Digital healthcare self-management education has the potential to increase the necessary knowledge and skills for the improvement of health outcomes for citizens, especially patients with a disability and chronic diseases. If the implementation of the e-health concept has to be considered, it is obvious that there is an emerging need for increasing the digital health literacy of the population. First, the digital health literacy of healthcare and medical staff has increased and in the second phase, disabled people, chronic disease patients, and the elderly have to be educated about their digital health literacy in order to use e-health services. The use of information and communication technologies provides an effective and efficient way to deliver health content prepared by medical staff as well as psychologists. The paper highlights the process of implementation of the e-learning platform for digital health literacy - Atutor, an open-source learning content management system suitable for a wider population with implemented WCAG compliance, and the challenges arising during its implementation
Managing care for the growing elderly population and increasing number
of patients with chronic non-communicable diseases requires efective measures
such as involvement and empowerment of patients in self-care. Additionally, the
coronavirus (COVID-19) pandemic had a huge impact on the normal lives of
people and led to the advent of a new normal. People increasingly use digital
technologies and the Internet to do every day professional, private as well health
activities. The project Cross4all addresses the e-health challenges in the
crossborder area, taking into consideration the problems of creating a PHR (Personal
Health Record) for patients from two national healthcare systems where the
patient is the data owner. The proposed architecture is cloud-based and distributed,
in order to support data collection from diferent types of sources and collected
in diferent ways such as patients’ healthcare data, medical practitioner data, data
collected from biomedical devices, sensors for measuring vital signs of life, many
times collected from remote patients, the disabled population, children and
elderly people [
The increased use of internet access and use of digital technology leads to
people relying on received and sent health information. The potential for health
technologies to be the catalyst for significant advances in healthcare cannot be
questioned, however from a scientifically standpoint, there is still much to be
done to create platforms and systems that activate and engage those who would
benefit from knowing before health issues arise and are too far along to be re
versed or efectively managed [
Today, digital literacy has been dubbed as a fourth literacy, after reading, writing, and mathematics are considered the cornerstone of being literate.
There are many advantages to having high-level digital Health literacy
skills—they allow patients to operate well within the health care system and find
better care by using online information more efectively, reduce waiting periods
and improve communication with healthcare professionals. Research has found
a positive connection between digital health literacy and joint patient–medical
professionals’ decision-making, [
The e-learning platform as a part of the Cross4all project makes a positive impact, increases the participants’ e-health and healthcare digital competencies, and speeds up the process of healthcare self-management.
The paper describes the implementation of an e-learning platform available cross-border in a real environment. After the introductory section, the second section presents research results regarding the digital and health literacy of the pilot project participants. In the next section, the paper considers some points of project aim and purpose, prerequisites, and security and safety standards, taken into account in the phase of LMS (Learning Management System) selection. The next section describes some of the challenges and obstacles and presents real solutions. The concluding section contains supportive concluding remarks and proposes some project improvements.
The Internet abounds with health information. For an illustration, about 3,770,000 results are returned by Google when searching for “blood pressure” and about 3,910,000 results when searching for “diabetes”.
In order to use digital information, three preconditions need to be met: access to a computer and high-speed internet; the digital literacy skills needed to use the computer; and necessary skills to evaluate online health information resources.
Digital health literacy is a set of basic skills acquired through efective digital
technology to search, understand, and evaluate an individual’s health
information. This relates to the use of digital health technology in the online environment
and to apply the knowledge acquired [
The level of digital literacy of the population in the border region is signifi cant. In order to determine how and to answer other important questions, a survey was conducted.
The analyzed research results show that 79% of adults use a smartphone, tablet and/or computer. Respondents rated the internet connection as satisfactory and good 73.4%, while 23.2% from very good to excellent, and 3.4% poor or have no Internet access at all.
57.9% say that they used digital devices to look online for digital health content within the past year. 34,4% find easy information and services related to health, 34% find information with dificulty and 31,6% say that they do not find such information and data (Figure 1). The language was highlighted as one of the problems in accessing the necessary health content (81.6%). They prefer health content in the Macedonian/Greek language, their respective mother tongue. The respondents who access the digital health content find it helpful to find informa tion regarding their health problems and possible. Some of them say they use the internet as a de facto second opinion.
Most of the respondents, 64.2%, believe that the accuracy and importance of the information depend on the source of the information, and the information obtained through the Internet sometimes is incomplete, confusing, and in some cases inaccurate. Only a small percentage 25.3% check the accuracy of the information and 10.5% do not find important and useful digital health information (Figure 2).
Following the results obtained from the research, we estimated that within the Croos4all project it is most appropriate to develop a digital learning platform that is easy to use and that incorporates the motto of the project a Cross4all promoting safe aging, early prevention, and independent living for all.
The digital learning platform will help project participants to know how to
use the mobile application as well as help citizens from cross-border regions to
use technologies to manage learning, keep up with any changes and encourage
them to seek knowledge by themselves, from digital media and social media [
The e-material was created and posted on the e-learning platform, taking into
consideration the needs of disabled people, the elderly population, and children.
This platform is free, accessible from anywhere, on disposal to the population with
many video materials, presentations, and brochures that have to support the
project’s aim of increasing the population’s e-health and digital health literacy [
The manuals about the new workflow and mobile applications, tutorials, and technical support needed for integration of e-health Services with PHR during the pilot project were prepared by two project partners (the Aristotle University of Thessaloniki, Department of Medicine and University “St. Kliment Ohridski” – Bitola, Faculty of Information and Communication Technologies). The health content about diabetes, cardio, Covid-19, and psychology, posted on the digital platform was prepared by medical professionals (Figure 3). The content is available in three languages: English, Macedonian, and Greek.
Several tasks need to be completed before the e-learning platform is implemented choosing the most suitable LMS; UI (User Interface) compliance with the WCAG (Web Content Accessibility Guidelines) standard; preparation of the content and upload to the platform; defining content groups and menus; content placement and preparation of documentation.
Learning Management Systems (LMS) are considered as platforms for elearning, taking into consideration their capability and accessibility from difer ent points of view.
LMS have big potential for continuous improvement of digital and health
literacy. There is a plethora of available LMS, and each one has diferent fea
tures, which are tailored to the diferent needs of the target groups. To find and
choose the most appropriate LMS is a very important task, and it has a big
impact on health literacy improvement [
We made research and analyzed some respectable e-learning systems with
W3C’s Web Accessibility principles, defined by ISO 9241-171:2008 standard as
priority (in mind). 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
[
The analysis was performed on the latest public version of the respective Learning management systems (LMSs) such as Moodle, Eliademy, Docebo, Sakai, and ATutor, considering the WCAG 2.0 standards and criteria.
Each of the analyzed LMSs presents a diferent learning platform with
unique features. Although the accessibility of learning management systems is
improving, there are still significant challenges for people with disabilities [
Our further testing continues with the evaluation of the criteria of Level AAA
for Moodle and ATutor, as these two systems are particularly prominent in terms
of availability for people with disabilities in the previous evaluation [
WCAG 2.1 provides 17 new success criteria for diferent levels of compli
ance. The five new success criteria for level A: Character Key Shortcuts, Pointer
Gestures, Pointer Cancellation, Label in Name, Motion Actuation. Seven
respective criteria from Level AA: Orientation, Identify Input Purpose, Reflow,
NonText Contrast, Text Spacing, Content on Hover or Focus, Status Messages; and
ifve new criteria for Level AAA which is the highest and also least common level
of compliance: Identify Purpose, Timeouts, Animation from Interactions, Target
Size, Concurrent Input Mechanisms. All these criteria were compared in a real
environment, on publicly accessible latest versions of Moodle and ATutor [
ATutor was selected as more suitable for the project activities of Cross4all
IPA2, as an LMS 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 [
ATutor, as an open-source LMS, gives the opportunity to develop and
manage online courses, and to create and distribute interoperable e-learning content.
ATutor is designed with accessibility as a priority. The newest version of ATutor
is adding course gamification and refinements [
This LMS has a user-friendly UI, which makes it an ideal tool for beginners
as well as people with disability. It has integrated one of the general principles
that underlie the Convention on the Rights of Persons with Disabilities to provide
access to all aspects for all people on an equal basis. It means “universal design”,
design usable by all people, to the greatest extent possible, without the need for
adaptation or specialized design [
The implemented e-learning platform (http://atutor.cross4all.uklo.edu.mk/ login.php) contained much public content: manuals about the new workflow and mobile applications, tutorials, technical support, and health content. All contents are available in three languages: English, Macedonian and Greek languages (Figure 4).
The users can register themselves, log in on Cross4all LMS and improve their e-health literacy in many areas such as cardiology, psychology, diabetes, how to use gadgets for measuring vital signs, and so on. The selected content can be viewed online or be exported – downloaded and viewed ofline.
The user can change elements of their personal profile, can enroll in courses that they are interested in, can control which versions of content are displayed, if for example, the primary version is not accessible to them, or they prefer an alternate format. Also, users can develop a network of contacts, create and participate in social groups, develop a social profile and use diferent gadgets (a user can add some of the available applications to their Social Networking environment that provide a whole range of potential networking functionality). Additionally, they can create “My Contacts“ – a list of people in the user’s social network.
Although the platform ofers a number of possibilities, during the implemen tation as well as during its use we faced some challenges.
Some of the problems that we were facing during implementation include lack of documentation or outdated documentation, installation instructions that were for older and legacy systems, and older versions of operating systems. One of the things is that we were trying to virtualize/dockerize the application for it to be easily movable to staging and production environments. ATutor supports several types of databases and we decided to go with the MySQL database.
The system has one big problem when it is not properly shut down. Then, it loses some of the configuration information, and then it needs to be reverted to some previously configured valid version. The additional downside of using a not properly configured MySQL database was that it did not support utf-8 character sets, we had significant challenges regarding implementation of the Cyrillic, and Greek alphabet and we needed to manually configure and provide support for such alphabets. Atutor is not an up-to-date system and does not provide the latest support for new versions of internet browsers, the latest version of the system has been released in 2018.
Because of the complexity of healthcare, and a large number of health topics, we are faced with the problem of finding digital and objective information accessible to both healthcare providers and patients. Content for patients with objective and irrelevant health information is the most requested to be prepared by medical professionals.
Medical professionals are pressed to integrate health IT into their jobs, while
also trying to stay up-to-date with emerging technologies. They often have to deal
with low-quality, bugged, or ineficient software and technologies that further
decrease the amount of time they can spend with their patients [
One more challenge we faced with was the older patients’ lack of digital literacy.
Designing and implementing an e-learning platform for increasing digital health literacy in the Cross4all project is one of the components of the digital health system (which we are keen to be just one part of a larger health system in both cross-border countries). The process to build and sustain a functional platform is made up of several stages: choosing the most suitable LMS; UI compliance with the WCAG standard; preparation of the content upload platform; documentation preparation and platform maintenance.
The dynamic nature of technology and healthcare made the process of implementation and maintenance non-linear and iterative. Some of the challenges we faced sometimes had to revert to some previously configured valid version, re garding implementation of the Cyrillic and Greek alphabet and the need to manually configure and provide support for such alphabets. Another big challenge is the preparation of heath content. This needs some systematic solution. Additional patients’ training of platform usage was needed.
In future work, we have to work on a digital learning platform that will feature special courses related to health literacy. This means the ability to obtain, read, understand, and use healthcare information in order to make appropriate health decisions and follow instructions for treatment. For example addressing or solving various health problems, and courses related to digital health l health literacy (set of skills, knowledge, and attitudes that a person needs in order to (a) seek, find, and appraise health information and services from electronic sources, and (b) to find, select and make efective use of available tools (PHRs, devices, mobile apps, etc..
Part of the work presented in this paper has been carried out in the framework of the project “Cross-border initiative for integrated health and social services promoting safe ageing, early prevention and independent living for all (Cross4all)”, which is implemented in the context of the INTERREG IPA Cross Border Cooperation Programme CCI 2014 TC 16 I5CB 009 and co-funded by the European Union and national funds of the participating countries. 7. References