG 2.0 exist. For example, the standard in Canada is the Standard on Web Accessibility [16], which follows the WCAG 2.0 guidelines. The Web Content Accessibility Guidelines for Japan, called JIS (Japanese Industrial Standards), was released in 2004 [17]. Recognizing the growing demand for an accessible Internet, more and more countries pass legislation concerning accessible digital information. Countries frequently support and adopt WCAG 2.0 by referring to the guidelines in their legislation [18‐21]. The USA, furthermore, specifies that all Federal electronic media must be made accessible to people with disabilities. WCAG 2.0 AA standard has been approved as an appropriate standard for accessibility by the US Department of Justice in multiple settlement agreements [22, 23]. The European Parliament approved a draft in February 2014 which states that all websites in the public sector have to be developed to be accessible for everyone [24]. This European standard, called EN 301 549 version 1.1.2, describes relevant accessibility requirements. The problem of accessibility is twofold at this juncture. Firstly, not all member states have harmonized their accessibility laws with that of the European Union, even though it was expected to take place by September 2018. Secondly, not all public sector websites had been able to comply with guidelines by September 2018. The next goal is that mobile apps in the public sector should comply by June 2021 [24, 25]. Although the newest version of WCAG, the WCAG 2.1 [26, 27], was released on 5 June 2018, there is no suitable, efficient automatic test tool based on these guidelines. There has been extensive research dealing with Web accessibility, mainly in the domain of testing the accessibility of governmental websites [28‐36] only to conclude that websites are barely accessible and further research is required. Goodwin et al. [33] conducted the first global analysis of the Web accessibility of government websites of 192 United Nation Member States almost 9 years ago. Among other things, they proved the following hypotheses:

Zheng [34] investigated 108 consumer health information websites in the USA. Although this research was performed in 2003 and based on WCAG 1.0 [14], Zheng’s research methodology used a taxonomy that classified the websites into six categories—E-commerce, corporate, government, portal, community and education. The result was that none of the websites was completely accessible to people with disabilities. Governmental, educational, health-related websites, nevertheless, exhibited better performance on web accessibility than other websites in other categories. They also established correlation between the accessibility and the popularity of a website.

Investigating web accessibility has become a frequently researched topic and a number of publications have appeared that address—among others—the accessibility of such institutions as universities. A group of Brazilian researchers [35], for instance, set out to investigate Brazilian federal universities to see whether they complied with e-government standards. Unfortunately, their results confirmed that most federal university websites do not follow important accessibility standards. Some of the reasons behind the findings include IT teams that are unable to cope with staff shortage, high demand, tight deadlines and the lack of specific development methods. Our own research [37] looks at the websites of Hungarian universities to discover potential accessibility issues of students who have some colour deficiency problems. Our results make it clear that, unfortunately, not every website is clearly visible; therefore, students with colour deficiencies cannot acquire information the same way as healthy ones. Our recommendation for web designers here is to create websites that do not only feature colour visual cues, that is, the implementation of various patterns and huge visual contrasts would be more efficient to promote visibility in texts, buttons and links. In general, website designers do not tend to develop different versions of the same site for each disability type; in fact, it is unlikely that further features are added for the comfort of different disability groups [38‐41].

The priorities of the European Commission include the simplification of modern digital contract rules, the promotion of access to digital content and the enhancement of online sales [42, 43]. The EC wishes to support digital market strategies in the member countries and introduce new e-commercial regulations in order to make buying and selling goods inside the EU easier [44]. In Hungary, people made online purchases more than 22 million times in 2015 [45]. The retail turnover rate in Hungary grew by 18% in the first half of 2016 compared to the data from the previous year, and it reached 131 billion forints [46].

In this paper, we present the results of testing and evaluating almost 100 healthcare-related websites from nine European countries. Based on the results, we will review our earlier recommendations outlined in an earlier paper [41] to see whether they still hold. The following sections will set out the context of the research, its implementation and results and, finally, look at the proposed hypotheses. Section 3 details the research methodology and hypotheses. Section 4 discusses the results, and Sect. 5 presents the discussion and main conclusions of the research.

The present study highlights the most acute accessibility problems of the examined healthcare-related websites. The investigation includes healthcare-related sites from nine European countries; 48 from Eastern Europe (the so-called V4 countries); and 51 sites from Western and Northern Europe (N–W-EU). Table 3 shows the number of tested websites in the investigated European countries.

We examined the V4 countries together because, on the one hand, they form one region and, on the other hand, economically, historically and from an educational point of view they are very similar. Salaries in the V4 countries amount to one-third or one-fifth of that in the western part of Europe, while the prices of basic foods and daily necessities do not differ between significantly.

As the accessibility properties of the web pages can be considered random qualities, the comparisons require statistical methods. This article uses both quantitative and qualitative research methods. The measurement of web accessibility is addressed in this section.

The websites that fall within the scope of interest of the present investigation were chosen based on Google search results, concentrating on top finds. For automatic testing, AChecker [47] and Nibbler [48] were used. AChecker is a free tool that checks single HTML pages for conformance with accessibility standards to ensure that the content can be accessed without limitations [47]. AChecker diagnoses known problems, likely problems and potential problems with their levels of conformance based on WCAG 2.0. Nibbler is a free tool for testing websites; it generates a report scoring the website on a scale of 10 for key areas including accessibility, SEO (search engine optimization), social media and technology [48]. Figure 2a and b presents screenshots featuring AChecker (Fig. 2a: before testing, Fig. 2b: test results), and Fig. 3 introduces the Nibbler automated tool. To improve the depth of the present research, we extended our automated tests by interviewing users in the framework of a questionnaire. We involved experts with considerable experience gained in the area of digital accessibility to compile a questionnaire (see Table 4) and elicit useful feedback from users with regard to their accessibility issues. The experts involved in the present investigation include MSc IT engineer university students specialized at software ergonomics, human–computer interaction, user interface design and web accessibility.

Despite the fact that both AChecker and Nibbler automatic are very effective, there were a number of cases in which they rather badly affected our research process. Some of the issues that influenced measurement and/or evaluation include test situations in which AChecker or Nibbler being unable to measure and detect certain human needs. Websites with a traditional blind version (yellow letters on a black background), for instance, are not refreshed frequently. Webmasters tend to forget to make new information available; consequently, those websites are likely to contain outdated information. Certain buttons lose their functions over time, which may make users confused. Automatic test tools, to move onto another area, do not measure colour vision problems well enough. At times, users of low or impaired can hardly read CAPTCHA figures (an audio version remedies this problem). Considering further user groups with accessibility issues, blind users or those who have motion problems with their hands use a special keyboard or just the TAB key to navigate. If one button or submenu is not available by the TAB key, the website becomes unsuitable for further use. These are the main aspects that we wanted our experts to investigate in a questionnaire based on our earlier experiences in the field.

As mentioned, the testing phase started with AChecker, followed by Nibbler and ended with the questionnaires (Table 4) including the use of the SEE web application [49] (question 3 in Table 4). The SEE web application proved to be the best and easiest test software from the point of view of handling because the user only needs to set a colour deficiency type with a slider and does not have to upload a picture to a web page as in the case of other testers. The test phase is concluded with the use of Variantor special glasses [50].

All these tests were performed in the time period of June–July 2018. The most frequently visited and most popular sites were chosen by Google statistics for the test upon searching for “healthcare”, “assistive technology”, “health related”, etc. keywords. The focus of interest was websites that contained health-related information or blogs about health topics or web shops for medicaments or assistive technologies. Moreover, we consulted native speakers in the respective countries and asked them to send us the URLs of the most popular websites in their areas of interest.

This chapter presents our research questions (Qs) and hypotheses (H) based on related questions. They are grouped based on closely related topics. The scenario is based on the order of first asking a question (Q); then, we formulate the statistical hypothesis together with its alternative (H).

Access to healthcare-related websites is of utmost importance to citizens all over the world, yet the present research demonstrates that people with disabilities are often excluded. Many of the accessibility problems identified in this study can be fixed relatively easily and do not require huge redesigns of the site, for example, adding appropriate ALT attributes for images. ALT tags convey the text equivalent of the image on display and are necessary for those with disabilities as they may not have the ability to physically see the image.

Providing adequate access especially to healthcare-related information is inarguably a vital task in the field of information technology. Our present research demonstrates, nevertheless, that people with disabilities are often excluded. For instance, a surprisingly large number of errors detected by AChecker (see Table 18) concern a major area of improvement, namely Alt attributes. ALT tags convey the text equivalent of the image on display and are necessary for those users who due to some visual impairment are not able to physically see the actual pictures themselves on the site. Alt attributes are responsible for what the screen reader can read in such cases as an alternative text about an image. The guidelines for implementation, handling and problem resolution are clearly stated in WCAG 2.0. [15], which already classifies Alt tags as a Level A area. Identifying and remedying Alt tag issues, as accessibility problems, is a relatively simple task and does not require huge redesigns of the site.

“Success Criterion 1.1.1 Non-text Content (Level A): All non-text content that is presented to the user has a text alternative that serves the equivalent purpose” [15]. “Success Criterion 1.3.1 Info and Relationships (Level A): Information, structure and relationships conveyed through presentation can be programmatically determined or are available in text” [15]. “The intent of this Success Criterion is to ensure that information and relationships that are implied by visual or auditory formatting are preserved when the presentation format changes. For example, the presentation format changes when the content is read by a screen reader or when a user style sheet is substituted for the style sheet provided by the author” [15]. “Success Criterion 1.4.4 Resize text (Level AA): Except for captions and images of text, text can be resized without assistive technology up to 200% without loss of content or functionality” [15]. “The intent of this Success Criterion is to ensure that visually rendered text, including text-based controls can be scaled successfully so that it can be read directly by people with mild visual disabilities, without requiring the use of assistive technology such as a screen magnifier. Users may benefit from scaling all content on the Web page, but text is most critical” [15]. “Success Criterion 1.4.6 Contract (Enhanced) (Level AAA): The visual presentation of text and images of text has a contrast ratio of at least 7:1” [15].

From the data collected and analysed on the basis of both our questionnaires and the figures produced by the applied automated tools, we accept hypotheses: H1, H4, H5, H6, H7, H8 and H11.

The answer is mixed for H3. For two subproblems, the first part of H3 is accepted; for another two, it is rejected. A few questions of the second part of H3 are rejected, but in the most cases they are accepted. H9 and H10 are mixed again.

The element of innovation this research presents is that it looks at some relevant accessibility issues concerning health-related websites in different historical and economic regions in Europe. Such a detailed statistical comparison has not yet been made in Europe for testing healthcare-related websites, even though their regular revision seems necessary owing to the demands of the growing elderly population. The authors would also like to draw attention to the fact that the two applied automatic testers yielded different accessibility results for the same sites; therefore, statistical evaluation based on user response has proved inevitable for thorough analysis.

This research demonstrates that a vast majority of healthcare-related websites in the North–West-European (N–W-E) and V4 countries (Czech Republic, Hungary, Poland, Slovakia) do not meet industry-related accessibility guidelines. Most of the websites in this research violated the same guidelines because their designers did not take the needs of people with disabilities into account. Consequently, these websites contain almost the same, very common errors. Accessibility errors should be identified by software testing tools based on WCAG 2.0 and user response. We did not find differences between the results of N–W-EU and V4 countries, in spite of the fact that the GDP and GNI of the N–W-EU countries are much higher than the GDP and GNI of V4 countries.

First of all, the findings in this paper might help web designers by providing a better understanding of their websites and can also be used to facilitate assessing web accessibility. Second, if service or software development has been carried out without taking the requirements of accessibility into consideration, it is certain that the result will not be an accessible solution and accessibility problems will emerge. The accessibility problems will remain until an expert in accessibility gives instruction to web designers; otherwise, web designers will have to familiarize themselves with all accessibility guidelines. There is no doubt that users with special needs are not involved in the design process and the testing of the usability of websites. Furthermore, it is clear that the cost of developing accessible websites from the first step of the design process is much cheaper than to redesign or transform the badly designed website and make it accessible.

All our measurements and research are based on the WCAG 2.0 guidelines; meanwhile, the newest version WCAG 2.1 [26, 27] has just been released. In the future, this research should be repeated based on WCAG 2.1, but currently there is a lack of effective automatic test tools based on WCAG 2.1.

In conclusion, a site that meets accessibility requirements opens the market to a wider range of customers. If we look at the growing number of elderly people, their demand for accessible websites can be expected to increase. If companies do not focus on these requirements, they will lose a high number of their customers. The overall benefit is that of increased value. The issues identified in this study can also be considered to be independent of financial considerations, since they require only a bit of attention and the willingness to identify the needs of people with disabilities.