Emergency Medicine

Limited accessibility of free online resuscitation education for people with disabilities

Journal logoUnlabelled imageAmerican Journal of Emergency Medicine 56 (2022) 100-103

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Limited accessibility of free online resuscitation education for people with disabilities

Alexei Birkun, M.D., Ph.D a,?, Yekaterina Kosova, Ph.D b

a Department of General Surgery, Anesthesiology, Resuscitation and Emergency Medicine, Medical Academy named after S. I. Georgievsky of V. I. Vernadsky Crimean Federal University; Lenin Blvd, 5/7, Simferopol 295051, Russian Federation

b Department of Applied Mathematics, Physics and Technology Institute, V. I. Vernadsky Crimean Federal University, Prospekt Vernadskogo, 4, Simferopol 295007, Russian Federation

Effective teaching of laypeople in basic life support (BLS) is currently acknowledged as a primary educational goal in resuscitation, and inter- national scientific community emphasizes the importance of system- level interventions by expanding cardiopulmonary resuscitation (CPR) education to broad population groups [1-3].

In order to reach more people with resuscitation education a variety of teaching modalities is suggested [1,2], among which an internet- based learning currently holds a unique place. The ongoing coronavirus disease 2019 pandemic has resulted in unprecedented lockdown re- strictions causing a disruption of face-to-face learning processes with a rapid shift toward e-learning approach. In particular, it has been rec- ommended to cease instructor-led CPR teaching for laypeople and to use individual Self-directed learning, including web-based learning, as an alternative [4]. A multifold increase in online BLS course enrollment and completion rates was observed after the pandemic start [5].

Meanwhile, the pandemic-driven quick transition to e-learning was hypothesized to create serious challenges for people with disabilities [6] who make up 15% of the global population [7]. Online courses com- monly do not meet web accessibility requirements [8,9], and the limited accessibility of learning content could be one of the major factors that undermine process of education and contribute to stress and depression among persons with disabilities [10,11].

Whereas people with disabilities, including those due to natural aging, constitute a tremendous force of potential lay rescuers, no re- search has investigated accessibility of digital content of online courses in resuscitation. Hence, we aimed to evaluate web accessibility of existing English-language massive open online courses (MOOC) in BLS. A search of MOOC (defined as online courses that are open for general public for free, potentially causing massive participation) [12] in BLS was carried out in December 2021 (see search strategy in Appendix Table A.1). The following inclusion criteria were applied: a course is devoted to or contains adult BLS as part of a curriculum; suitable for any layperson; English-language; free of charge; self- paced and provided on an ongoing basis. Duplicate courses based on

identical learning materials were excluded.

Web accessibility assessment of was based on an automatic evalua- tion of digital content in concordance with Web Content Accessibility

* Corresponding author.

E-mail address: [email protected] (A. Birkun).

Guidelines (WCAG) 2.1 [13] utilizing the WAVE web accessibility evalu- ation tool (WebAIM, USA) that automatically identifies and highlights webpage content accessibility issues in browser interface. All accessibil- ity errors (failures to meet certain WCAG 2.1 success criteria [13] that should impact users with disabilities) and accessibility alerts (web con- tent elements that may cause accessibility issues) were collected using a predesigned table (see Dataset [14]).

All eligible courses (n = 30) had web accessibility violations, that were recognized by the WAVE tool as errors (1-9 per course) and alerts (5-12 per course) and concerned 9 of 13 (69.2%) WCAG 2.1 guidelines (basic goals that authors should work toward in order to make content accessible for users with disabilities) [13] (Fig. 1). De- tailed characteristics of the identified errors and alerts are shown in Appendix Table A.2.

Only two courses (6.7%) passed the automatic web accessibility check satisfying all criteria for level A of conformance to WCAG 2.1 (minimum acceptable level of conformance), and none of the courses met levels AA (medium) or AAA (maximum) of the guidelines’ confor- mance [13].

Detected accessibility issues could create significant challenges for people with visual disabilities (including blindness, low vision, color vision deficiency), Cognitive disorders (such as limited short- term memory, reading, language or learning disabilities), physical disorders (e.g., hand tremors, impairments of mobility, motor dis- turbances) and auditory disabilities (including deafness or hard of hearing) (Fig. 2). Further, these accessibility faults can limit ability of Elderly people to use web interface and learn content of the MOOC [15].

An important additional finding is that the overall number of re- vealed free English-language online courses in BLS is low, that is in line with results of international studies that demonstrated limited availability of resuscitation training for lay public [16-19].

Although our literature search did not reveal any reports of web ac- cessibility evaluation for courses in resuscitation, previous research has shown that MOOC in other educational areas have serious accessibility flaws that prevent persons with disabilities from fully participating in learning activities [20-24].

Whereas the optimal way of delivering CPR knowledge and skills remains unknown, it is currently recommended to utilize alternative in- structional strategies to involve more people in resuscitation education

https://doi.org/10.1016/j.ajem.2022.03.039

0735-6757/(C) 2022

Image of Fig. 1

Fig. 1. Distribution of English-language MOOCs in adult BLS according to detected web accessibility violations in terms of conformance to WCAG 2.1 guidelines.

[2,3]. Self-directed digital learning, optimally accompanied with hands- on practice, constitutes an effective means for improving resuscitation awareness, attitudes and competencies [25-28]. Making resuscitation e-learning more available and accessible could contribute to engaging millions of lay people in provision of the lifesaving help and improve survival from cardiac arrest.

We suggest the necessity of creation of international best prac- tices for design and development of digital resuscitation education content based on current international web accessibility guidelines

[13] and standards [29] in order to provide guidance for online course developers on how to make the learning content more usable by people with disabilities and by older individuals with limited abil- ities due to aging. Along with that, it is important to draw attention of public and scientific community to the accessibility issues in re- suscitation education.

Image of Fig. 2

Fig. 2. Distribution of the web accessibility violations of English-language MOOCs in adult BLS in terms of types of affected disabilities.

This study is not without limitations. First, the applied automatic evaluation of web accessibility has limitED capacity to detect certain ac- cessibility violations, including issues concerning people with auditory and neurologic disabilities [12]. Further manual accessibility evaluation may bring additional meaningful findings. Second, web search with other search engines besides Google could reveal more potentially eligi- ble courses. Third, we did not cover courses in other languages than En- glish or paid courses.

In conclusion, free online courses in BLS have numerous web acces- sibility flaws that could greatly affect chances of people with disabilities and older people to gain the lifesaving competencies. More research and organizational efforts are required to raise awareness of the accessibility problem and to establish a framework for making resuscitation educa- tion available and accessible for maximum possible range and number of people.

Funding

None.

CRediT authorship contribution statement

Alexei Birkun: Writing – review & editing, Writing – original draft, Validation, Supervision, Project administration, Methodology, Investi- gation, Formal analysis, Data curation, Conceptualization. Yekaterina Kosova: Writing – review & editing, Visualization, Software, Methodol- ogy, Investigation, Formal analysis, Data curation, Conceptualization.

Declaration of Competing Interest

The authors have no conflicts of interest to declare.

Appendix Table A.2 (continued)

Appendix Table A.1

Search strategy.

Sources Keywords

Violated WCAG

    1. success criterion (level

of conformance*)

Errors, n (% of all courses)

Alerts, n (% of all courses)

Explanation of success criterion violation

Affected disabilities

Google search engine* Free, basic life support, course, online Free, bls, course, online

Free, cardiopulmonary resuscitation, course, online

Free, cpr, course, online

Free, basic life support, training, online

1.4.3 Contrast (Minimum) (AA)

30 (100.0) 0 (0.0) The visual presentation

of text, including rendering text in a non-text form (such as

an image), has a contrast ratio less than 4.5:1

Visual

MOOC aggregators

(Class Central, CourseBuffet, MOOC List, My

Free, bls, training, online

Free, cardiopulmonary resuscitation, training, online

Free, cpr, training, online Basic life support

BLS

      1. Keyboard (A) 9 (30.0) 10 (33.3) Some functionality of

content is not operable through a keyboard interface without requiring specific timings for individual keystrokes

Visual, physical

Education Path)

MOOC platforms

(Coursera, edX, FutureLearn, Swayam, Udemy)

Cardiopulmonary resuscitation CPR

Basic life support BLS

Cardiopulmonary resuscitation CPR

      1. No Keyboard Trap (A)
      2. Bypass

0 (0.0) 1 (3.3) Keyboard focus is locked

on one of the page elements and cannot be moved from it using only the keyboard

2 (6.7) 29 (96.7) No mechanism is

Visual, physical

Visual,

Notes. * The United Kingdom was selected in the Google search settings as a default search region. For every keyword combination, first 100 consecutive Google search results were screened for eligibility. Abbreviations: BLS, basic life support; CPR, cardiopulmonary resus- citation; MOOC, massive open online course.

Appendix Table A.2

Web accessibility errors and alerts of English-language MOOCs in adult BLS as detected by

Blocks (A)

      1. Page Titled (A)
      2. Focus Order

available to bypass blocks of content that are repeated on multiple web pages

1 (3.3) 0 (0.0) Web pages have no titles

that describe topic or purpose

The focus order of webpage elements is

cognitive, physical

Visual, cognitive, physical Visual, cognitive,

the WAVE tool.

(A) 0 (0.0) 1 (3.3)

broken

physical

      1. Link Purpose

Violated WCAG

Errors, n

Alerts, n

Explanation of success

Affected

(In Context) (A)

links is not determined

cognitive,

2.1 success

(% of all

(% of all

criterion violation

disabilities

by the link text alone or

physical

criterion (level

courses)

courses)

by the link text together

of conformance*)

with its

27 (90.0) 26 (86.7) The purpose of some

Visual,

      1. Non-text Content (A)
      2. Audio-only and Video-only (Prerecorded) (A)
      3. Captions (Prerecorded) (A)
      4. Audio Description or Media Alternative (Prerecorded)

27 (90.0) 24 (80.0) Non-text content (with

the exception of media) has no text alternative that serves the equiva- lent purpose

0 (0.0) 22 (73.3) Prerecorded audio-only

or video-only media has no alternative that pre- sents equivalent infor- mation

0 (0.0) 22 (73.3) Prerecorded audio

content in synchronised media has no captions

Prerecorded media has no audio description or alternative for

Visual, cognitive

Visual, auditory, cognitive

Auditory

Visual,

2.4.6 Headings and Labels (AA)

3.1.1 Language of Page (A)

3.3.2 Labels or

Instructions (A)

not provided when content requires user

input

4.1.2 Name, Role,

16 (53.3)

0 (0.0)

For some user interface

Visual,

Value (A)

components, the name, role and values are not programmatically determined

physical, cognitive

programmatically determined link context

18 (60.0) 29 (96.7) Headings and labels do

not clearly describe topic or purpose

6 (20.0) 0 (0.0) The default human

language of some web pages is not programmatically determined

16 (53.3) 11 (36.7) Labels or instructions are

Visual, cognitive

Visual, auditory, cognitive

Cognitive

(A) 0 (0.0) 22 (73.3)

1.2.5 Audio Description (Prerecorded)

(AA) 0 (0.0) 11 (36.7)

time-based media

Prerecorded media has no audio description

cognitive

Visual, cognitive

Notes. Abbreviations: WCAG, Web Content Accessibility Guidelines. *All success criteria are systematised on three levels of conformance to WCAG 2.1: A (minimum acceptable level of conformance, the highest priority for web content developers), AA (medium level of conformance, medium priority) and AAA (maximum level of conformance, least

      1. Info and Relationships (A)
      2. Meaningful

22 (73.3) 30 (100.0) Information, structure or

relationships conveyed through presentation cannot be programmatically determined and not available in text form Correct reading sequence of content is not programmatically

Visual

Visual,

priority) [13].

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