Healthcare Workers’ Motivations for Enrolling in Massive Open Online Courses During a Public Health Emergency: Evidence from a Case Study of COVID-19 Training

Background: Massive Open Online Courses (MOOCs) are increasingly used to educate healthcare workers in low-income and lower-middle-income countries (LICs/LMICs). Early in 2020, the World Health Organization developed a series of MOOCs for COVID-19, introducing the disease and strategies to control its outbreak, with six courses specifically targeting healthcare workers as learners. In August 2020, Stanford University also launched a MOOC, the “COVID-19 Training for Healthcare Workers”, designed to deliver accurate and timely education on COVID-19 for healthcare workers across the globe, improving their ability to provide healthcare safely and effectively to patients suffering from the novel infectious disease. While MOOCs in LICs/LMICs have expanded during the COVID-19 public health emergency, more descriptive data is needed in the literature regarding healthcare participants' characteristics and motivations for enrolling in MOOCs. Objective: In this study, we conducted a descriptive analysis of the types of healthcare workers who enrolled in COVID-19 MOOCs. Furthermore, we sought insight into healthcare workers' motivations for enrolling in and completing COVID-19 MOOCs. Previous studies have shown that a primary intrinsic motivator for MOOC enrollment generally is for their personal interest or knowledge acquisition; however, there is minimal available data on motivating factors for enrollment in healthcare-specific MOOCs. We aimed to understand better the types of learners who enroll in healthcare-related MOOCs and their motivations for participation. Methods: Surveys were distributed to all course completers of six OpenWHO COVID-19 courses and Stanford’s “COVID-19 Training for Healthcare Workers” course. This study combines enrollment data, with survey responses, including demographic data, ranked motivations for course enrollment, and perceptions of the MOOCs. Results: Among healthcare workers, the primary motivator for COVID-19 MOOC enrollment generally and across subgroup analyses was to improve clinical practice and for personal learning. To earn a certificate ranked consistently as a middle-tier motivator. However, 70% of respondents reported they chose to earn the certificate, with 59% indicating they would provide a copy to their employer and 63% indicating they would use the certificate to fulfill continuing education requirements. Conclusions: The results demonstrate that the primary reason most healthcare workers enrolled in COVID-19-related MOOCs was for clinical practice improvement and personal learning. Furthermore, most healthcare workers used course certificates professionally. Identifying the motivations for specific groups of learners, like those in LICs/LMICs, will help the future design of MOOCs to encourage participation and completion.


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Yes, but please make my accepted manuscript PDF available only to logged-in users; I understand that the title and abstract will remain v Yes, but only make the title and abstract visible (see Important note, above).I understand that if I later pay to participate in <a href="http  Across all types of healthcare workers, the primary motivation to enroll was for personal learning to improve clinical practice.At the same time, continuing education credit and employer recommendation remained important motivators, particularly for non-physicians and learners in LICs/LMICs.Course cost and certification were also important to a majority of learners.effectiveness in facilitating learning among practicing healthcare professionals [5][6], and their capability to deliver content rapidly and flexibly has established e-learning as a preferred method for transferring clinical skills and knowledge [6].Their broad applicability, accessibility, and costeffectiveness make MOOCs particularly appealing for continuing education (CE) requirements, also known as continuing medical education (CME) [5,[7][8].Consequently, MOOCs have been utilized

Conclusions
for skill development and retention, competency assessment, and lifelong learning [9].In lowincome and lower-middle-income countries (LICs/LMICs), MOOCs potentially increase access to essential health education content and reduce training costs for healthcare professionals [5,[10][11].
Despite the increasing data on general MOOC enrollee motivations [12][13][14][15], there remains a significant gap concerning the specific factors motivating practicing healthcare professionals.
Understanding the motivations of healthcare workers in LICs/LMICs to enroll in and complete healthcare-related MOOCs is crucial, as engagement and completion rates among this group are notably low (16)(17)(18).By identifying what drives their participation, we can enhance MOOC design and dissemination, particularly for just-in-time learning initiatives during health emergencies-a time when organizations like the World Health Organization (WHO) and national governments increasingly rely on MOOCs to rapidly disseminate critical information to healthcare workers.
This study aims to uncover the characteristics and motivations of healthcare professionals who enrolled in healthcare-related MOOCs during the COVID-19 pandemic-a period marked by an urgent need to rapidly disseminate critical healthcare information.Research indicates several potential reasons for enrolling in MOOCs.As a teaching model, MOOCs support adult learning principles targeting self-directed learners [17].The self-directed learning model allows individuals to guide their learning process, establish their learning objectives, engage in individualized learning strategies, and manage their time based on their interests while still receiving access to curated content [17].It can be presumed that learner motivations for engaging in MOOCs differ from those in traditional brick-and-mortar educational venues [19].Prior studies suggest that primary intrinsic motivations for MOOC enrollment include personal interest and knowledge acquisition [12], while extrinsic motivations often involve certification and professional development opportunities [17].
However, the specific motivations driving healthcare workers, particularly in LICs/LMICs, remain underexplored.
While recent studies, such as Garrido et al. ( 2016) and a scoping review on MOOCs for health worker education in low-and middle-income countries, have begun to explore the usage of MOOCs for professional and workforce development, these insights predominantly focus on broad educational outcomes and employment advancements [20][21].Such research underscores the potential of MOOCs to enhance skill sets and career opportunities, highlighting the alignment of MOOC coursework with job market needs and professional certifications.However, these studies

Study Design
In this study, we present a descriptive analysis of MOOC learner data to identify the characteristics and motivations of healthcare workers enrolled in seven MOOCs designed to serve as just-in-time education for clinically practicing healthcare workers during the COVID-19 pandemic.We examine two sources of data: (1) course enrollment data (N=49,098) collected during course registration and (2) follow-up survey data (N=6,272) collected from course completers.

Course Descriptions
In Table 1, we detail the seven focal courses examined in this study.We [Insert Table 1 about here] The

Statistical Analysis
Because of the study focus, we limited our analytic sample to healthcare workers exclusively.To investigate the generalizability of our survey sample, we summarized the characteristics of all healthcare workers completing the courses (n=49,098) and healthcare workers completing the survey (n=6,272) using descriptive statistics (mean, standard deviation, and response rates).To compare the proportion of learners by characteristic between course completers and survey completers, we used Pearson's chi-square test.To examine ranked enrollment motivators and compare across learner subgroups, we conducted multiple comparison tests using one-way ANOVA, comparing the mean rank of motivations (dependent variable) by learner characteristics.The independent variables compared include differences by occupation (physicians vs. nurses; physicians vs. other health professionals) and country income classification (LICs/LMICs vs. UMICs/HICs).All statistical analyses were conducted using Stata SE V15.

Ethics Approval
Informed consent was obtained from all learners.Approval for all aspects of this study design, including consent, outreach, data collection, surveying, and data analysis, was obtained from the Stanford University School of Medicine Institutional Review Board (protocol number: 57831).

Learner Characteristics
As shown in Figure 1, as of September 2021, the seven courses had 856,263 total enrollees, 90%  patients or anticipated caring for them at the time of survey completion.

Learner Motivations
In the survey, healthcare workers were asked to rank in importance the following six potential motivating factors for course enrollment: to improve practice, to earn a certificate, continuing education (CE), course brand, free cost of course, and employer recommendation.Figure 2 shows the ranking preferences across survey respondents.Among survey respondents ranking all factors (n=5,518), the majority (56%) ranked "improve practice" as their top preference, with an additional 16% ranking it as the second most important factor, and 10% as the third most important factor.The second and third most important factors were CE and to earn a certificate, with employer recommendation as the least most important factor ranked.
[Insert Figure 2 here] In Table 4, we show the ranking differences, by type of healthcare worker.While the motivation of improving practice was ranked highest across all subgroups, it was ranked higher by physicians, with a mean rank of 1.86, versus nurses with a mean rank of 2.06 and other healthcare providers with a mean rank of 2.24.Non-physicians ranked CE and employer recommendations higher in comparison to physicians.Certification also appears to matter more to non-physicians, with a higher proportion choosing to obtain a certificate, providing a copy of the certificate to their employer, and using the certificate for a continuing education requirement.The course brand appears to be a more important motivating factor to physicians compared to non-physicians.Course cost did not appear to differentially influence course enrollment by type of healthcare worker.
[Insert Table 4 here] In Table 5, we show ranking differences by the location of healthcare workers, comparing differences in UMICs/HICs compared to LICs/LMICs.In LICs/LMICs, healthcare workers ranked CE and employer recommendation higher on average compared to learners in UMICs/HICs.
Conversely, course brand appears to matter more for learners in UMICs/HICs.Certification was obtained by roughly the same proportion of learners in both subgroups; although learners in UMICs/ HICs were more likely to give a copy of the certificate to their employer, while learners in LICs/LMICs were more likely to use the certificate for a CE requirement.
Generally, the fact that MOOCs were free was a lower-ranked motivator.Though interestingly, in subgroup analysis, the course being free of cost was ranked lower in LICs/LMICs at 3.97 than in UMICs/HICs at 3.68 (Table 5).However, when survey respondents were asked about their perspectives on the cost of MOOCs, more than half of the healthcare workers indicated they would not have taken the course if there was an associated cost.This perspective was consistent across subgroup analyses of healthcare worker professional types and country-income levels.
[Insert Table 5 here An additional benefit of online learning is the reduced cost for participants to obtain CE credits.Our study found that cost was a significant consideration for course participants, with nearly half of the learners indicating they would not have taken the course if it had not been free.While the course being free was slightly less to learners in LICs/LMICs than those in UMICs/HICs, we speculate that in lower-income countries, learners with access to the technology required to participate in an online course may be relatively better off financially within their respective countries and that those with lower incomes may not have the technology to enroll in the courses at all -only 3% of learners were from LICs.It is also possible that a single course participant may have shared access to the course with others.
Identifying the characteristics and motivations of specific groups of learners, like those in LICs/LMICs, will aid in the design of future healthcare-related MOOCs to encourage participation and completion.While many public health emergencies and disease outbreaks occur in LICs/LMICs with devastating impact, little data exists that examines the motivations of healthcare workers in

Limitations
We recognize several methodological limitations inherent in our survey-based research.Firstly, the potential for social desirability bias and selection bias due to voluntary participation limits the generalizability of our findings.To mitigate these biases, we deployed the survey across multiple learning platforms (Coursera, EdX, and OpenWHO), each likely attracting different user demographics, and achieved a substantial sample size of 6,272 respondents representing a diverse economic and geographic distribution.Additionally, we examined and reported only marginal differences between survey respondents and the overall course participants as detailed in Table 2, though it remains a limitation that survey completers may not fully represent the broader learner population.
Secondly, the exclusive use of English for the survey dissemination likely influenced the diversity of the respondents and further constrained the study's generalizability.Future studies could incorporate multiple language options to better capture a wider demographic.with the evolving availability of other educational tools, presents a complex backdrop against which these motivations were formed.Future studies could benefit from aligning course enrollment data with local COVID-19 case trends to better understand these motivations.

Conclusion
Our study examined the motivations and characteristics of healthcare workers who engaged with MOOCs during the unprecedented COVID-19 health emergency.The analysis showed that the primary motivation for healthcare professionals was enhancing their personal practice.Continuing education credit also proved to be a significant motivator, especially for those from LICs/LMICs.
Additionally, the necessity of free access was clear, with half of the participants indicating they would not have enrolled if fees were charged.These findings are important for the future to thank all the learners who directly contributed to this research, especially the learners who participated in the survey and shared their experiences with our team.

Methods:
We analyze (1) course registration data of the 49,098 healthcare workers who completed the seven focal courses and (2) survey responses from 6,272 healthcare workers recruited from the course completers.The survey asked respondents to rank their motivations for enrollment and to share feedback about their learning experience.We use descriptive statistics to compare responses by types of healthcare professions and by World Bank country income classification.Results: Healthcare workers completed the focal courses from all regions of the world, with approximately one third practicing in LICs/LMICs.Survey data revealed a diversity of professional roles are represented among learners including physicians (35%, 2171/6272), nurses (25%, 1599/6272), and other healthcare professionals including allied health professionals, community health workers, paramedics, and pharmacists (40%, 2502/6272).

:
Our results demonstrate that a diverse range of healthcare professionals access MOOCs for just-in-time training during a public health emergency.While all healthcare workers are motivated to improve their clinical practice, different factors are influential across professions and locations.These factors should be considered in MOOC design to meet the needs of healthcare workers, particularly those in lower resource settings where alternative avenues for training may be limited.Keywords: Massive Open Online Course; MOOC; online learning; healthcare education; medical education; COVID-19 training; infectious disease outbreak response; humanitarian emergency response Introduction Background During the COVID-19 pandemic, Massive Open Online Courses (MOOCs) emerged as an invaluable source of training for healthcare workers globally [1-4].Studies have demonstrated MOOCs' generally do not delve deeply into the specific intrinsic motivations of healthcare workers in LICs/LMICs to enroll in MOOCs, especially during health emergencies.In fact, in 2023 the WHO commissioned three systematic reviews of the literature to support guidelines for building just-intime training during public health emergencies, finding a gap in the literature regarding the motivations of learners enrolling in relevant online courses, particularly in LMICs [22-24].Our study seeks to fill this void by examining the unique motivations behind MOOC enrollment, particularly during the unprecedented global crisis triggered by the COVID-19 pandemic.This study contributes uniquely to the literature by investigating the key motivations for healthcare workers to enroll in MOOCs with a special emphasis on provider type and country income level during a global health crisis.These insights are vital as learners in LICs/LMICs face challenges such as linguistic and cultural barriers, limited access to digital technology, low-bandwidth connectivity, infrastructure constraints, and limited digital literacy [5,10].By understanding what motivates learners in these settings, our study provides foundational knowledge that can inform more thoughtful and effective MOOC design and recruitment strategies, ultimately improving knowledge transmission, learning outcomes, and course completion rates in regions with critical needs for healthcare worker training.This broad impact underscores the potential of targeted online education strategies to significantly enhance global health responses.
selected six courses developed by the World Health Organization (WHO) early in 2020 to respond to the growing COVID-19 crisis.These courses were launched on the OpenWHO.orgonline platform, which serves as the WHO's learning hub for health emergencies.These courses build on the WHO's initial introductory COVID-19 course, which had 232,890 enrollments across thirteen published languages by the end of March 2020 and provided general information about the disease for a broad audience[25].The six WHO courses were selected out of 43 total COVID-19 courses offered on the OpenWHO platform due to their greater content relevance to practicing healthcare workers.The six MOOCs focused on introducing healthcare workers to the novel disease and providing them with strategies to control its outbreak.Three courses were designed to provide healthcare workers with the basic tools needed to combat the pandemic and protect themselves from infection when providing healthcare services.Another three courses were designed to provide healthcare workers with an overview of the COVID-19 disease and provide learners with specific clinical strategies to address the pandemic.The courses were initially published in English and then rapidly translated into over 19 languages in the subsequent two months.To broaden the reach of learners in the study, we also included a Stanford University MOOC launched in August 2020 to equip healthcare workers with timely in-service education to improve their ability to safely and effectively treat patients suffering from the novel disease[26].The Stanford MOOC was launched on both the Coursera and EdX platforms, two U.S.-based MOOC providers founded in 2012 that routinely provide university-level courses on various topics including health.As of November 2020, nearly 900 health-related courses were available on the Coursera platform alone[27].The Stanford course was first developed in English and then translated into four additional languages.

Figure 1
Figure 1 describes the flow diagram for study participation and data collection.We obtained data on all course enrollees via the respective course platforms (OpenWHO for WHO courses and EdX and

] Discussion Through a survey of 6 ,
272 healthcare workers worldwide who completed COVID-19 training MOOCs across multiple platforms and organizations, our study provides unique insight into the factors motivating healthcare workers to enroll in and complete MOOCs during public health emergencies.We identified that the primary motivator for enrollment among healthcare workers was to improve their personal practice, followed by the pursuit of continuing education credit and certification.Course cost is an influential factor in the decision to enroll in a MOOC, with nearly half of respondents indicating they would not have enrolled if the course had not been free.This first-of-its-kind analysis of healthcare worker motivations in just-in-time training MOOCs during a public health emergency fills an important gap in the existing literature, providing key insights for future course development and marketing.Our findings highlight the widespread demand among healthcare workers for MOOC training during a public health crisis.Healthcare workers from over 200 countries and territories enrolled in and completed the COVID-19 MOOCs examined in this study, with more than a third of course completers located in LICs/LMICs.Compared to the typical MOOC completion rates of under 10% [17-18], the 43% completion rate among healthcare workers in the COVID-19 MOOCs in this study is notably high.While the high rate of completion likely reflects the limited alternatives for training during the start of the COVID-19 pandemic, it may also indicate intrinsic motivation among healthcare workers, whose predominant reason for enrollment was to improve their personal practice.We also observed that the COVID-19 training MOOCs attracted a diverse range of healthcare providers globally.While the majority of respondents were nurses and physicians, nearly 40% reported working in other healthcare capacities including allied health, community health, emergency medical services, and pharmacy.Furthermore, we noted that motivations for enrollment varied by profession.Compared to physicians, nurses and other healthcare professionals were more motivated by CE credit, employer recommendations, and certification.Nurses and other health professionals were more likely to obtain certificates, provide a copy of the certificate to their employer, and use certificates for CE requirements.Recognizing these differences in motivating factors across types of healthcare workers can inform the design of MOOCs that more effectively respond to the interests and needs of the targeted audience.Despite these differences, the majority of all healthcare workers, including physicians, indicated their intention to use their certificates professionally, either by providing them to their employers or by earning CE credit.This finding underscores the potential for MOOCs to fill a gap in the CE arena, where traditional approaches often present barriers to completion.The common traditional route for obtaining CE credits involves attendance at national or international medical conferences[7][8]; however, many such conferences were either canceled or transitioned to a virtual format during the pandemic.Given the time and travel requirements associated with conference attendance, MOOCs can serve as a viable and accessible alternative for learners.Interestingly, our study found the use of course certificates for CE among learners in LICs/LMICs was higher than that in UMICs/HICs, which may reflect a lack of economically feasible options to earn CE credits in resource-limited geographies.Including certification in MOOC design may serve as an important motivator to increase enrollment and completion, particularly in LICs/LMICs, enhancing the attainment of timely healthcare education for the global healthcare workforce.
these regions to enroll in just-in-time training MOOCs.Nevertheless, the World Health Organization and various national health agencies frequently leverage MOOCs to disseminate critical health information during these emergencies.Future work should particularly investigate how to overcome barriers related to technology access and content accessibility with an eye toward equity, ensuring that delivery of crucial healthcare worker training, particularly in times of emergency, is available to all.Likewise, future investigations should examine how online content is used and shared offline in contexts where the broader population has limited access to digital platforms thereby enhancing the delivery of course materials through offline sharing.
Thirdly, while the survey instrument was tailored to the specific contexts of the courses and discussed rigorously by experts across various fields-including educational assessment, emergency medicine, public health, and online learning-its lack of external validation presents a limitation.No prior studies identified during our review provided a validated instrument for assessing learner motivations in MOOCs, emphasizing the innovative aspect of our research while also necessitating a careful interpretation of our findings.Fourthly, our study's scope was restricted by the limitations in identifying patient-facing healthcare workers among enrollees, due to data collection methodologies on the OpenWHO platform until June 2020.This limitation hindered our capability to fully classify professions among participants.Future studies should aim to enhance the categorization of healthcare worker types and delve deeper into the differing motivations among these groups Finally, the dynamics of the COVID-19 pandemic-characterized by fluctuating case rates and mortality-suggest that motivations for enrolling in COVID-related MOOCs likely varied over time.Some healthcare workers might have enrolled early in anticipation of patient care needs, while others joined after gaining first-hand experience.This temporal variation in motivations, coupled development and deployment of MOOCs, ensuring that they are not only accessible but also resonate with the intrinsic and extrinsic motivations of healthcare professionals from diverse geographies, training, and economic backgrounds.Future research should further investigate these motivations to see if they hold consistent across different types and stages of health emergencies.
The region with the most healthcare workers that completed a course was Latin America and the Caribbean (25%, 10,665 / 49,098), followed by South Asia (17%, 7,264 / 49,098), North America (16%, 7,019 / 49,098), Europe and Central Asia (13%5,365 / 49,098), East Asia and the Pacific [Insert Table2here] Table 2 also compares the characteristics of healthcare workers completing the course with the 13% completing the survey (6,272 / 49,098).We observe slight differences in the age and gender composition of survey completers with course completers, with the survey sample skewing older and more male.The survey sample includes a slightly larger share of participants from LICs (4%, 222/6,272) and LMICs (39%, 2,468).

Table 3
describes the professions of the healthcare workers who completed the survey and their levels of physician supervision.Physicians represent 35% (2,171 / 6,272) of the survey sample, followed by nurses representing 25% (1,599 / 6,272), followed by allied health professionals at 19%(1,190/6,272).This breakdown of professional roles is similar in LICs/LMICs and UMICs/HICs.Of non-physician healthcare workers, more than a third reported having access to a physician for consultation during less than 50% of their workday (36%, 1,315 / 6,272), though the majority could contact a physician by phone if needed.Most healthcare workers either already cared for COVID-19

Table 4 . Mean rank of motivation (1 = highest rank, 6 = lowest rank) and course perspectives, by healthcare worker type
Physician is a reference category for comparisons.Nursing includes nurses, nurses/midwives, and nursing assistants.Mean ranking does not include observations that skipped ranking altogether (N=745).Course perspectives include observations that skipped ranking but provided responses for these questions.

Table 5 . Mean rank of motivation (1 = highest rank, 6 = lowest rank) and course perspectives, by country classification
This table shows differences by World Bank income classifications: high-income country (HIC), upper-middleincome country (UMIC), lower-middle-income country (LMIC), and low-income country (LIC).Mean ranking does not include observations that skipped ranking altogether (N=745).Course perspectives include observations that skipped ranking but provided responses for these questions.