Apparent skin tone rendering in recommended undergraduate optometric textbooks in England - a descriptive content analysis

Oct 13, 2026

A descriptive cross-sectional content analysis examines how apparent skin tones are rendered in recommended undergraduate optometric textbooks used in England. From 28 textbooks selected from eight of eleven English optometry programmes, 1,623 gradable graphics were classified on the six-point Fitzpatrick phototype scale by independent mixed-composition teams. Results show 78.1% light, 18.4% intermediate, and 3.5% dark depictions, with substantial inter-rater agreement (quadratically weighted kappa 0.69). Dark skin tones were rare across textbooks and robust to analytic choices. The study frames 2021 Census comparisons as contextual benchmarks, not normative standards.

LanguageEnglish

CategoryPresentations

FormatPDF

Pages19

Reading Time7 min

AccessFree to download

Background

Visual imagery and representational patterns

International evidence and gaps

Methods

Sampling and dataset

Classification and reliability

Statistical reporting

Results

Distribution across Fitzpatrick phototypes

Textbook-level prevalence

Robustness checks

Conclusions

Implications for publishers and educators

Apparent skin tone rendering in recommended undergraduate optometric textbooks in England: a descriptive content analysis Daniela Oehring University of Plymouth Andrew Taylor University of Plymouth Charlotte Barsdell University of Plymouth Haleema Ajaib University of Plymouth Kaashish Sidhana University of Plymouth Katey Hooper University of Plymouth Research Article Keywords: skin tone representation, medical education, optometry, Fitzpatrick scale, content analysis, textbook imagery, health equity, visual pedagogy Posted Date: July 7th, 2026 DOI: [https://doi.org/10.21203/rs.3.rs-9855135/v1](https://doi.org/10.21203/rs.3.rs-9855135/v1) License: 􀁱 􀅏 This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Additional Declarations: Competing interest reported. The study was conducted as part of an undergraduate research project at the University of Plymouth. Abstract Background Lighter skin tones are overrepresented in medical educational imagery across several disciplines, yet no study has examined optometric teaching materials. This study describes the distribution of apparent skin tone rendering in recommended undergraduate optometric textbooks used in England. Methods A descriptive, cross-sectional content analysis was conducted on 28 textbooks identiﬁed through purposive sampling of recommended reading lists from eight of eleven English university optometry programmes. Two independent mixed-composition teams classiﬁed 1,623 gradable graphics (1,446 photographs, 177 schematics) on the six-point Fitzpatrick skin phototype (FP) scale. Inter-rater reliability was assessed using quadratically weighted Cohen's kappa. Proportions are reported with 95% Wilson conﬁdence intervals. Textbook-level analyses were also performed, treating the textbook as the unit of analysis. Descriptive comparisons with the 2021 Census are presented as contextual, not normative, benchmarks; no inferential hypothesis tests were conducted against the census comparator. Results Quadratically weighted kappa was 0 . 69, indicating substantial agreement on the ordinal scale, while unweighted exact agreement (61 .8%) reﬂected moderate category-by-category concordance. Across all graphics, 78 . 1% were classiﬁed as light (FP I-II; 95% CI 76 .1–80. 1%), 18 .4% as intermediate (FP III-IV; 95% CI 16.6–20.4%), and 3 . 5% as dark (FP V-VI; 95% CI 2 .7–4. 5%) . Fourteen of 28 textbooks (50%) contained no images classiﬁed as FP V-VI, and no schematic diagram across the corpus was classiﬁed as FP V-VI (0/177) . At the textbook level, median FP V-VI prevalence was 0 .9%(IQR 0 .0-3.8%), substantially below the census contextual comparator of 18.95% non-White. Findings were robust to exclusion of the single largest contributing text and restriction to books with ten or more gradable images (photographs plus schematics) . Conclusions In this sample of recommended optometric textbooks, graphics classiﬁed as depicting dark skin tones are rare. The ﬁnding is consistent across textbooks and robust to analytical choices. These data describe a pattern that warrants attention from publishers, educators, and curriculum developers, thoughthe study does not directly assess educational outcomes or establish a normative standard of adequate representation. Background Visual imagery is a cornerstone of clinical training in medicine and its allied professions, including optometry. Educational graphics serve as tools through which clinicians learn to recognise and interpret disease presentations [1] . A well-documented tendency towards lighter skin tone depiction exists across medical educational resources, with potential implications for diagnostic training, clinical competence, and health equity [2, 3] . International research has established the existence of this representational pattern. In the United States, Louie and Wilkes [4] demonstrated that while major anatomy textbook

FAQs

What was the study’s main goal?

To describe the distribution of apparent skin tone rendering in recommended undergraduate optometric textbooks used in England.

How were skin tones categorized in the analysis?

Researchers classified 1,623 gradable graphics using the six-point Fitzpatrick skin phototype (FP) scale.

What were the key findings about dark skin tone depictions?

Across all graphics, only 3.5% were classified as dark (FP V-VI), and 14 of 28 textbooks (50%) contained no images in FP V-VI.

Oct 13, 2026

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