Why is Accessibility Important?

Scientific publications that are accessible provide equal opportunities for everyone to engage with the contents. This helps new scientific developments reach a wider audience, thereby enhancing the impact of research. Additionally, making scientific publications accessible ensures they are compliant with relevant legal frameworks including the European Accessibility Act (EAA) and the Americans with Disabilities Act (ADA). Karger Publishers is committed to making our website, products and platforms accessible and usable to the widest audience possible. Please see our Accessibility Statement for information and updates on our work on accessibility matters.

How to present images, graphics and figures in an accessible way?

When preparing figures or images, there are a number of steps you can take to ensure that the presentation of the graphic is accessible. This is particularly beneficial for those with colour blindness and vision impairments.

Another important element in the accessibility of an image or figure is the associated alt text. Read on for more information on this topic.

 

What is Alt Text?

Alternative text (alt text) is an attribute linked to an online image that provides a textual description of the image's content or message. It allows interpretation of an image through words, without needing to see the image. Alt text is essential for accessibility as it ensures that everyone, including screen reader users, can absorb the content of an image in a web page or publication. Alt text descriptions should be concise and be described within the context of the publication.

Which Items in a Publication Require Alt Text?

Any visual communication such as photographs, drawings, diagrams, infographics, charts, and graphs. Please see our table below for comprehensive examples.

Which Items in a Publication do not Require Alt Text?

Alt text is not needed for tables that are text based (for example in a Word document). However if a table is presented within a figure in an image format, it would require alt text.

What Makes Good Alt Text?

Good alt text enables all those engaging with the publication to achieve the same level of understanding of the image, regardless of how they engage with the publication.

When you are preparing or reviewing alt text for an image, remember that alt text should be:

Brief – Alt text should not be a long paragraph describing the contents of figure. Aiming for 40-50 words can provide a good balance between conciseness and detail. Alt text should ideally be less than 100 words, but more than 10 words.

Contextual – While alt text should be brief, it should not be so short that relevant information is lost. Alt text should always be provided in the context of the overall publication. This means that information should not be repeated in the alt text that is available in the main text or figure legend as this can inadvertently decrease the clarity of the message. Avoid using acronyms, instead spell out the whole word for the benefit of screen reader users, for example do not write “RCT”, instead write “randomised control trial”.

Exact – Avoid writing in generalisations in alt text or oversimplifying the message in the interest of brevity. Do not write “The number of participants completing the survey decreased over time”, instead be specific and write “There was a thirty percent decrease in the number of participants who completed the survey from one hundred participants at six months to seventy participants at one year”. It is important for the alt text to be short and concise. When writing the alt text, describe the images in a consistent manner (for example, always from top to bottom or left to right) so that information is presented in a logical manner. It is also important to remember that demographic information such as age, gender, or race should only be included if it is directly relevant to the context of the image.

Not redundant – Do not start the alt text with “this figure shows” or “an image of” as screen readers will already note that the description is of an image. Alt text provides the message of the figure in the context of the article. Avoid repeating information that is in the figure caption or the main text. Alt text should not feature the same description across multiple images or figures. The image’s alt-text should include what makes the figure or image unique and important to the publication. If relevant to the image, do mention colours in graphics as this is helpful for users with low vision.

Formatted correctly – Alt text is designed to be read by a screen reader and, therefore, should not contain formatting such as bullet points or include any lists. Each alt text description should be punctuated correctly and finished will a full stop to ensure a screen reader pauses at appropriate moments. In addition, avoiding writing fraction numbers, symbols or abbreviations. Instead, type out the full words, for example “one and a half” instead of 1½. If the image contains an equation, the alt text should spell out the names of each of the symbols in the equation.

Example of Types of Images and Their Accompanying Figure Legend and Alt Text

Below you will find a table with examples of various images and graphics, with their accompanying figure legend and alt text. You may use this table to assist you in understanding how to convey and word the alt text, as well as the differences between the figure legend and the alt text.

 
Image Figure Legend Alt Text

Graphic

Figure 2 from Zhi Tong Zuo, Ya Ma, Yan Sun, Cui Qing Bai, Chun Hua Ling, Feng Lai Yuan; The Protective Effects of >strong>Helicobacter pylori Infection on Allergic Asthma. Int Arch Allergy Immunol 4 January 2021; 182 (1): 53–64. https://doi.org/10.1159/000508330

H. pylori has a protective effect on asthma by inducing highly immunosuppressive Tregs and inhibiting Th17. HP, H. pylori; Tregs, regulatory T cells; RORγt, retinoid-related orphan receptor (ROR) gamma t; Foxp3, forkhead transcription factor p3.

Two pathways of the H. pylori protective effect on allergic asthma. The top pathway, via inhibition of Thl7 cells secretion of IL-17. The bottom pathway, via promotion of Tregs cells secretion of IL-10 and immune tolerance.

Clinical imaging

Figure 2 from Miyuki Nemoto, Kiyotaka Nemoto, Hiroyuki Sasai, Shinji Higashi, Miho Ota, Tetsuaki Arai; Long-Term Multimodal Exercise Intervention for Patients with Frontotemporal Lobar Degeneration: Feasibility and Preliminary Outcomes. Dement Geriatr Cogn Disord Extra 1 January 2025; 15 (1): 19–29. https://doi.org/10.1159/000542994

Results of near-infrared spectroscopy (NIRS)-SPM analysis.

Individual pre and post intervention, at twenty-four to forty-eight weeks, near-infrared spectroscopy - Statistical Parametric Mapping analysis results for each participant showing increased areas and level of frontal lobe activation post intervention.

Complex graphs

Figure 3 from Jordi Kühne Escolà, Bessime Bozkurt, Bastian Brune, Lennart Steffen Milles, Doreen Pommeranz, Philipp Dammann, Yan Li, Cornelius Deuschl, Michael Forsting, Clemens Kill, Christoph Kleinschnitz, Martin Köhrmann, Benedikt Frank; Sex Differences in Clinical Presentation of Women and Men Evaluated at a Comprehensive Stroke Center for Suspected Stroke. Cerebrovasc Dis Extra 1 January 2025; 15 (1): 110–117. https://doi.org/10.1159/000543835

Forest plot showing adjusted odds ratios and 95% confidence intervals of being diagnosed with cerebrovascular disease for presenting symptoms in women and men with suspected stroke. aOR, adjusted odds ratio; CI, confidence interval.

There is a positive relationship for women and men between diagnosis with cerebrovascular disease and presenting with aphasia, gaze deviation, neglect, dysarthria, facial droop, limb ataxia, limb paresis, sensory impairment or visual field deficiency but not impaired completion of tasks, impaired consciousness or impaired orientation, which show a negative relationship.

Flowcharts

Figure 2 from Daisuke Azuma, Kingo Hirasawa, Reo Atsusaka, Yuichiro Ozeki, Atsushi Sawada, Masafumi Nishio, Ryosuke Kobayashi, Chiko Sato, Shin Maeda; Muscular Injury Is a Risk Factor for Post-Entire Circumferential Esophageal Endoscopic Submucosal Dissection Stricture. Dig Dis 2025; https://doi.org/10.1159/000543846

Study flowchart. Fifty-three lesions in 53 patients were subjected to EC-E-ESD. Four patients were excluded because they could not be followed up for more than 6 months or had non-curative resections and underwent additional CRT. Of the 32 lesions with esophageal stricture, 25 with EBD ≥6 were classified into the refractory stricture group; 7 lesions with EBD <6 and 17 with no stricture (a total of 24 lesions) were classified into the non-refractory stricture group. CRT, chemoradiotherapy; EBD, endoscopic balloon dilation; EC-E-ESD, entire circumferential esophageal ESD; ESD, endoscopic submucosal dissection

Outcomes of patients who underwent circumferential esophageal Endoscopic Submucosal Dissection in the study period, including those excluded. The forty-nine included patients were categorized based on the presence of esophageal strictures post-procedure and the number of endoscopic balloon dilations required for correction.

Diagram illustrating anatomy

Figure 4 from Zhi Tong Zuo, Ya Ma, Yan Sun, Cui Qing Bai, Chun Hua Ling, Feng Lai Yuan; The Protective Effects of Helicobacter pylori Infection on Allergic Asthma. Int Arch Allergy Immunol 4 January 2021; 182 (1): 53–64. https://doi.org/10.1159/000508330

The gut-lung axis theory: Gut and lung interactions through microbiota and immune function. LPS, bacterial lipopolysaccharide; SCFAs, short-chain fatty acids; Tregs, regulatory T cells; DCs, dendritic cells; Th17, helper T cells 17.

A human torso with the digestive and respiratory systems highlighted. Arrows indicate pathways of blood circulation and lymphatic circulation connecting the gut and lungs. Icons represent the interacting elements; gut microbes, lung microbes, H pylori, LPS SCFAs, Tregs, DCs, IgA, and Th17 cells.

Photographs of medical cases

Figure 2 of Joseph Ryan, Lee Na Chong, Robert Jared Dunn; Preemptive, Self-Applied Photobiomodulation in the Treatment of Oral Mucositis: A High-Risk Case Study. Case Rep Oncol 1 January 2025; 18 (1): 311–318. https://doi.org/10.1159/000541966

A series of clinical photographs of the oral cavity throughout RT. Top left: left lateral tongue ulceration with generalized erythema at session 9. Top right: left lateral tongue ulceration resolving at session 43. Middle left: slightly erythematous right buccal mucosa at session 18. Middle right: normal right buccal mucosa at session 46. Bottom left: erythematous soft and hard palate with ulceration and pseudomembrane formation at session 20. Bottom right: soft and hard palate displaying improved erythema with resolution of ulceration at session 46.

Six clinical photographs of open mouths showing the presentation and resolution of oral cavity conditions during radiotherapy.

Graphs

Figure 3 of Darren M. Brenner, Gregory S. Sayuk, Brooks D. Cash, Lucinda A. Harris, Nitin K. Ahuja, Jill K. Deutsch, Yang Yang, Suling Zhao, David P. Rosenbaum, Anthony J. Lembo; Tenapanor Improves Abdominal Symptoms Irrespective of Changes in Complete Spontaneous Bowel Movement Frequency in Adults with Irritable Bowel Syndrome with Constipation. Dig Dis 2024; https://doi.org/10.1159/000543166

Weekly AS3 response rates in the no-CSBM subgroup (a) and the ITT excluding no-CSBM subgroup (b). The weekly AS3 response was defined as achieving a reduction from baseline of ≥2 points in AS3 for a given week. Response rates were analyzed using Pearson’s chi-square tests with a worst-case imputation approach (patients with missing data were considered to not have achieved a response). AS3, 3-item abdominal score; bid, twice a day; CSBM, complete spontaneous bowel movement; ITT, intent-to-treat; n, the number of patients with a valid week in the corresponding study week.

Two bar graphs comparing the weekly three-item abdominal score response rates between a placebo group and a Tenapanor fifty mg bid group over twelve weeks. Graph (a) represents the no- complete spontaneous bowel movement subgroup, while graph (b) represents intent-to-treat excluding no-complete spontaneous bowel movement subgroup. The x-axis represents the weeks (one to twelve), and the y-axis represents the percentage of patients achieving a reduction from baseline of ≥two points in three-item abdominal score for each week.

Diagram

Figure 1 from Tomoharu Yamaguchi, Yohko Maki, Haruyasu Yamaguchi; Yamaguchi Facial Expression-Making Task in Alzheimer’s Disease: A Novel and Enjoyable Make-a-Face Game. Dement Geriatr Cogn Disord Extra 1 December 2012; 2 (1): 248–257. https://doi.org/10.1159/000339425

Parts of the Y-FEMT, exemplary results and error patterns. a The Y-FEMT consists of one outline plate and six simple parts of the human face. Exemplary results of the Smile task (b; Smile score was 10/10) and Anger task (c; Anger score was 10/10) in healthy elderly people. d–f Examples of the Smile task in AD patients. The score was decreased by 1 point for incorrect orientation of the eyes, but adopting the eyebrows as a moustache was not considered a mistake (d; Smile score was 9/10). Orientation of the nose is upside-down (e; Smile score was 9/10). Placement of the nose and symmetric property are different and expression score was 3 (f; Smile score was 7/10). g, h Examples of the Anger task in mild-to-moderate AD patients. Only the position of the eyebrows and eyes are correct, each gaining 1 point (g; Anger score was 2/10), and the fundamental structure of the face was good, except that the orientation of the eyes is left-right reversed, but the facial expression is different (h; Anger score was 5/10).

Examples related to the Yamaguchi Face Emotion Matching Test. Panel (a) shows the components of the test including one outline plate and six simple parts of the human face such as eyes, eyebrows, nose, and mouth against a black background.

Multi panel images

Figure 3 from Hewei Cheng, Lu Gao, Rixing Jing, Bo Hou, Xiaopeng Guo, Yong Yao, Ming Feng, Bing Xing, Feng Feng, Yong Fan; Reversibility of Impaired Large-Scale Functional Brain Networks in Cushing’s Disease after Surgery Treatment: A Longitudinal Study. Neuroendocrinology 1 March 2024; 114 (3): 250–262. https://doi.org/10.1159/000534789

Two informative functional brain networks as well as emotion scales with significant longitudinal changes in CD patients before treatment and at the 3-month follow-up. a Brain regions with significant longitudinal changes in functional connectivity within circuits of CerebN and FPN for CD patients, identified using non-parametric permutation tests (AlphaSim-corrected p < 0.01). b, c Significantly different functional connectivity measured by IC’s z scores across voxels within circuits of CerebN and FPN as well as emotion scales measured by the self-rating depression scale (SDS) and self-rating anxiety scale (SAS) between any two of NCs, CD patients before the treatment (i.e., active CD patients), and endocrine-remitted CD patients at 3-month follow-up (FDR-corrected p < 0.05). A pseudo paired t test with age, sex, and years of school education as covariates was conducted to compare all IC’s z scores within each functional network as well as the SDS scores and SAS scores between CD patients before treatment and at the 3-month follow-up. While a pseudo two-sample t test with age, sex, and years of school education as covariates was conducted to compare IC’s z scores within each functional network as well as SDS scores and SAS scores between NCs and CD patients before treatment, and endocrine-remitted CD patients at 3-month follow-up. CerebN, cerebellar network; FPN, fronto-parietal network; CD, Cushing’s disease; Pres, CD patients before treatment; Posts, endocrine-remitted CD patients at 3-month follow-up; NCs, normal controls; ICs, independent components; FDR, false discovery rate.

Regions of the cerebellar network and the fronto-parietal network show altered functional connectivity in Cushing’s disease patients between active and endocrine-remitted states. Box plots in panel b indicate significant between group differences in both networks between normal controls, Cushing’s disease patients before the intervention and endocrine-remitted Cushing’s disease patients at three month follow-up. Box plots in panel c show no significant between-group difference in either self-rating depression scale or self-rating anxiety scale scores.

 

How to Submit Alt Text with a Manuscript

As the author of the manuscript, you are the subject matter expert to your research and so you have the best ability to provide the relevant alt text for your manuscript’s images. When you are submitting a manuscript, you will be prompted to add the Figure captions and Figure alt text for each figure, directly in the journal’s submission system. These will appear alongside the Figures for the Editors and peer reviewers to assess.

Please note that alt text is not needed for tables that are editable or text based. However, if a table is presented within a figure in an image format, it would require alt text. Therefore. we kindly ask you to upload your text based table as a separate Word document during online submission.

For any questions or requests for assistance regarding alt text, our team will be happy to help you. Please contact them using our on-demand request. We thank you for your work on making your research more accessible and reach a wider audience.