Distance-Learning Collaborations for Rapid Knowledge Sharing to the Occupied Palestinian Territory During the COVID-19 Response: Experience from the OxPal Partnership

Abstract

Distance-learning increasingly forms part of many academic and professional courses. OxPal, a collaboration between University of Oxford medical students and doctors and their counterparts in the occupied Palestinian territory (oPt), sought to evaluate the feasibility and efficacy of interactive online distance-learning through a pre-established international partnership as a method for rapid knowledge sharing during the novel coronavirus disease 2019 (COVID-19) response. Two interactive online lectures for medical students and clinicians in the oPt on the COVID-19 pandemic were conducted. The first lecture was an “Introduction to COVID-19” and the second focused on “Data-sharing during the pandemic”. 212 and 174 attended each lecture, respectively. Feedback was via an online questionnaire. >95% of respondents indicated the lectures covered a gap in their medical education. 87% and 77% of respondents rated lecture quality “Good” or “Excellent” for the two lectures respectively. Qualitative feedback elicited requests for more clinically focused lectures, which have since been provided. Online lectures are feasible and effective for rapid education of medical students and clinicians in the oPt in a public health emergency. We hope this encourages other institutions to provide similar support in the oPt and other ‘tutor-deplete’ regions facing specific geopolitical challenges to local medical education.

Introduction

The ongoing coronavirus disease 2019 (COVID-19) has spread globally. The occupied Palestinian territory (oPt) is hugely vulnerable to the effects of a pandemic. The area faces a number of potential geopolitical barriers to effective implementation of a best-response to COVID-19. Currently, 203,000 people remain internally displaced in the Gaza Strip, a number living in refugee camps (World Health Organization Regional Office for the Eastern Mediterranean 2017), diminishing the possibility of effective social distancing. Equally, the oPt’s healthcare system does not have additional capacity of resources nor a surge capacity of ICU beds. Before the outbreak, Italy had 12.5 critical care beds per capita, the UK had 6.6 per capita (Rhodes et al. 2012). Whereas, there are reports that the Gaza Strip has 2 critical care beds per 100 000 (Hearst 2020) and healthcare workers report a lack of key PPE elements (Alser et al. 2020). In early March 2020, the spread of COVID-19 in the oPt was of great imminent concern and survey data showed only a minority of respondents in the oPt were engaging in measures such as reducing social contacts (Gallup International Association 2020). As of 9th July 2020, cases are now rising exponentially in oPt with 90% of the >5000 total cases occurring in just the prior 25 days (Nazzal 2020).

Medical students can be an invaluable resource in healthcare crises. Many final year medical students in the UK were granted early provisional registration to practice to augment clinical surge capacity (Harvey 2020). Equally, medical students are well placed to communicate with their communities, disseminating information on disease prevention (Chapman et al 2016; Patil & Chan Ho Yan 2003).

OxPal is a collaboration between University of Oxford academics and medical students and doctors in the oPt. OxPal’s network in oPt includes students at all Palestinian medical schools. OxPal has previously demonstrated the efficacy of a web-based distance-learning platform to supplement medical education in oPt (Penfold et al. 2014). Online learning courses on COVID-19 have been rapidly developed for the general public and professionals alike (Johns Hopkins Hub Staff Report; OpenWHO n.d.). However, there was a relative lack of interactive courses and those aimed at medical students - who have different baseline knowledge and learning objectives. Online learning is more effective when delivered through an interactive environment (Skylar 2009), in the local language of learners. Further we used tutors with locally relevant knowledge, and our established and ongoing institutional links maximized uptake.

We present here an evaluation of the first two interactive real-time web-based lectures in a series of lectures on the subject of the COVID-19 pandemic for medical students and early-career doctors in oPt, organized by OxPal. The first lecture (herein Lecture 1) was an introductory lecture providing background on the COVID-19 pandemic. The goal of this lecture was preparing medical students and clinicians to respond to the outbreak in Palestine, in a clinical or community educational capacity. As such, the aims of this lecture were to:

1. Improve attendee knowledge of the coronavirus pandemic.

2. Build confidence informing those around them about the outbreak.

3. Build confidence in students/early career clinicians to assist clinically within the scope of their competencies.

The second lecture (herein Lecture 2) was a more specialized lecture on the role of Data Sharing in the COVID-19 pandemic. This lecture aimed to introduce students to timely ideas for, and challenges in, research in this pandemic and going forward.

The impact of both lectures is increased as the established OxPal network reaches relatively high numbers of students in the region. The establishment of institutional links to underserved areas augments resilience during healthcare crises. Web-based teaching is a low cost, feasible and rapidly deployable method of knowledge sharing to regions with challenges to local medical education, particularly in the context of a public health emergency.

Methods

OxPal enrolled an expert in Infectious Disease and Critical Care to conduct the introductory Lecture 1 and a Clinical Research Director and expert in AI to conduct the data-sharing focused Lecture 2. Both lectures were conducted using Zoom, a commercial platform. Lectures were advertised to students on the OxPal email distribution list (790 unique emails at the time of the first lecture) and via social media. Lecture slides were in English (the language used for medical education in Palestine). Lecture 1 was conducted in Arabic and Lecture 2 in English. The lectures were interactive in that attendees were able and encouraged to ask questions of lecturers in real-time. At the end of Lecture 1 there were approximately 35 minutes for questions. Content of Lecture 1 included virology of the novel coronavirus; concepts of spread including R0 and modes of transmission; response strategies and preventive measures. After the lecture and feedback collection attendees were sent management framework documents by email for self-study. Documents included a framework for initial assessment and triage of cases, and another for the management of critical care cases; both could be downloaded for future reference. At the end of Lecture 2 there were approximately 10 minutes for questions. Content included a background and examples of ‘big data’ and AI in healthcare and how this science is already being applied in the COVID-19 pandemic. Both lecture recordings were later published on YouTube, as of 9th July 2020 they had 565 and 63 views respectively (OxPal Medlink 2020a; OxPal Medlink 2020b).

Attendees were emailed an online questionnaire after each lecture to collect quantitative and qualitative feedback on the quality and usefulness of the lecture. The questionnaires gathered information on respondents’ medical schools and stage of training. Consent to use anonymized responses to the questionnaire for research was obtained. Herein the term ‘respondents’ refers to those who filled out the feedback survey in question. Where a respondent filled an answer field such that it could not be coded for analysis, their response for that field alone was removed from analysis. We used descriptive statistics to summarize results in counts (n) and percentages (%). Microsoft Excel software was used for data analysis.

Results

A total of 212 and 174 oPt students/doctors attended Lecture 1 and Lecture 2 respectively. The feedback forms received 68 and 43 responses corresponding to a 32% and 25% response rate for Lecture 1 and Lecture 2 respectively. Table 1 shows characteristics of respondents to each feedback survey.

Table 1.

Feedback questionnaire respondent characteristics.

Characteristic	Lecture 1: Introduction	Lecture 2: Data-sharing
Medical school	Respondents (n=68)	Respondents (n=43)
Islamic University of Gaza	20 (29.4%)	7 (16.3%)
Al Quds University	19 (27.9%)	14 (32.6%)
Al Azhar University	15 (22.1%)	12 (27.9%)
An-Najah National University	6 (8.8%)	4 (9.3%)
Hebron University	1 (1.5%)	1 (2.3%)
Other (medical schools outside oPt)	6 (8.8%)	7 (16.3%)
Stage of training
2nd year	8 (11.8%)	4 (9.3%)
3rd year	8 (11.8%)	5 (11.6%)
4th year	6 (8.8%)	4 (9.3%)
5th year	16 (23.5%)	9 (20.9%)
6th year	4 (5.9%)	7 (16.3%)
Intern	15 (22.1%)	6 (14.0%)
Resident	5 (7.4%)	5 (11.6%)
Specialist/Consultant	6 (8.8%)	3 (7.0%)

Overall feedback was overwhelmingly positive. 95–96% of respondents to both surveys indicated the lectures covered a gap in their medical knowledge. Moreover, general feedback about lecture quality and level was positive when asked to rate quality, difficulty, and relevance on 5-point scales (Figure 1) for both lectures.

Figure 1.

Quality, difficulty and relevance of online teaching as assessed by questionnaire respondents.

With regard to the specific outcomes of Lecture 1, all respondents indicated they felt more informed about the outbreak having attended this lecture, and the majority felt more confident with target outcomes after it (Figure 2).

Figure 2.

Participant self-report of Lecture 1 teaching outcomes.

Of the 26 doctors that responded, 18 (69%) said they would feel more capable assisting in a clinical setting and only 1, who was a consultant, indicated they would not.

When grouped into students vs qualified clinicians, there were no significant differences in respondents evaluation of the lecture quality, difficulty and relevance on 5-point Likert scales (Table 2a). However, within Lecture 1’s specific outcomes, clinicians were more likely to respond with “Yes”, as opposed to “Maybe” or “No” compared to students when asked if they felt more prepared to inform those around them about the outbreak (p=0.047) (Table 2b).

Table 2.

Outcomes when grouped by respondent stage of training

Table 2a: Quality, difficulty and relevance outcomes rated on a 5-point scale
Question asked	Medical students	Clinicians	p-value
N	71	40	-
“How would you rate the tutorial quality (1 = bad, 5= excellent)?”, median (IQR)	4 (4, 5)	4 (4, 5)	0.800
“How challenging was the tutorial (1 = not challenging, 5= very challenging)?”, mean (SD)	2.7 (0.9)	2.9 (0.8)	0.270
“How relevant was this to teaching/training in Palestine (1 = not relevant, 5= very relevant)”, median (IQR)	4 (3, 5)	4 (3, 5)	0.100
Table 2b: Lecture 1 Outcomes
“Do you feel more prepared to be able to inform those around you about the outbreak (yes vs maybe/no)?”, n (%)	33 (79%)	25 (96%)	0.047
Would you feel more capable of assisting in a clinical setting during the outbreak, having attended this lecture (yes vs maybe/no)?”, n (%)	21 (50%)	18 (69%)	0.120

Qualitative feedback reflected general satisfaction with both lectures. When asked what worked well about the Lecture 1, 18 (69%) respondents said “Everything” or “Perfect”, and a further 26 described appreciating the content of the lecture: “All the information [was] accurate and based on scientific research and studies, which increases its credibility and the knowledge of [the lecturer] was perfect”. When asked what could be improved about the lecture, 31 respondents said “nothing” could be improved or gave no response at all. Similarly, with regards to Lecture 2, 18 respondents indicated “Everything” or “All” of it was good; a further 10 specifically made positive comments on the content or topic of the lecture: “We see another side of medicine […] in COVID-19 which is th[is] artificial intelligence, and how it will improve the diagnosis, it’s very interesting” and “Information sharing tips especially for the developing countries”. From the given suggestions for improvement, key themes in both lectures were requests for more lectures and tutorials on the subject, and more discussion or audience participation (Figure 3): “Multiple lectures in the same session” (Lecture 2 feedback) and “share a question related to the e-lecture which will […] happen, then discuss the information in the live meeting” (Lecture 1 feedback). Lecture 1 qualitative feedback showed a key theme of requests for a more clinical focus, as opposed to theoretical or research teaching (Figure 3): “[…] more topics should be included [such] as discussing some protocols of management”.

Figure 3.

Emergent themes from respondent qualitative feedback on areas for improvement of the lecture.

Discussion

We present an evaluation of two interactive online lectures on the COVID-19 pandemic, as a method of rapid knowledge-sharing with the oPt, a region facing specific barriers to local medical education. Evaluation through online questionnaires has shown teaching to be high quality, relevant to students in the oPt and the vast majority of attendees indicated the lectures covered gaps in their medical education thus far. An interactive real-time web-based lecture series is scalable and increasingly simple to provide, consistent with our previous findings that technology infrastructure in the West Bank was adequate for this purpose (Penfold et al. 2014). Students and qualified clinicians did not significantly vary in their ratings of quality, difficulty, and relevance of the lectures, reflecting applicability of this mode of teaching for all levels.

Lecture 1 was designed to provide general knowledge for students and clinicians responding to the COVID-19 pandemic. Encouragingly, the majority of attendees responded indicating the lecture did improve their confidence in communicating with those around them about the outbreak, and assisting clinically during the outbreak, the lecture’s primary aims. Interestingly, a significantly greater proportion of qualified clinicians than students reported feeling more able to inform those around them about the outbreak. Notably, only 57% of respondents felt more capable assisting in a clinical scenario during the outbreak and 9% (6 respondents) indicated they did not. This fits with the qualitative feedback we received (Figure 3) where a key theme in the feedback specifically for Lecture 1 was requests for more clinical teaching, such as more practical advice around prevention and/or management of the disease – reflecting a general lack of confidence in this area. This lecture did not explore in detail the clinical course of the disease or management, though there was discussion of this in the subsequent Q&A. Shortly after feedback was collected a set of custom-made management protocol documents were sent to attendees, that may have somewhat assuaged this concern.

Lecture 2 was on Data Sharing and AI in the era of the COVID-19 pandemic. As with Lecture 1 the overwhelming majority of respondents gave positive feedback. When comparing feedback for the two lectures, Lecture 2 was overall judged marginally less relevant and more difficult (Figure 1), which is largely expected for a more specialized lecture, with less immediate local relevance. There was only one request for more clinical teaching in qualitative feedback for Lecture 2, this could suggest the content of this as a research lecture was expected and accepted by attendees.

We recognise that there are limitations to questionnaire feedback as a method of identifying success of such a teaching approach. An alternative could be pre- and post- lecture quizzes for an objective measure of the knowledge gained from a lecture. However, given the urgent situation pre- and post-lecture questions/quizzes were not deemed appropriate. Equally, we note 33% and 25% of lecture attendees responded to the respective feedback questionnaire. We envisage that further work in non-emergent scenarios will be best placed to delineate the relationship of feedback questionnaire responses and more objective measures such as quizzes or tests. Future work should also include direct comparisons of this real-time online format to other lecture modes including traditional in-person lectures.

At the time of writing, we have begun an ongoing lecture series into management of COVID-19. Results are not analysed and reported here as live attendance at lectures has been lower than at earlier lectures. From communications with students in the region this could be because lectures fell during Ramadan and then examinations took place for some schools. It could also be due to relative control of virus transmission being achieved in the oPt between the first lecture in March and the beginning of the management lectures in May, though the case rate has since risen again. We are continuing lectures and will place them on YouTube to be a reference resource should students or clinicians seek to return to the subject.

We place all lectures on YouTube as a matter of course. In doing so we hope students and junior doctors who could not attend or access the live lecture can still benefit, and attendees may return to the content for reference. The experience of watching a YouTube video will not involve interactivity as students cannot have their questions answered. It is likely that learners will vary in their preferred format and some will appreciate the ability to pause, rewind and repeat a YouTube video. This is reflected in common informal requests to OxPal (by Zoom chat or email) for lecture recordings to be made public, when we are in the process of editing a recorded lecture which is not yet uploaded. However, as OxPal has consistently put all recent lectures on YouTube and uploads are announced via OxPal’s mailing list and social media, we believe the majority of those engaged with our work are aware they will be made available. Therefore, we consider that many of those who chose to attend the live lectures in this work did so as they perceived an intrinsic benefit to the live and interactive format.

The oPt have been the focus of OxPal’s work as circumstances that limit healthcare provision in the region also generate barriers to local medical education, which could reduce healthcare system resilience in the future. A long history of political instability has left the healthcare system financially and resource-depleted; for example, 32% of essential medicines were totally depleted in the Gaza Strip in the last 4 months of 2017 according to a WHO report (World Health Organization Regional Office for the Eastern Mediterranean 2017). This depletion strains public sector hospitals and reduces the availability of clinical learning environments. Equally, the same WHO report also showed significant movement restrictions on staff and patients alike, with 90% of ambulance trips from the West Bank requiring entry to Jerusalem denied direct access or 60% of humanitarian health staff applying for exit from the Gaza strip unsuccessful (World Health Organization Regional Office for the Eastern Mediterranean 2017). Students also face significant movement barriers, with one study reporting 6.7% of students at Al Quds Medical School being denied the necessary permit to travel to their primary teaching hospital (Shahawy & Diamond 2016). Distance-learning through lectures and tutorials is relatively unaffected by these movement barriers, and provides a platform for students and clinicians alike to supplement education they receive locally, including having opportunities to discuss and ask questions. Through this method OxPal’s overarching goal is to educate medical students and early career clinicians in oPt as a sustainable from the ground-up approach to maximising human capital in a self-perpetuating manner, and boost healthcare system resilience in the oPt.

These lectures fell within the context of many institutions rapidly running online courses on the COVID-19 pandemic. One such course is an epidemiology focused course from Johns Hopkins University which was available free to the public; it aimed to equip people with basic knowledge and thus ‘empower [people] to be part of the solution’ (Johns Hopkins Hub Staff Report). Based on the positive feedback on our previous work in providing online distance-learning for Palestinian students (Penfold et al. 2014) and the results of the present study, we would strongly encourage institutions everywhere to consider publishing their teaching and resources on the ongoing pandemic in open access forums. Historically in public health crises, there has been a paucity of free online courses aimed at medical or healthcare students, despite the fact that they represent a key strategic group for education in a public health emergency (Swathi, Gonzalez & Delgado 2017). Therefore, we would additionally encourage institutions to replicate our model of actively seeking to establish, develop and maintain collaborations with students and clinicians in relatively ‘tutor-deplete’ regions or contexts. Having a pre-established trusted infrastructure that consistently provides responsive high-quality information, can facilitate uptake of courses, and can engage a critical mass of learners in a school, region or community. We have shown the approach is sustainable and scalable in the present study and previously (Penfold et al. 2014).

OxPal will continue to provide online lectures and tutorials to students and doctors on COVID-19 as long as there is a notable demand. Collaborators from outside of the oPt have also shared oPt-tailored public health infographics for dissemination through social networks of medical students and professionals. This work shows the feasibility and potential usefulness of distance-learning collaborations for bolstering the response to this crisis and any future crises we face globally.

Conclusions

Interactive distance learning is a feasible and beneficial method for education during a pandemic response in the oPt. OxPal has employed such an approach to teach medical students and doctors about the current COVID-19 pandemic, equipping them with essential knowledge which is locally relevant and contextual. We encourage ‘tutor-surplus’ regions and institutions to consider how they might knowledge-share in the pandemic, especially with territories facing enhanced barriers to on-site medical education and/or outbreak response. In particular, we encourage them to actively include medical students in these initiatives as they are a vital human resource during this global pandemic.