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  <front>
    <journal-meta />
    <article-meta>
      <title-group>
        <article-title>A Comparison of Accessible e-Learning Projects for Improving of Digital Health Literacy</article-title>
      </title-group>
      <contrib-group>
        <contrib contrib-type="author">
          <string-name>Andrijana Bocevska</string-name>
        </contrib>
        <contrib contrib-type="author">
          <string-name>Snezana Savoska</string-name>
        </contrib>
        <contrib contrib-type="author">
          <string-name>Blagoj Ristevski</string-name>
        </contrib>
        <contrib contrib-type="author">
          <string-name>Natasha Blazheska- Tabakovska</string-name>
        </contrib>
        <contrib contrib-type="author">
          <string-name>Igor Nedelkovski</string-name>
        </contrib>
      </contrib-group>
      <fpage>50</fpage>
      <lpage>60</lpage>
      <abstract>
        <p>Access to the information and communication technology for people with disabilities as well as elderly people is an important prerequisite for their social inclusion. With the advance of the e-learning platforms and recent regulations of the European Union, which impose conformance to Web Content Accessibility Guidelines (WCAG) for web applications of public institutions, Learning Management Systems (LMSs) have to be accessible to enable people with disabilities to participate in the learning and educational processes. This article compares the accessibility of the following LMSs Moodle and АTutor for people with disabilities, according to the WCAG 2.1 standard criteria of different levels of compliance. The visual, hearing and motor impairments are included in this comparative analysis. The concluding purpose is to develop an e-leaning project that will increase e-health and medical digital literacy among population with particular emphasis on the people with disabilities, elderly people and children. The proposed project will be used as a reference for healthcare and educational institutions to identify the essential adjustments needed to integrate accessibility into their e-learning courses.</p>
      </abstract>
      <kwd-group>
        <kwd>Learning Management Systems</kwd>
        <kwd>e-learning</kwd>
        <kwd>WCAG 2</kwd>
        <kwd>1 standards</kwd>
        <kwd>ehealth</kwd>
        <kwd>digital health literacy</kwd>
      </kwd-group>
    </article-meta>
  </front>
  <body>
    <sec id="sec-1">
      <title>1. Introduction</title>
      <p>Numerous recent EU project activities were connected with assisted living
concepts taking into consideration improvement of the living conditions of
the EU population, especially for elderly population, children, people with
chronical diseases and people with disabilities. EU population has the trend of
aging, demanding more specified and accessible healthcare and social services.
But, some vulnerable categories as elderly people, children and people with
disabilities in some EU countries do not have the equal possibilities for
healthcare and social services. For this reason, EU helps to get better condition
financing projects which have to follow the corresponding standards in order
to improve the living conditions of the population, providing funds to increase
the knowledge for digital health literacy, increasing opportunities of vulnerable
categories of people to improve the health and social services, using emerging
ICT technologies. One of such benefits is the distance learning, which provides
accessible knowledge for all categories of citizens, as elderly people, children
or people with disabilities. This article is focused on available e-learning
systems that are accessible according to emerging WCAG (Web Content
Accessibility Guidelines) standard 2.1 provided by W3C (World Wide Web
Consortium). The WCAG 2.1 standard provides accessibility of the websites
or the systems for all. The application of this standard in the improvement
of health and social services is crucial for wider population, so that it can
significantly contribute to increase the level of digital e-health literacy in the
EU and worldwide.</p>
      <p>
        In this article, we made a research and analyzed some respectable e-learning
systems for W3C’s Web Accessibility principles, defined by ISO 9241-171:2008
standard. According to this research, despite its personal characteristics and
environment type, web assets as learning objects have to be accessible and to provide
information for specific categories of people [
        <xref ref-type="bibr" rid="ref1">1</xref>
        ]. In the research, considerable
attention was dedicated to the following four principles: Perceivable, Operable,
Understandable and Robust in order to provide the basics of web accessibility
with 12 guidelines for the authors [
        <xref ref-type="bibr" rid="ref1">1</xref>
        ]. For each guideline, we provided testing
according to WCAG 2.0 for three levels of compliance: A (lowest), AA and AAA
(highest) [
        <xref ref-type="bibr" rid="ref2">2</xref>
        ].
      </p>
      <p>
        This paper examines the criteria with different levels of compliance according
to WCAG 2.1 for Moodle and ATutor, as these two systems are particularly
prominent in terms of availability for people with disabilities [
        <xref ref-type="bibr" rid="ref3">3</xref>
        ], taking into
consideration the analysis tabled in [
        <xref ref-type="bibr" rid="ref5">5</xref>
        ]. Recommendations will be used to choose
the best system for e-learning on e-health in order to increase the digital literacy of
health of the population of the cross border area for which the project is intended.
      </p>
      <p>The paper is organized as follows. Related works are described in Section 2. The
new criteria included in the WCAG 2.1 standard are depicted in next section.
A comparison of some WCAG 2.1 criteria of LMSs Moodle and ATutor, are
provided in the Section 4. Last section gives a brief review of the research,
providing concluding remarks and directions for further work.</p>
    </sec>
    <sec id="sec-2">
      <title>2. Related Works</title>
      <p>
        Learning management systems (LMSs) are considered as platforms for e-Learning,
taking into consideration their capability and accessibility from different points
of view. The accessibility in context of e-learning usually is regarded as some
defined criteria for instructors, authors of the contents, specialists for e-learning
platforms and courses. But, when talking about e-inclusion and e-accessibility
[
        <xref ref-type="bibr" rid="ref3">3</xref>
        ], there are many generally accepted definitions that have to be clarified as
common visual, verbal and kinetic dysfunctions, affecting the learning style and
especially the design of content accessible to everyone [
        <xref ref-type="bibr" rid="ref4">4</xref>
        ]. There are discussions
among authors that there have to be many software tools that have to provide
some alternatives for people with disabilities to understand and access to these
contents [
        <xref ref-type="bibr" rid="ref6">6</xref>
        ]. Many people with significant impairment have difficulties when
using a mouse or a keyboard to access to web contents. The people from this
group will often rely on various keyboard technologies to access web contents,
including a “large key” keyboard, an onscreen keyboard, or a scanning keyboard
that is operated with a single switch or head mouse [
        <xref ref-type="bibr" rid="ref4">4</xref>
        ]. Some aspects of disability
consider cognitive impairments as well as learning disabilities [
        <xref ref-type="bibr" rid="ref10">10</xref>
        ]. In this case,
some material consistency, predictability, complexity, and memory, that have the
ability to understand and match the subject is of particular importance are taken
into consideration [
        <xref ref-type="bibr" rid="ref4">4</xref>
        ].
      </p>
      <p>
        In order to obtain understandable materials for a wide community, it is also
important to adopt them to the people’s personality and problem solving, making
influence to the users to remember and recognize the tasks that have to be solved.
Also, the materials have to be written in a simple language, without sarcasm,
idioms, metaphors, and other risky forms that lead to ambiguity. Also, e-learning
systems have to be created according to the standards and specifications of actual
WCAG 2.1 [
        <xref ref-type="bibr" rid="ref8">8</xref>
        ].
      </p>
      <p>
        Some researchers [
        <xref ref-type="bibr" rid="ref7">7</xref>
        ] had considered the concept of cloud computing as a
new inspiration for creative learning environment which provides a high level
of accessibility, considering the usability of cloud technology for the third world
countries and solving the problems with hardware and software [
        <xref ref-type="bibr" rid="ref9">9</xref>
        ]. These research
summarize the main advantages and drawbacks of using cloud online learning,
comparing services, assess risk and benefit and concluding that the concept saves a
lot of efforts of organizations, overcoming the obstacles with internet connections
[
        <xref ref-type="bibr" rid="ref9">9</xref>
        ] and giving opportunities for the inclusion of new technologies as Internet
of Things (IoT) and Ambient Assisted Living, especially for vulnerable groups
[
        <xref ref-type="bibr" rid="ref10 ref11">10, 11</xref>
        ]. In order to detect the accessibility problems in LMSs, a combination of
accessibility expert and end-user evaluation is very useful.
      </p>
    </sec>
    <sec id="sec-3">
      <title>3. E-accessibility using WCAG2.1 standard</title>
      <p>
        Following the concluding remarks and the directions for further work in [
        <xref ref-type="bibr" rid="ref5">5</xref>
        ], we
compare the LMSs Moodle and ATutor, since these two platforms provide the
best environment for people experiencing disability. In this paper the analysis
made in [
        <xref ref-type="bibr" rid="ref5">5</xref>
        ] is enhanced with evaluation of the compliance of Moodle and ATutor
with success criteria from WCAG 2.1. The accessibility testing and evaluation
using an analytical method was performed on the latest public version of the
respective Learning management systems.
      </p>
      <p>
        Moodle is one of the most popular open source LMS options available today.
A simple interface, drag-and-drop features, and well-documented resources along
with ongoing usability improvements make Moodle easy to learn and use. This
open source Learning Management System also gives the ability to create
mobilefriendly online courses and integrate third-party add-ons. As a highly flexible
LMS, Moodle can be used to conduct courses online or to support face-to-face
teaching, learning and training. It can also be extended with over 500 plugins for
assignments, quizzes, grading, certification, and social and collaborative learning
[
        <xref ref-type="bibr" rid="ref12">12</xref>
        ].
      </p>
      <p>
        ATutor is an Open Source LMS, whose functionality and visualization can
be extended with various modules and themes. It also offers a wide selection
of themes to speed up the e-learning course development process, as well as
e-learning assessment tools, file backups, analytics, and poll integration. Tutors
can easily upload and manage the content which will be published for the students
in a user-friendly environment. ATutor developed as a proof of concept that a
fully inclusive e-learning environment was possible. Since its initial release,
ATutor has continued to evolve, with a development focus on its accessibility and
conformance with interoperability standards [
        <xref ref-type="bibr" rid="ref13">13</xref>
        ].
      </p>
      <p>
        Web Content Accessibility Guidelines (WCAG) 2.1, as a newer standard,
extends Web Content Accessibility Guidelines 2.0. WCAG 2.1 builds on and
is backwards compatible with WCAG 2.0, meaning web pages that conform
to WCAG 2.1 also conform to WCAG 2.0. WCAG 2.1 covers a wide range of
recommendations for making Web content more accessible. Accessibility criteria
are organized in four principles i.e. Perceivable, Operable, Understandable and
Robust that should provide the basics of web accessibility with 13 guidelines for
the authors [
        <xref ref-type="bibr" rid="ref8">8</xref>
        ]. Following these guidelines will make content more accessible to a
wider range of people with disabilities, including accommodations for blindness
and low vision, deafness and hearing loss, limited movement, speech disabilities,
photosensitivity, and combinations of these, and some accommodation for learning
disabilities and cognitive limitations. A big part of this update includes guidelines
for mobile device accessibility, so these guidelines address accessibility of web
content on desktops, laptops, tablets, and mobile devices [
        <xref ref-type="bibr" rid="ref8">8</xref>
        ].
      </p>
      <p>WCAG 2.1 provides 17 new success criteria for different levels of compliance.
Table 1 shows the five new success criteria for level A, which is the lowest level
of conformance you can achieve (aka the easiest). In Table 2, seven respective
criteria from Level AA, which is the mid-level conformance that can be achieved,
are shown. Finally Table 3 presents five new criteria for Level AAA, which is the
highest and also least common level of compliance.
LEVEL A
2.1.4 Character Key Shortcuts
2.5.1 Pointer Gestures
2.5.2 Pointer Cancellation
2.5.3 Label in Name
2.5.4 Motion Actuation</p>
      <p>Table 1 shows that Moodle and ATutor differ in the fulfillment of the
first criterion. ATutor uses HTML access keys, which cannot be turned off or
remapped. Probably the reason because of which ATutor is not compliant with this
criterion is that WCAG 2.1 came after ATutor’s last development cycle. Moodle
automatically satisfies it, since there are no shortcuts that users can use. Similarly,
the criterion Motion Actuation is automatically satisfied by both LMSs, because
they do not have an action that is triggered by motion (such as shaking or tilting
the device), so there is no need for an alternative of such actions. Both LMSs
offer options to comply with the remaining three criteria. For Pointer Gestures,
all functionality that uses multipoint or path-based gestures for operation can be
operated with a single pointer without a path-based gesture. Examples include
arrows used to access previous/next page (Figure 1), or horizontal slider (Figure
2) in Moodle and arrow up/arrow down (Figure 3) used instead of vertical swiping
in ATutor.</p>
      <p>Speech input users can navigate by speaking the visible text labels of menus,
links and buttons that appear on the screen. The intent of the success criterion
Label in Name is to help ensure that people with disabilities who rely on visual
labels can also use those labels programmatically. Users have a much better
experience if the visible text labels of controls match their accessible names. In
Moodle and ATutor, for user interface components with labels that include text
or images of text, the name contains the text that is presented visually (Figure 4
Moodle and Figure 5 ATutor). The compliance with this criterion has also been
proven successful using Screen reader and Speech Recognition Systems.</p>
      <p>Table 2 gives an overview of some criteria recommended to meet Level AA
of compliance. The first success criterion Orientation is crucial for people with
certain types of impairments. Some websites and applications automatically set
and restrict the screen to a particular display orientation and expect that users
will respond by rotating their device to match, but this can create problems.
The intent of this criterion is to ensure that content displays in the orientation
(portrait or landscape) preferred by the user. Since Moodle and ATutor meet the
criterion people with impairments can benefit in many ways such as: users with
dexterity impairments, who have a mounted device will be able to use the content
in their fixed orientation; users with low-vision will be able to view content in
the orientation that works best for them, for example to increase the text size by
viewing content in landscape, etc.</p>
      <p>Moodle</p>
      <p>Yes
No</p>
      <p>Yes
Partial
Partial</p>
      <p>ATutor</p>
      <p>Yes
No
Yes
No
Yes
1.4.13 Content on Hover or Focus
4.1.3 Status Messages</p>
      <p>The only criterion that is not satisfied by any of the platforms is Identify
Input Purpose. The autocomplete attribute is set to “off” in Moodle (Figure 6) and
is not used in ATutor (Figure 7).</p>
      <p>The success criterion Reflow requires support for the reflow of content
(also known as ‘Responsive Web Design’) and is very important for people with
low vision, since enlargement and reflow enable perception of characters and
tracking. Both Moodle and ATutor allow reflow of content and meet this criterion.
Another criterion which is supported by both LMSs is Status Message. In ATutor
the technique role=”alert” is used, as shown below in Figure. 8. In Moodle, after
submitting a form and leaving a required fill blank, error is shown as inline text
and it receives focus automatically, so there is no need of additional techniques
such as attribute role=”alert”, since they are used only when the list of problems
does not receive focus.</p>
      <p>The fulfillment of the criterion Non-text Contrast in Moodle and ATutor is
evaluated as Partial and No respectively. The contrast of the colors of active and
inactive buttons is lower than the required level in both platforms. The reason
because it is evaluated as Partial in Moodle is that users can choose their custom
colors, which would satisfy this criterion, while ATutor does not provide this
option. If the criterion Text Spacing is taken into account, Moodle is evaluated as
Partial because it does not provide a way to meet the required specifics, but the
user can add custom CSS. In ATutor spacing would depend on the theme being
used and can be easily adjusted to meet the criterion. The criterion Content on
Hover or Focus is evaluated as Partial, since the content that shows or hides from
hover or focus in both LMSs is persistent, but not dismissible and hover able, as
required in WCAG 2.1.</p>
      <p>Table 3 systematizes the five new success criteria from WCAG for level
AAA, which is the highest conformance that can be achieved. For the purpose of
the first criterion, in content implemented using markup languages, the purpose
of User Interface Components, icons, and regions can be programmatically
determined. The intent of this success criterion is to support personalization and
preferences in order for more people to use the web, communicate, and interact
with society. In this context, Moodle uses ARIA landmarks (Figure 9) and the
user can add custom icons in the “Theme settings” sections, which makes Moodle
compliant with this criterion. On the other side, ATutor uses ARIA landmarks
(Figure 10), but does not support personalization and adding custom icons, so it
is evaluated as Partial.</p>
      <p>The usage of timed events can present significant barriers for users with
cognitive disabilities, as these users may require more time to read content or to
perform functions, such as completing an online form. The user may not be able
to complete the process in one sitting and may need to take a break. As required
in the criterion Timeouts, users should be warned of the duration of any user
inactivity that could cause data loss, unless the data is preserved for more than 20
hours when the user does not take any actions. In terms of this criterion, there is a
difference between the LMSs we analyzed. In Moodle the session is over without
previous warning, while ATutor informs the user about the session timeout and
provides a way to continue the session (Figure 11).</p>
      <p>There is only one criterion from AAA Level of compliance that is not met by
any platform i.e. Target Size. Testing done by measuring the touch target size on
the device when focus borders are displayed showed that the size of the target for
pointer inputs of some elements is less than required. Furthermore, the criterion
Animation from Interactions is satisfied by both LMSs, due to the circumstance
that animations are not usual for Moodle and ATutor, so there is no need of way to
turn animations off. The intent of the last success criterion is to ensure that people
can use and switch between different modes of input when interacting with web
content. Users may employ a variety of input mechanisms when interacting with
web content. Compliance with this criterion by both platforms can be noted
by many examples, such as: a speech input user navigates content using voice
commands which translate to simulate mouse (and keyboard) commands. When
talking with a colleague, however, the user turns speech recognition off and uses
the mouse instead; a user opens a menu with a mouse, and then navigates between
the menu items with arrow keys etc.
4.</p>
    </sec>
    <sec id="sec-4">
      <title>Concluding Remarks</title>
      <p>
        The paper’s purpose is to analyze the additional demands of WCAG 2.1 standard
and to enhance the research made for evaluation of e-Leaning platforms and their
suitability for implementation in increasing of e-health and digital health literacy
for the project of IPA2 - CROSS4ALL. The analysis of this paper complements
the research in [
        <xref ref-type="bibr" rid="ref5">5</xref>
        ]. It is in accordance with the complementation of the WCAG
standard and includes 17 new success criteria i.e. 5 for Level A, 7 for Level AA and
5 for Level AAA of compliance. The improvements are in terms of accessibility
for certain disabilities, as well as application of mobile devices. The aim is to
perceive some features that cannot be modified and variable features that can
be adapted for the specific accessibility requirements of people with disabilities.
According to the CROSS4ALL requirements, the criteria from WCAG 2.0 Level
AA of compliance need to be satisfied.
      </p>
      <p>These analyses are made in real environment, on public accessible latest
versions of e-learning systems Moodle and ATutor, evaluating the new criteria
for WCAG2.1 standard. Some perceptions from the practical use of these LMSs
are given in this paper in order to highlights the improvement of WCAG standard
with a new version and consider if they are more suitable for the project activities
of CROSS4ALL IPA2. The selected system needs to provide the most suitable
website with e-leaning system that has to satisfy the demands of elderly people,
children, people with chronic diseases as well as people with disabilities in order
to increase e-health and medical digital literacy for the cross border region,
including all partners’ contribution.</p>
    </sec>
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