**4.1 Accessibility**

*Assistive and Rehabilitation Engineering*

tion of the ePHoRT project.

increasingly popular.

human rights and fundamental freedoms."

and it is estimated that it will continue to increase.

accessible to all users of the telerehabilitation platform?

tive, curative, and maintenance processes.

multimedia resources, especially those related to video and audio.

content, including documents and digital resources.

disabilities. Therefore, the educational resources of the Tele-habilitation platform must provide instantaneous and ubiquitous access to all types of services and

The digital educational resources have become a valuable alternative to support the teaching and learning processes, taking advantage of the possibility of presenting the contents through different multimedia formats. Therefore, it is necessary that educational resources for learning apply accessibility features that allow the interaction of users regardless of their conditions and preferences. This document presents a proposal for the evaluation of the accessibility of multimedia educational resources, where it is suggested to apply the WCAG 2.1 in addition to a series of phases to automatically and manually assess the level of accessibility of the educational resources used in the platform of telerehabilita-

Accessibility is related to the degree to which people can use or access a service, regardless of their technical, cognitive, or physical abilities [17]. Web accessibility describes methods and theories to make resources, in their multiple forms, more accessible for all people especially for the elderly and people with disabilities. In general, the educational resources of any website or platform must provide universal access, that is, if it includes videos, subtitles must be placed so that the content can be interpreted by people with visual disability or low vision; if people have hearing problems, an audio

The United Nations [18] "Recognizes the importance of access to the physical, social, economic and cultural environment, to health and education and to information and communication, so that persons with disabilities can fully enjoy all

According to Kurtz et al. [19], the number of people who have undergone surgery for total hip arthroplasty (THA) has increased significantly in the last 10 years,

In line with Ravi et al. [20], THA is a surgery that refers to the replacement of the femoral head and acetabulum of the hip joint. This surgery is usually performed in older adults, due to degenerative joint disease or progressive wear and tear of the joint, and the demographics of patients who decide to undergo THA has become

In agreement with Salavati et al. [21], the young persons may have higher functional objectives than older persons, which may modify the structuring of rehabilitation protocols. In any of the cases, what is intended after surgery is to calm

In this study, we started with the following question: Are multimedia resources

It is considered an accessible multimedia resource if the content is available to all users, regardless of their disability or application context [22]. It is of vital importance that the educational resources of the platform are accessible even for people who use a screen reader. This research analyzes accessibility problems with

According to Rybarczyk et al. [23] in the telerehabilitation platform, learning processes can be oriented in different stages of rehabilitation and include preven-

For the early recovery of the patient on the platform, instructions are included

intended to guide the patient through the rehabilitation process at all stages. Proper guidance can help the patient make the right movements to reinforce the safety of functional tasks and motivate the patient to complete the rehabilitation program. Considering that the patient should perform the exercises in a standing position and

on the general consequences of the procedures and their likely risks, so it is

the pain, restore normal function, and improve the quality of life of people.

description should be included, making sure that the resources are inclusive.

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Baruch et al. [25] indicate that multimedia accessibility policies propose that "All multimedia elements such as audio or video, produced or published must be accessible at the time of publication." Multimedia accessibility proposes a simple text transcription, so that it is necessary to place a transcript in audio-only recordings, to meet all the success criteria suggested by WCAG 2.1. On the other hand, multimedia resources according to the World Wide Web Consortium (W3C) [26] include texts, images, graphics, animations, video, and sound to present or communicate specific information. Consequently, to cover all the parameters that intervene in the accessibility of educational resources, it is necessary to evaluate a set of dependent components such as human factors, in this case all the users of the telerehabilitation platform are considered, including users with special needs, technological factors to provide accessibility, and user interaction with the device in the environment of the platform, which include criteria to favor accessibility with the indicated components. ISO/ IEC 40500: 2012 [27] is equivalent to the Web Content Accessibility Guidelines 2.0 (WCAG 2.0), is related to the Web Content Accessibility Guidelines 2.1 (WCAG 2.1) which consists of 4 principles, 13 guidelines, and 76 compliance criteria (success), plus an undetermined number of sufficient techniques and counseling techniques.

The four principles are the same as those contained in WCAG 2.0:


#### **4.2 Method**

In March 2012, Web Accessibility Initiative (WAI) published the Methodology of Website Accessibility Conformance Evaluation Methodology (WCAG-EM) 1.0. In 2014, a new version was published [28]. The WCAG-EM methodology allows

**Figure 13.** *Evaluation of multimedia resources.*

determining if the contents of the websites are evaluated to comply with the WCAG 2.1 accessibility guidelines or not. In this research the WCAG-EM 1.0 was applied. In this case, it was used to apply the evaluation of multimedia resources specifically to the videos. It consists of five sequential phases, as shown in **Figure 13**.

**Phase 1:** Selection of the resource. In this phase, the educational resource to be evaluated is selected. For this study, the video located on the telerehabilitation platform was selected. **Figure 14** shows a screenshot; it is observed that the patient performs rehabilitation exercises. It should be noted that this resource is part of the patient education section and the educational resources will be hosted on the platform located at http://telerehabilitation.udla.edu.ec/learning/resource/2/media/1.

**Phase 2:** Identify the type of user. In this phase, the type of users is defined; for our case we will focus on older people who have age-related disabilities [29]; this may affect the way they use the web, like first, the reduction of the vision that includes a sensitivity reduced to the contrast, the perception of the color, and the near approach. This makes difficult the reading of the web pages. Second is the reduction of physical capacity including dexterity. This makes it difficult to use the mouse and click on small targets. Third is the difficulty of listening, including the difficulty to hear sharp sounds and separate sounds. This makes it difficult to listen to podcasts and other audio, especially when there is background music. Fourth, cognitive ability includes short-term memory reduction, difficulty concentrating, and being easily distracted, which makes it difficult to track browsing and online tasks. These problems are related to the accessibility needs of people with disabilities. Therefore, websites, applications, and tools that are accessible to people with disabilities are also more accessible to older users.

**Phase 3:** Identify the user's real scenario. In this phase, it is determined what the patient wants to learn in the telerehabilitation platform so that the educational resource adequately explains the process so that the patient learns and reinforces his learning.

**Phase 4:** Explore and become familiar with the resource. In this phase, we review the resource format for our case study and review the video format, size, and

**87**

http://

**Table 3.**

telerehabilitation. udla.edu.ec/ learning/ resource/2/ media/1

<sup>1</sup> http://trace.umd.edu/peat

*Efw = extended flash warnings, P = passed*

Analysis Tool1

*Screenshot of the resource to evaluate.*

**Figure 14.**

detailed in **Table 4**.

*Technical Contributions to the Quality of Telerehabilitation Platforms: Case Study—ePHoRt…*

duration. This information is relevant to review with the Photosensitive Epilepsy

**Table 3** records the results obtained in the evaluation with PEAT. It contains the video identifier, length of material, luminance flash failures, red flash failures,

**Phase 5:** List the barriers according to the type of user. In this phase, the possible barriers that the user can find in the resource are established, such as the keyboard compatibility, the colors with good contrast, the design and bright design, the text of voice, extensive links, buttons and controls, video descriptions, customizable text, speech recognition, understandable content, notifications and comments, and selection to different language types. That relates to the WCAG 2.1 success criteria

**Phase 6:** Evaluate each barrier according to WCAG 2.1. In this phase, the criteria of success are evaluated manually according to WCAG 2.1. About the principle of perceptible [31], the Guideline 1.2 related to time-based media. According to the criterion of success 1.2.1, either only audio or only prerecorded video (Level A), it is necessary to provide an alternative that describes the content of the prerecorded video, for example, placing an audio track. Criteria of success 1.2.2 subtitles

**URL Description Standard Success criterion Fr Lm Rs Lff Rff Efw**

*Fr = frame rate, Lm = length of material, Rs = result status, Lff = luminance flash failures, Rff = red flash failures,* 

WCAG 2.1 2.3 25 00:06.19 P 0 0 0

required that the video is in Audio Video Interleave (AVI) format.

extended flash warnings, result status, and percentage.

Patient in the process of learning exercises on the telerehabilitation platform

*Evaluation with the photosensitive epilepsy analysis tool.*

(PEAT) [30] of the University of Wisconsin Trace Center. It is

*DOI: http://dx.doi.org/10.5772/intechopen.83686*

*Technical Contributions to the Quality of Telerehabilitation Platforms: Case Study—ePHoRt… DOI: http://dx.doi.org/10.5772/intechopen.83686*

*Assistive and Rehabilitation Engineering*

determining if the contents of the websites are evaluated to comply with the WCAG 2.1 accessibility guidelines or not. In this research the WCAG-EM 1.0 was applied. In this case, it was used to apply the evaluation of multimedia resources specifically

**Phase 1:** Selection of the resource. In this phase, the educational resource to be evaluated is selected. For this study, the video located on the telerehabilitation platform was selected. **Figure 14** shows a screenshot; it is observed that the patient performs rehabilitation exercises. It should be noted that this resource is part of the patient education section and the educational resources will be hosted on the platform located at http://telerehabilitation.udla.edu.ec/learning/resource/2/media/1. **Phase 2:** Identify the type of user. In this phase, the type of users is defined; for our case we will focus on older people who have age-related disabilities [29]; this may affect the way they use the web, like first, the reduction of the vision that includes a sensitivity reduced to the contrast, the perception of the color, and the near approach. This makes difficult the reading of the web pages. Second is the reduction of physical capacity including dexterity. This makes it difficult to use the mouse and click on small targets. Third is the difficulty of listening, including the difficulty to hear sharp sounds and separate sounds. This makes it difficult to listen to podcasts and other audio, especially when there is background music. Fourth, cognitive ability includes short-term memory reduction, difficulty concentrating, and being easily distracted, which makes it difficult to track browsing and online tasks. These problems are related to the accessibility needs of people with disabilities. Therefore, websites, applications, and tools that are accessible to people

**Phase 3:** Identify the user's real scenario. In this phase, it is determined what the patient wants to learn in the telerehabilitation platform so that the educational resource adequately explains the process so that the patient learns and reinforces his learning. **Phase 4:** Explore and become familiar with the resource. In this phase, we review the resource format for our case study and review the video format, size, and

to the videos. It consists of five sequential phases, as shown in **Figure 13**.

with disabilities are also more accessible to older users.

**86**

**Figure 13.**

*Evaluation of multimedia resources.*

#### **Figure 14.** *Screenshot of the resource to evaluate.*

duration. This information is relevant to review with the Photosensitive Epilepsy Analysis Tool1 (PEAT) [30] of the University of Wisconsin Trace Center. It is required that the video is in Audio Video Interleave (AVI) format.

**Table 3** records the results obtained in the evaluation with PEAT. It contains the video identifier, length of material, luminance flash failures, red flash failures, extended flash warnings, result status, and percentage.

**Phase 5:** List the barriers according to the type of user. In this phase, the possible barriers that the user can find in the resource are established, such as the keyboard compatibility, the colors with good contrast, the design and bright design, the text of voice, extensive links, buttons and controls, video descriptions, customizable text, speech recognition, understandable content, notifications and comments, and selection to different language types. That relates to the WCAG 2.1 success criteria detailed in **Table 4**.

**Phase 6:** Evaluate each barrier according to WCAG 2.1. In this phase, the criteria of success are evaluated manually according to WCAG 2.1. About the principle of perceptible [31], the Guideline 1.2 related to time-based media. According to the criterion of success 1.2.1, either only audio or only prerecorded video (Level A), it is necessary to provide an alternative that describes the content of the prerecorded video, for example, placing an audio track. Criteria of success 1.2.2 subtitles


*Fr = frame rate, Lm = length of material, Rs = result status, Lff = luminance flash failures, Rff = red flash failures, Efw = extended flash warnings, P = passed*

#### **Table 3.**

*Evaluation with the photosensitive epilepsy analysis tool.*

<sup>1</sup> http://trace.umd.edu/peat


#### **Table 4.**

*Manual evaluation of the video resource.*

#### **Figure 15.**

*Recommendations for the creation of accessible videos.*

(Level A) are as follows: subtitles are provided for all prerecorded audio content in synchronized media, except when the media are an alternative media for text and are clearly labeled as such. The criterion of success 1.2.3 related to the description of audio or alternative of prerecorded media (Level A). It suggests that an alternative is provided for synchronized media, except when the medium is a multimedia alternative to the text and is clearly labeled as such. Success criteria 1.2.4 subtitles

**89**

dataset.2

*Technical Contributions to the Quality of Telerehabilitation Platforms: Case Study—ePHoRt…*

(live) (Level AA) are as follows: subtitles are provided for all live audio content in synchronized media. Success criterion 1.2.5, which refers to the description of prerecorded audio (Level AA), provides audio description for all prerecorded video content in synchronized media. Success criterion 1.2.6 sign language (level AAA) provides sign language interpretation for all prerecorded audio content in synchronized media. Success criterion 1.2.7 related to having an extended audio description for all prerecorded video content (Level AAA) to use when the foreground audio is insufficient to convey the meaning of the video. Success criterion 1.2.8 on the prerecorded media alternative (Level AAA) provides an alternative for time-based media for all prerecorded synchronized media and for all prerecorded video media only. Finally, success criterion 1.2.9 audio only (Level AAA) provides an alternative for time-based media that presents equivalent information for live audio-only content on media only. **Table 2** shows the data of the manually evaluated video resource. It contains the success criterion of WCAG 2.1 of the perceptible principle, level, and compliance that indicate whether it meets the success criteria, where 1 indicates

**Phase 7:** Record the data with severity problems. In this phase, the results are recorded in a spreadsheet; in this case, Microsoft Excel was used. The data record and the analysis of the results to replicate the research are available in the Mendeley

**Phase 8:** Analyze the results. In this phase, the authors used Microsoft Excel statistical graphs. The dispersion graph was applied with the trend line to analyze the value of R between the success criteria and compliance with the WCAG 2.1.

1.Preferences. In this option, it should allow the configuration of subtitles,

2.Show the subtitle settings. In this case, it should include the options to configure according to the preference of users such as position, font, font size, text

3.Video speed, subtitles, and audio in the application. The user should have the option to customize the speed of the video, subtitles, and audio according to

4.Language. In this option, the user could customize and choose the language for the audio description and subtitles. This option should allow moving the

5.Audio description preferences. In this option, the media player must allow the configuration of the audio description format in several ways so that it is displayed in the highlighted form of the color the user wishes while the video is presented. In addition, it is vital to include the option of automatic video pause and the option to make the description visible. On the other hand, it is essential to include keyboard preferences using keyboard shortcuts. This option should allow moving the window to the position you want the user to.

**Phase 9:** Recommendation. In this phase, some recommendations are suggested so that the video resource is accessible and inclusive, according to WCAG 2.1. In **Figure 15** according to the numbering, it is described what it should contain in each element so that the video resource is more inclusive and accessible. See details below:

*DOI: http://dx.doi.org/10.5772/intechopen.83686*

that it meets and 0 indicates that it does not comply.

descriptions, keyboard, and transcription.

color, background, and opacity.

the user's preference and disability.

<sup>2</sup> http://dx.doi.org/10.17632/tjf47zxmv2.1

window to the position you want the user to.

*Technical Contributions to the Quality of Telerehabilitation Platforms: Case Study—ePHoRt… DOI: http://dx.doi.org/10.5772/intechopen.83686*

(live) (Level AA) are as follows: subtitles are provided for all live audio content in synchronized media. Success criterion 1.2.5, which refers to the description of prerecorded audio (Level AA), provides audio description for all prerecorded video content in synchronized media. Success criterion 1.2.6 sign language (level AAA) provides sign language interpretation for all prerecorded audio content in synchronized media. Success criterion 1.2.7 related to having an extended audio description for all prerecorded video content (Level AAA) to use when the foreground audio is insufficient to convey the meaning of the video. Success criterion 1.2.8 on the prerecorded media alternative (Level AAA) provides an alternative for time-based media for all prerecorded synchronized media and for all prerecorded video media only. Finally, success criterion 1.2.9 audio only (Level AAA) provides an alternative for time-based media that presents equivalent information for live audio-only content on media only. **Table 2** shows the data of the manually evaluated video resource. It contains the success criterion of WCAG 2.1 of the perceptible principle, level, and compliance that indicate whether it meets the success criteria, where 1 indicates that it meets and 0 indicates that it does not comply.

**Phase 7:** Record the data with severity problems. In this phase, the results are recorded in a spreadsheet; in this case, Microsoft Excel was used. The data record and the analysis of the results to replicate the research are available in the Mendeley dataset.2

**Phase 8:** Analyze the results. In this phase, the authors used Microsoft Excel statistical graphs. The dispersion graph was applied with the trend line to analyze the value of R between the success criteria and compliance with the WCAG 2.1.

**Phase 9:** Recommendation. In this phase, some recommendations are suggested so that the video resource is accessible and inclusive, according to WCAG 2.1. In **Figure 15** according to the numbering, it is described what it should contain in each element so that the video resource is more inclusive and accessible. See details below:


*Assistive and Rehabilitation Engineering*

*Manual evaluation of the video resource.*

**Table 4.**

**Success criterion Level Comply** 1.2.1 Audio-only and video-only (prerecorded) A 1 1.2.2 Captions (prerecorded) A 0 1.2.3 Audio description or media alternative (prerecorded) A 0 1.2.4 Captions (live) AA 0 1.2.5 Audio description (prerecorded) AA 0 1.2.6 Sign language (prerecorded) AAA 0 1.2.7 Extended audio description (prerecorded) AAA 0 1.2.8 Media alternative (prerecorded) AAA 0 1.2.9 Audio-only (live) AAA 0

**88**

**Figure 15.**

*Recommendations for the creation of accessible videos.*

(Level A) are as follows: subtitles are provided for all prerecorded audio content in synchronized media, except when the media are an alternative media for text and are clearly labeled as such. The criterion of success 1.2.3 related to the description of audio or alternative of prerecorded media (Level A). It suggests that an alternative is provided for synchronized media, except when the medium is a multimedia alternative to the text and is clearly labeled as such. Success criteria 1.2.4 subtitles

<sup>2</sup> http://dx.doi.org/10.17632/tjf47zxmv2.1

