Hearing Loss in Children: Critical Medical Education Delivered as Massive Open Online Course (MOOC)

Abstract

Purpose:

Although early identification of pediatric hearing loss is crucial, a formal online training course has not been freely accessible to a global audience. In response, we created a novel course for health professionals worldwide.

Method:

Course development occurred from February 2019 to May 2020. Seventeen multidisciplinary experts provided video lectures and demonstrations, including a tour of ear anatomy, operating footage of cochlear implant insertion, and demonstrations of children undergoing hearing testing. Content also included steps for interpreting audiograms, an overview of early screening programs, interviews with Deaf/Hard of Hearing children, and an introduction to public health/educational infrastructure. The course was hosted on Coursera and launched on May 4, 2020.

Results:

The course was approved for 11.5 Continuing Medical Education (CME) and American Board of Pediatrics Maintenance of Certification (MOC)-Part 2 credits and spanned five modules comprised of 50 video learning segments: 1) Ear Anatomy, 2) Hearing Loss and Assessments, 3) Hearing Loss Diagnosis and Impact on Speech and Language Development, 4) Interventions for Hearing Loss, 5) Pediatric Vestibular System and Balance. Since its launch, 6,556 learners have enrolled and 1,540 have fully completed the course; Fifty percent were 25–34 years old, 62% were female, and 43% were from Asia. Average rating was 4.9/5 (n=180 reviews).

Conclusions:

We created a freely accessible course for a global audience that provides a broad overview of pediatric hearing loss. Our multidisciplinary approach addresses an educational gap and can serve as a model for developing other online courses.

Introduction

The World Health Organization (WHO) estimates that 34 million children live with significant hearing loss (World Health Organization, 2021). The vast majority of children affected live in low- and middle-income countries, as compared to high-income countries (World Health Organization, 2021). In the United States (US), the Centers for Disease Control (CDC) estimates that 2 to 3 of every 1,000 children born has a detectable level of hearing loss in one or both ears (Quick Statistics About Hearing, 2021). Early identification and intervention of pediatric hearing loss are crucial to improving children’s lifelong learning outcomes. Late identification and intervention can lead to delays in children’s speech, language, and literacy, as well as social and emotional development (Ching et al., 2018; Moeller, 2000; Nicholas & Geers, 2007). Appropriate management of pediatric hearing loss requires an interprofessional team of experts, including but not limited to pediatricians, otolaryngologists, audiologists, speech-language pathologists, and teachers.

Despite the global burden of pediatric hearing loss and the need for interprofessional collaboration, a formal training course on pediatric hearing loss has yet to be accessible in a free, online format for a broad spectrum of learners, with the potential to reach providers that work with children from low- and middle-income countries. Limited information is available about hearing loss education for healthcare professionals. One single-institution study found that most first-year, pre-professional healthcare students in fields other than speech-language pathology had not received any education on hearing loss (Squires et al., 2019). A more recent study found that most physicians thought their education on hearing loss during medical school was inadequate (Brothers et al., 2022).

Massive Open Online Courses or MOOCs are open-access, online courses that allow for unlimited (i.e., massive) participation (Kaplan & Haenlein, 2016; Nicholas & Geers, 2007). MOOCs enable students to learn independently at their own pace and to connect with learners across time and space (Kaplan & Haenlein, 2016). The use of MOOCs has gained traction in medical education, with some MOOCs being transformed into Small Private Online Courses (SPOCs) designed for smaller, closed cohorts of designated learners (e.g., medical students) (Blum et al., 2020; de Jong et al., 2020; Hendriks et al., 2020; Ibrahim et al., 2021; Kaplan & Haenlein, 2016). In 2021, 220 million learners enrolled in over 19,000 MOOCs in a broad array of subjects from over 900 universities (“By The Numbers,” 2021). Among the MOOCs offered, approximately 7.3% were in ‘Health and Medicine’ (“By The Numbers,” 2021). However, awareness and utilization of MOOCs remain limited in many medical fields (Eyigor et al., 2020). At the time of the course development, there were no MOOCs dedicated to pediatric hearing loss (Hearing Loss - Free Online Courses/MOOC Search Results | Class Central, n.d.). To address this educational gap, we aimed to create a new online course on pediatric hearing loss for health professional learners worldwide.

Method

Curriculum Development

Curriculum development on the MOOC titled, ‘Hearing Loss in Children,’ began in February 2019 and was completed in May 2020. An interprofessional team including pediatricians, otolaryngologists, geneticists, audiologists, speech-language pathologists, physical therapists, and medical students assisted in curriculum development. The University of Michigan’s Center for Academic Innovation (CAI), which partners with faculty to develop online learning materials, supported the team in curriculum development, including course design and course assessment.

Course Design

The overall general course learning objectives were to 1) identify components of ear anatomy and vestibular systems, 2) interpret an audiogram to identify the type and degree of hearing loss, and 3) describe non-surgical and surgical interventions for children identified with permanent hearing loss and vestibular problems. Each module within the course had specific learning objectives. The syllabus (Supplemental Material) consisted of five distinct modules for learners to complete sequentially: 1) Ear Anatomy, 2) Hearing Loss and Assessments, 3) Hearing Loss Diagnosis and Impact on Speech and Language Development, 4) Interventions for Hearing Loss, and 5) Pediatric Vestibular System and Balance. Each module consisted of pre- and post-tests, video lectures, demonstrations, and online readings and was designed to be completed in two to five hours. The audio and visuals of the course were in English, with English, French, Russian, Portuguese, and Spanish subtitles available.

Using the same content within the MOOC, a SPOC was designed as a two-week elective for third- and fourth-year medical students at the University of Michigan. The course was hosted on the largest e-learning platform, Coursera (Coursera Inc., Mountain View, CA), and launched on May 4, 2020. The MOOC was disseminated through e-mail listservs (e.g., Educational Audiology Association (EAA) listserv, University of Michigan Sound Support listserv, University of Michigan pediatric residency listservs) and social media. Components of the MOOC were required curriculum elements for the Michigan Leadership Education on Neurodevelopmental Disabilities (MI-LEND) program. The SPOC was advertised to University of Michigan medical students through internal student email listservs.

The University of Michigan’s Office of Continuing Medical Education and Lifelong Learning oversaw the credit approval process for continuing medical education (CME). In addition, the office oversaw the credit approval process for the American Board of Pediatrics Maintenance of Certification Part 2 (MOC-Part 2).

Course Assessment and Learner Data

Each module contained five ungraded pre-test questions to gauge the learner’s baseline knowledge and ten graded post-test questions to evaluate knowledge of the module content. All questions were in multiple-choice format and allowed unlimited attempts. A minimum passing score of 80% was required for the post-tests to advance to the next module. After the final module, there was an additional quiz with 33 multiple-choice questions for those seeking CME and MOC-Part 2 credit. Learners were allowed up to four quiz attempts, and a score of 70% was required to achieve credit for the course. The SPOC was graded based on course completion on a satisfactory/unsatisfactory scale.

MOOC learner data were captured by the learning platform (i.e., Coursera) registration data and an optional additional survey from the CAI embedded within the course. Data included the number and timeline of learners accessing the course, demographic features of learners, performance on assessments, and course evaluations. De-identified data were extracted and analyzed in May 2023 using SAS Version 9.4. (SAS Institute, Cary, NC). The University of Michigan Institutional Review Board (IRBMED) deemed the secondary analysis of this dataset as exempt from ongoing review (HUM00204740).

SPOC Course Assessment and Learner Data

Medical students enrolled in the SPOC were sent a learner feedback survey following course completion. The survey used both a Likert-like scale and open-response questions. De-identified data were provided by the University of Michigan Medical School’s Office of Assessment and Evaluation and analyzed in May 2023.

Results

Final Course

The ‘Hearing Loss in Children’ MOOC officially launched on May 4, 2020 on the Coursera platform. The MOOC contained 50 video learning segments comprised of 40 lectures, five demonstrations, three case examples/discussions, and two expert interviews across the five modules (Figure 1). These video learning segments were supplemented by links to additional course readings at the end of each module (Figure 2).

Figure 1.

Exemplary video learning content. Four stills from the online course demonstrate the types of video learning content, including lectures (top and bottom left), demonstrations (top right), and interviews (bottom right). This work is reprinted from Hearing Loss in Children MOOC under a CC BY-NC 4.0 license.

Figure 2.

Course overview. Each of the five modules contained a pre- and post-test, along with lessons delivered through video lectures, demonstrations, case examples/discussions, expert interviews, or supplementary readings.

The University of Michigan’s Office of CME and Lifelong Learning approved the MOOC for 11.5 AMA PRA Category 1 CME credits and 11.5 American Board of Pediatrics MOC-Part 2 credits that were available at no cost if learners completed the course and fulfilled CME requirements.

MOOC Learner Demographics and Feedback

In the three years since its launch (May 2020 to May 2023), 6,556 learners enrolled in the course, 3,872 started the course, and 1,540 fully completed the course. Based on available metrics of course enrollees, 50% of learners were between 25–34 years old, 25% were between 35–44 years old, 13% were between 18–24 years old, and 12% were greater than or equal to 45 years old. Sixty-two percent of learners were female and 36% were male. For the highest level of education obtained, 36% of learners had a bachelor’s degree, 21% had a master’s degree, 20% had a high school diploma or some college but no degree, 12% had another professional school degree, and 6% had a doctorate degree. The course demonstrated global reach, with 43% of learners from Asia, 26% from North America, and 14% from Europe. The United States (n=1,414) was the most represented country, followed by India (n=1,361), the Philippines (n=268), Egypt (n=243), Turkey (n=181), Canada (n=169), Pakistan (n=164), Chile (n=129), and the United Kingdom (n=129). Learner engagement peaked in early August 2020 and in late September 2021 (Figure 3). The MOOC achieved a place among the “Top 20” most popular MOOCs in July 2020, and its overall rating was 4.9 out of 5 stars based on 180 ratings (“20 Most Popular Online Courses Starting in July,” 2020).

Figure 3.

Learner engagement. There is a peak in learner engagement in early August 2020 and again in late September 2021.

A subset of learners completed optional pretests and quizzes for each module and the continuing education quiz (Figure 4). Module 1 had the highest number of participants completing the pretest and quiz, with 2,243 and 1,963 completing each, respectively. Modules 2, 3, 4, and 5 all had more learners complete the quiz than the pretest for that module. The number of learners who completed the pretest and quiz gradually decreased as the course progressed, with 1,537 and 1,745 completing the pretest and quiz for module 2, respectively, and 1,177 and 1,443 completing the pretest and quiz for module 5, respectively.

Figure 4.

Quiz completion. Each module had an optional pretest and post-quiz. There was also an optional quiz for continuing education credit. The number of learners who completed each is displayed in the chart.

Over the same three-year period (May 2020 to May 2023), 101 medical students from the University of Michigan enrolled in the SPOC as a two-week elective. Students’ quiz scores ranged from 80% to 100%. Twenty-three students opted to complete the learner feedback survey. All respondents felt the course learning outcomes were clear, understood what was expected of them in the course, felt the technology worked well, and the online course material was easy to access and navigate. Most students (96%, n=22) felt the course content challenged them at an appropriate level. All were likely (30%, n=7) or extremely likely (70%, n=16) to recommend the course to other medical students. Students expressed appreciation for the course interface and interactive features, content organization, and the self-paced, clear tasks with estimated time allotments. A suggested improvement was to remove passing thresholds for the pretests.

All respondents agreed that the course increased their understanding of the anatomy and physiology of the human auditory pathway and the components of a comprehensive pediatric audiological assessment. Most respondents (96%, n=22) felt the course increased their understanding of types of hearing loss. All respondents indicated an improved understanding of risk factors associated with late-onset or progressive hearing loss in children, the potential impact of hearing loss on speech and language development, and of amplification options for children who are Deaf/Hard of Hearing. All learners also reported having an increased understanding of the role of an interdisciplinary approach to dizziness and balance disorders in children.

Discussion

Health care professionals’ knowledge gaps about newborn screening programs can reduce the effectiveness of such programs (Ravi et al., 2018). One study found that only 14% of primary care physicians felt they received adequate training during medical school to care for infants with permanent hearing loss (Moeller et al., 2006). Knowledge gaps have been identified in appropriate next steps, referrals, and interventions after diagnosis of hearing loss (Dorros et al., 2007; Moeller et al., 2006). Oliveira et al. demonstrated that online continuing education on infant hearing loss could effectively improve healthcare professionals’ knowledge about the topic and referral practices (Oliveira et al., 2022). Their results indicate that hearing loss education can be effectively disseminated using virtual learning; however, their course focused exclusively on infant hearing loss instead of pediatric hearing loss more broadly. Our MOOC delivers education on pediatric hearing loss through a similar format, making this critical information readily available and widely accessible. There is evidence that the knowledge gained from MOOCs is translatable to clinical practice with increased levels of confidence and competence reported by participating healthcare professionals (Pickering & Swinnerton, 2017).

A strength of this course is the Interprofessional Education it provides, which brings together the expertise of pediatricians, otolaryngologists, geneticists, audiologists, speech-language pathologists, and physical therapists using Interprofessional Collaborative Practice. An interdisciplinary team is essential for early detection of and intervention on hearing loss (Journal of Early Hearing Detection and Intervention, 2019). This course may benefit a variety of healthcare professionals and trainees, including physicians, audiologists, and speech-language pathologists, by increasing their knowledge from pediatric hearing experts. The responses of medical students enrolled in the course indicated they gained new knowledge and appreciation of the different health care professionals involved in diagnosing and treating hearing loss in children.

‘Hearing Loss in Children’ was launched in May 2020, during the COVID-19 global pandemic. Interest in MOOCs surged in 2020, with 60 million new users and 2080 new courses launching (“By The Numbers,” 2020). This increased interest in MOOCs was also demonstrated in health-related topics, such as pediatric injury prevention, which saw increased enrollment in March 2020 after COVID-19 was declared a pandemic (Ibrahim et al., 2021).

The American Medical Association and the American Board of Pediatrics have approved this course for CME credits. Continuing Medical Education (CME) requirements are intended to ensure that healthcare providers update their knowledge and medical practice as new evidence emerges and have been shown to impact health outcomes positively (Setia et al., 2019). Traditionally, CME credits have largely been obtained from conference attendance which can be cost or time prohibitive. Online CME can increase CME opportunities for healthcare providers in low- and middle-income countries (Setia et al., 2019). The quizzes required for CME credit reinforce the information delivered in the course.

While the learner retention rate (23%) of this course is higher than the average MOOC retention rates (range from 3–15%), the attrition rate remains a limitation of the course (Deshpande & Chukhlomin, 2017; Jordan, 2014; Liyanagunawardena et al., 2013). This may be due in part to the non-linear nature of the course, which allows its users the flexibility to just participate in modules of interest. Another limitation of this course is that it focuses on technology used to diagnose and treat hearing loss in the United States and other high-income countries. Most children with hearing loss live in middle or low-income countries (World Health Organization, 2021). While providers in these countries may have access to the education provided in this MOOC, they may not be able to apply it clinically due to resource limitations. Future work would be creating a course focusing on hearing loss detection and intervention in resource-limited environments.

Data Availability Statement

The data are available from the corresponding author upon reasonable request.