Massive Open Online Courses on Health and Medicine: Review

Background Massive open online courses (MOOCs) have become immensely popular in a short span of time. However, there is very little research exploring MOOCs in the discipline of health and medicine. Objective We aim to provide a review of MOOCs related to health and medicine offered by various MOOC platforms in 2013, by analyzing and comparing the various offerings, their target audience, typical length of course, and credentials offered. We also discuss opportunities and challenges presented by MOOCs in health and medicine. Methods Health and medicine–related MOOCs were gathered using several methods to ensure the richness and completeness of data. Identified MOOC platform websites were used to gather the lists of offerings. In parallel, these MOOC platforms were contacted to access official data on their offerings. Two MOOC aggregator sites (Class Central and MOOC List) were also consulted to gather data on MOOC offerings. Eligibility criteria were defined to concentrate on the courses that were offered in 2013 and primarily on the subject of health and medicine. All language translations in this paper were done using Google Translate. Results The search identified 225 courses, of which 98 were eligible for the review. Over half (58%, 57/98) of the MOOCs considered were offered on the Coursera platform, and 94% (92/98) of all the MOOCs were offered in English. Universities offered 90 MOOCs, and the John Hopkins University offered the largest number of MOOCs (12/90). Only three MOOCs were offered by developing countries (China, West Indies, and Saudi Arabia). The duration of MOOCs varied from 3-20 weeks with an average length of 6.7 weeks. On average, MOOCs expected a participant to work on the material for 4.2 hours a week. Verified certificates were offered by 14 MOOCs, while three others offered other professional recognition. Conclusions The review presents evidence to suggest that MOOCs can be used as a way to provide continuous medical education. It also shows the potential of MOOCs as a means of increasing health literacy among the public.


Introduction
Massive Open Online Courses (MOOCs) are a recent innovative addition to the online learning landscape. They are online courses that are accessible through the web and open to registration generally without limit imposed on numbers or prerequisites. The course registration and course materials are free of charge though in some courses one can pay to obtain a certificate of participation or verified certificate (for credit). These courses have start and end dates but even after the start date registration is kept open (in many courses) unlike traditional online courses that closes registration at the start of the course. MOOCs carry great potential to reach large numbers of learners from across the world as they can be accessed by anyone anywhere in the world as long as they have internet access, computer literacy and language proficiency.

Brief History
Connectivism and Connective Knowledge CCK an online course facilitated by George Siemens and Stephen Downes, in 2008, offered through the Learning Technologies Centre and Extended Education at the University of Manitoba [1], is considered the first MOOC [2]. This online course had around 2,200 non-credit, nonfee paying students along with 25 paid enrolments (for credit). Unlike the traditional form of online courses that rely primarily on resources posted by the facilitators through a learning management system (LMS), this course was conducted according to the principles of connectivism [3] encouraging learning through a network (peer learning) across multiple learning spaces.
Within a short time span MOOCs have attracted wide interest from educators, learners, businesses, media and the general public. Many prominent universities are now offering their courses as MOOCs. For example, Massachusetts Institute of Technology, Harvard University, Berkeley University of California and the University of Texas offer MOOCs through the MOOC platform edX. There have also been forprofit ventures such as Coursera MOOC platform that partners with over 100 institutions (108 as of March 19, 2014) from around the world.
In some MOOCs the number of enrolments is in the order of hundreds of thousands. However, not all students enrolled return for the course and only a small number of them finish all parts of the course [2]. Given the nature of the courses, where participation is voluntary and no financial commitments are made up front as would be in other traditional courses (for example, registration fee and course fees), whether the number who progresses through the course should be a concern is debated. If the aim of a MOOC was to provide the opportunity or access to learn from high-quality courses (taught by the experts in the field from world class universities) the numbers completing the course should not be of prime concern [4]. On the other hand, if the aim was to get everyone registering for the course through to the end, similar to a traditional higher educational institution where a student failing to complete within a given time-frame could impact adversely on the university s profile family student himself and lecturers these completion rates would be a disaster. The problem here though could be the use of traditional metic in this non-traditional or disruptive form of educational provision. However, more evidence based research would reveal the true nature of MOOCs and possibly better ways of understanding and evaluating them.
Although the MOOC revolution began in the North Americas, it has now spread to universities and institutions in many parts of the developed world. For example, in 2013 the UK MOOC platform, FutureLearn, started offering courses. Initially MOOCs were offered in English. But today there are many MOOCs offered in various languages including Chinese, Arabic, Spanish and French. For example, in 2012 a Spanish MOOC platform MiriadaX was founded; in 2013 the platform Rawq was started to offer courses in Arabic; similarly Xuetangx was created to offer courses in Chinese. However, English remains the dominant language in MOOC provision.

MOOC Pedagogy
MOOCs as other online courses use a variety of learning materials including: videos, documents, and quizzes. At present MOOCs are mainly classified according to their pedagogical position cMOOCs or connectivist MOOCs and xMOOCs or MOOC as eXtension of something else [6]. cMOOCs harness the strength of networks and peer learning generally using multiple learning spaces. Participants in cMOOCs are likely to find that there is lot of emphasis on participants stories and learning from them (for example, Rhizomatic Learning: The community is the curriculum on P2PUniversity) than on the learning materials provided by the instructor or course designer. On the other hand, xMOOCs seems to have a more individualist learning approach [7] surrounding the course on a given MOOC platform. In xMOOCs learning and understanding the content provided in the course is given priority. Original cMOOCs were based on open education practices making their content available using open licensing [8]. However, many xMOOCs offered in platforms such as Coursera use copyright materials. However, it is worthwhile noting that there is a continuum of possibilities between these two distinct pedagogical positions.
MOOCs are offered in wide range of subjects: varying from cell biology to astronomy. In this paper, the courses offered by major MOOC platforms on topics related to Health and Medicine is explored. Several methods were used to collect relevant courses for the review: directly making contact with MOOC platforms to get course data, accessing publicly available information on MOOC platform websites and using MOOC aggregator sites. Data relating to courses offered in 2013 were collected as earlier offerings lacked relevant details. The paper provides a comprehensive review of MOOCs offered in in (ealth and Medicine or related category.

Data Collection
In general, researchers use different methods to identify data to be included in a review. For example, to collect papers (data) for a systematic review of literature researchers would search in data bases and/or search engines and chaining from known sources [2]. Similarly, in collecting details of MOOCs offered in topics related to Health and Medicine for this review, it was important to collect an as complete set of data as possible. A list of MOOCs offered by various providers was not readily available for analysis. Thus in identifying relevant MOOCs, a range of methods were employed to obtain related information that would form a more complete data set for the analysis.

MOOC Platforms
With the growing popularity of MOOCs there have been various commercial and non-commercial organizations providing platforms on which MOOCs can be offered. Identification of such MOOC platforms was carried out using the literature, news items and web resources. LISTedTECH (a database of educational companies, educational products, and educational institutions that anyone can edit) lists 19 systems as MOOC platforms as of December 19, 2013 [9]. Using news articles, blogs and other literature nine additional MOOC platforms that are in operation were identified. The total of 28 identified MOOC platforms (Multimedia Appendix 1: MOOC Platforms) and their offerings were considered in this review.
During the period 17th December 21st December each of these MOOC platforms websites were accessed to find the list of MOOCs offered by each of them on topics relating to Health and Medicine. In instances where the websites were in languages other than English, Google translation facility was used.

Official Records
In parallel, MOOC platform providers were contacted via email to obtain official records when their web sites did not have the necessary information. Only five MOOC platform providers (Canvas, Iversity, Openlearning, MiriadaX and Crypt-4-you) responded to this request with information while another MOOC provider (Coursera) responded without the information.

MOOC Aggregators
The two MOOC aggregator sites Class Central [10] and MOOC List [11] were also consulted to collect a list of MOOCs.

Free Courses
When platforms provided both paid-for and free courses (such as Udemy) only free courses were considered. Courses offered by University of Miami Global required an upfront payment of US$90 non-refundable one time registration fee and tuition fee depending on the number of credits taken. Thus none of the courses offered by this platform was included in this review.

Subject
MOOCs listed under (ealth and Medicine or related category such as (ealth Sciences on MiriadaX, Health Science on CourseSites, Health and Society on Coursera) were considered. When MOOCs were not categorized (such as OpenupEd and FutureLearn), the course title and where available the course description was used to determine if it was related to health and medicine (for example )mproving your image Dental Photography in Practice on FutureLearn MOOCs categorized under Psychology or Biology and Life Sciences (or were predominantly on them) were not considered in this analysis. MOOCs on veterinary sciences but categorized under Health and Medicine for example Canine Theriogenology for Dog Enthusiasts on Coursera were also discounted But when the courses discussed animal health or diseases and their impact/influence on human health, such as Enfermedades transfronterizas de los animales (Animal transboundary diseases) on the MiriadaX platform, they were included.

Start Date
The time period for the review was defined as 01st January 2013 and 31st December 2013 (inclusive). MOOCs having a start date within this period were considered for the review. Self-paced MOOCs (that do not have a specified start date) were omitted. This included 39 courses listed under Health and Medicine in Veduca platform, 10 courses listed under Health and Fitness in Udemy platform, and 44 courses listed under (ealth Literacy in AL)SON platform and four course Stress post-traumatic disorder difficulties and debate in making a diagnosis Valutazione clinica e strumenti di indagine nell area traumatica -Clinical assessment and survey instruments in traumatic area Programmi e modelli di intervento nelle situazioni traumatiche -programs and intervention models in traumatic situations, and Anatomo-physiological bases of mental activity -Anatomy physiological bases of mental activity) offered by the OpenupEd platform. On the Saylor platform all courses are self-paced (the titles that seemed relevant were categorized under Biology The course La Seguridad del Paciente Patient Safety on MiriadaX had to be discounted as start date for the course could not be established.

Class Central
A 113 Health and Medicine related MOOCs were listed in the MOOC aggregator site Class-Central [10] Under the Finished Courses section there were exactly a courses listed while 13 were listed in the Courses in Progress section th December 2013). A number of courses were discounted for a variety of reasons.

Five courses were discounted from Courses in Progress
Exploring anatomy the human abdomen offered by the University of Leeds

Results
Quantitative and Qualitative analysis of the data was performed using Microsoft Excel and Nvivo software.

MOOC Platforms
The majority (58%, 57) of Health and Medicine related MOOCs was offered by Coursera ( Figure 2) followed by Open2Study (Figure 3). Full analysis of course offerings by platform/provider is shown in Table 2.

Language
The language breakdown of Health and Medicine related MOOCs shows that the vast majority of MOOCs, 94% (92), were offered in English (Table 3). Four MOOCs were offered in Spanish (Castilian) on MiriadaX platform while one MOOC each was offered in Arabic on Rwaq and in Chinese on Coursera platforms.

Offering Institution
The highest number of MOOCs in this review were offered by John Hopkins University (12) (Table 4). These MOOCs were offered by 14 universities (Table 5): five in Australia, four in Spain, two in the UK, one in the Republic of Ireland, one in Denmark, one in Switzerland, one in the West Indies and one in China. Also considering the MOOC (Introduction to Psychiatry) offered on Rwaq MOOC platform, only three MOOCs out of the 98 MOOCs (~3%) were from developing countries.

Number of Instances
Many MOOCs have run only one instance within the considered period. However, the MOOCs Food Nutrition and Your (ealth and )ntroduction to Nursing in (ealthcare both offered by Open Study has both run six times. The MOOCs that were offered more than once are listed in Table 6.

Recognition
Some of the MOOCs considered in the review provided certificates for successful participants. The terminology used in different platforms to refer to certificates varied. For example in Coursera a statement of accomplishment referred to the free instructor or educator (professor) signed certificate while in edX the similar credential was referred to as an honor code certificate On MiriandaX, the free certificate was referred to as certificados de participación certificate of participation) and the paid-for certificate was referred to as certificado de superación (certificate of overcoming).

Prerequisites
Out of the considered courses, 59 course descriptions specifically mentioned whether there were prerequisites or not (Table 8). Some courses used no prerequisites or all are welcome to describe that the course did not have prerequisites, while some others for example Training and Learning Programs for Volunteer Community (ealth Workers course mentioned Some background in community health programs is helpful but not necessary these are categorized under no prerequisite but helpful background

Qualitative Analysis
A word Frequency analysis (in Nvivo) of course titles (titles in other language were translated using Google Translate) showed that the word most frequently used was (ealth with occurrences ( Table 9). The next highest used word was )ntroduction with occurrences Together with MOOCs without prerequisites to join suggests that many courses offered are introductory level.

Target Groups
Only 16 courses specified the target audience for the course. A word Frequency analysis (in Nvivo) of the audience specified showed that the word most frequently used to define target audience was health with occurrences followed by the word professionals with occurrences . This is not unusual as to date the large majority of MOOCs are offered by institutes in the developed countries. A contributor for this observation specifically in Health and Medicine related MOOCs could be the advanced technologies used in prevention, detection and treatment in the health care systems of the developed countries and their willingness to showcase the success. On the other hand, it can also be an indicator of health inequality between the countries. None of the developing countries expertise, for example in tropical diseases, is offered as MOOCs. It is noted that, open education resources (OERs) on tropical diseases developed by experts of the subject in Malawi and Ghana from the African Health OER Network [12] are used in the University of Michigan s medical programmes [13]. Similar collaborations with experts from developing countries/universities on MOOCs may create MOOCs that would be of wider interest. The recent edX partnership with Google to jointly develop the edX open source learning platform perhaps will expand the availability of the platform [14] to individuals and institutions.

Continued Medical Education
Volandes et. al [15] argues that online video learning techniques could empower both clinicians and patients. In fact, MOOCs could well be used as a method for Continuing Medical Education (CME). In this review it was found that there were a number of MOOCs that offered verified certification and counted credits toward Continuing Nursing Education, Continuing Dental Education and CME. Hoy [16] shows that MOOCs can be a convenient and economical method of CME, with the declining industry funding for CME activities.

Medical Student Education
MOOCs can also provide education to students currently undergoing training to become health professionals For example the Coursera course Clinical Terminology for )nternational and U S Students offered by University of Pittsburgh is aimed at new students in medical field Courses such as Going out on a limb Anatomy of the upper limb on Coursera platform by University of Pennsylvania can supplement traditional medical education or perhaps could even be considered to be taken as a flipped-classroom [17] experience where the MOOC replaces the lecture and the contact hours with the professor used for a more meaningful discussion.

Health Literacy
Health Literacy is a broad concept with different definitions. Here we consider it to be: t he degree to which people are able to access understand appraise and communicate information to engage with the demands of different health contexts in order to promote and maintain good health across the life-course [18]. Health literacy, similar to literacy is of critical importance for everyday living [19]. It is not just the ability to make sense of health information; but also a strategy for citizenship and empowerment [19,20]. In this information age, eHealth Literacy, or the ability of people to use emerging information and communications technologies to improve or enable health and health care [21], is becoming even more relevant.
Specialist information on subjects including Health and Medicine is becoming widely available today. However, information overload and the availability of unreliable information sources on the internet present a huge challenge for the general public looking for information on a specific medical condition. Availability of MOOCs (especially if the content is open) is likely to help those who are seeking for information. As the content is offered by a reputed institution it becomes easy to identifying it as an authentic and credible source.

Patient Education
MOOCs on Health and Medicine allow the general public to acquire health education on very specialist topics. One potential area that can be targeted by Health and Medicine MOOCs is patient education For example the MOOC Care of Elders with Alzheimer s Disease and other Major Neurocognitive Disorders provide information to anyone who is interested in knowing about the Alzheimer s Disease This MOOC welcomes patients in early stages of the disease to help them understand the implications of the disease. Participation in these MOOCs is likely to inform patients of their condition and advanced techniques and interventions that are available. It could, to some extent, bridge the language gap (medical terminology) and knowledge gap between patients and doctors. Thus patients would be able to engage in a meaningful discussion with medical professionals on the care they receive and other alternative treatments.
However, in high power distance cultures, this enlightenment of patients may not be well received by health care professionals. In some instances, informed patients or carers may request treatment not yet available in their contexts. On the other hand, informing patients of possible treatments could facilitate medical tourism for those who can afford it.

Educating the Public
MOOCs can also be used as a tool to educate the public on important health issues. For instance the Coursera MOOC Contraception Choices, Culture and Consequences offered by University of California educates the public of the importance of reproductive health. Such courses could help people educate themselves without having to talk to a health professional about family planning, which in some cultures is a taboo or discouraged by faith. Being able to access trustworthy information through a MOOC could empower people; especially females who may otherwise not know the options open to them.
Educating the masses on taboo topics such as Drug Addiction could also be achieved with the use of MOOCs. MOOCs generally operate entirely on online spaces; exceptions would be MOOC participants from a locality meeting up for discussions or MOOC participants seeking support from blended provision such as Coursera Learning Hubs [22]. As one can project a persona in an online space that may differ to who they are in real life, both patients with such conditions and others who seek information can join in, if they wish, without revealing their true identity.
However, suggesting MOOCs may be a way to educate the public assumes that other conditions for participation in a MOOC (for example, access to technology, skills to use them and international language competency) are already met. But as Liyanagunawardena, Williams, and Adams [23] show, at present MOOCs may not reach a large proportion of people, especially in developing areas of the world. Current data suggests that a typical course registrant is a male with a bachelor s degree who is 26 or older ] showing that presently MOOCs have not reached universal accessibility.

Limitations
This review was conducted by collecting data from various sources. However, as very few MOOC platforms provided official data on their MOOC offerings, only the courses with publicly available course details were used in the review. Collection of data for the review using aggregator sites could have the disadvantage of not including all MOOCs on offer, especially foreign language offerings. By using two aggregator sites and independently collecting data from MOOC platforms the possibility of this occurring was minimized. In collecting MOOCs for the review, courses categorized under Health and Medicine or related was considered. However, had a MOOC been wrongly classified, it will not be captured in the review. In instances where the MOOCs were offered in languages other than English, Google Translate was used to translate the content. Had there been a translation error it could have affected the data collection process.

Conclusions
Massive Open Online Courses (MOOCs) have become popular within a short span of time and there are dozens of providers offering courses in a variety of subjects. Reviewing MOOCs offered on (ealth and Medicine in it was found that 94% of them (92) were offered in English and the large majority of MOOCs were offered by North American institutions. Only about 3% of the MOOCs (three) were offered by institutions in the developing world. Many courses offered were introductory level. Some courses offered credit toward continuous professional development of medical professionals and verified certificates for a fee while others offered statement of participation for successful participants.
There is potential to use MOOCs to educate health care practitioners and students; for example in continuous professional development of health care professionals. As they can reach massive numbers across the globe, MOOCs can provide an enormous boost in educating the public on health and medicine, especially on taboo subjects such as AIDS, Tuberculosis and contraception. However, in order to unleash this great potential of MOOCs in educating masses around the globe on health and wellbeing there are various challenge such as access language access, physical access to technology, skills access to use technology) to be overcome. Health literacy is a powerful tool that empowers people and MOOCs could be used to educate the general public to increase their health literacy. The wide variety of MOOCs on various subjects relating to Health and Medicine offered in 2013 show a glimpse of what is achievable through MOOCs in this discipline.
Abbreviations CME: Continued Medical Education MOOC: Massive Open Online Courses OER: Open Educational Resources