Health and Sexual Rights: Design,Development,and Assessment of the Massive Open Online Course on Lesbian,Gay,Bisexual,Transgender,and Intersex Health Promotion in Brazil

Introduction

There is an increasing demand for health training and qualification that incorporate broader participation mechanisms and a more flexible teaching-learning process. This demand is in line with the online-based education teaching-learning technology model via virtual learning environments. In this context, Massive Open Online Courses (MOOCs) have risen as a teaching format with universal access and the potential and viability to be implemented by health professionals. ¹

The MOOC format was developed in Canada ² in 2008 to expand and share the teaching-learning process freely and massively, with the help of network technologies. In little over a decade, it emerged as a teaching mechanism in the health field in high-income countries, for example, the United States, Canada, Australia, and Western European countries. ³

Despite its proven success in enabling high-quality continuous education, most of the literature in this topic is in English and needs to be expanded into low and middle-income countries. ⁴ In Latin America, the first MOOC was launched in 2013 at the University of São Paulo, using the Veduca platform. ⁵ In stark contrast with high-income countries, where the number of massive health courses surpasses 4,000, usage and offerings of this technology are still scarce in Brazil. ⁶

A glaring gap is the lack of training on sexual health and human rights, given that continuous education about contents, skills, and practices is crucial in this area. For health professionals, information is key for reducing the stigma around gender identity and sexual orientation, remedying the lack of knowledge regarding sexual rights, standing against discrimination and other forms of violence, and supporting the fight against HIV/AIDS and the spread of sexually transmitted diseases. ^{7 –9}

Therefore, there is an urgent need inside the Brazilian public health system to establish public policies regarding gender identity, race, and ethnicity markers, since these policies help balance severe inequities inside the country. ¹⁰ As a strategy to hinder this inequity, the National Policy for the Health of Lesbian, Gay, Bisexual, and Transgender (LGBT) People was enacted in 2011 and identified various urgencies, including the need to promote this topic and train professionals for promoting the civic and sexual rights of the Lesbian, Gay, Bisexual, Transgender, and Intersex (LGBTI+) population. ^11,12

In 2018, the World Health Organization (WHO) published an extensive report addressing the causes of disparities in health services access and utilization for LGBT Persons in Latin America. ¹³ This document pointed that stigma and discrimination as major obstacles that prevent LGBT persons from accessing healthcare services and that one of the most urgencies are training and sensitization of healthcare providers. Particularly in Brazil, studies show that professionals of health have poor knowledge about the theme and that leads to fragility and disarticulation of the care regarding the LGBT community. ¹⁴

This study describes the design, development, and assessment process of an online-based course that uses the MOOC format to offer a new and pioneering training on the topic of sexual rights and health involving LGBTI+ health promotion in Brazil.

Materials and Methods

Results

The introductory MOOC course on the health of the LGBTI+ population was launched in May 2019 and has had 3,000 people enrolled as of July 2019.

Out of the 3,000 people enrolled, 19.4% (n = 582) concluded the final evaluation and obtained certification. Table 1 shows the heterogeneity of participants in regards to age group (from 15 to 68 years of age) and gender identity (57.4% cis women and 20.4% cis men). The table also shows that 60.3% (n = 351) of people identified themselves as white and 35.6% (n = 207) identified themselves as black (comprising black and mixed, as per the methodology used by the Brazilian Institute of Geography and Statistics).

It is also possible to see that, out of the total of people who completed the course, 57.6% (n = 335) identified themselves as heterosexual, whereas 14.1% (n = 60) identified themselves as gay men, 7.7% (n = 45) as lesbian women, and 7.2% (n = 42) chose not to report their sexual orientation.

There was a predominance of participants who lived in an urban area, totaling 88.8% (n = 517), in comparison to 6.2% (n = 36) who lived in a rural area. In regards to the level of education, undergraduates were the majority, with 42.3% (n = 246), whereas 26.6% (n = 155) of participants were postgraduates and 19.9% (n = 116) were graduates. 18.7% (n = 109) of the people who completed the course were professionals from the Brazilian Public Health System (SUS).

Table 2, about the main topics discussed on the MOOC, shows that 63.6% (n = 370) of participants who completed the MOOC stated they had never participated in training related to health of the LGBTI+ population and 48.1% (n = 280) had never interacted with social movements or Nongovernmental Organizations related to the LGBTI+ population in their region. A considerable percentage of participants, 60.1% (n = 350), declared they were not aware of health service actions aimed at the LGBTI+ population on their region.

Table 3, about how participants came across information about the MOOC, shows that 53.1% (n = 309) of the participants were introduced to the course by recommendations from friends and colleagues, whereas 17.2% (n = 100) of participants found the information on the website of the UFRGS.

Figure 1 is a map of Brazil maps showing the areas to which certificates were issued, as a way of subsidizing a geographic scale analysis.

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Fig. 1.

MOOC concluding participants in Brazil. MOOC, Massive Open Online Course.

Discussion

The completion rate of ∼20% for this MOOC exceeds the typical average, which stands at about 2–10%, considering the number of people who reached the necessary grades and received the certificate by the total number of people enrolled. ¹⁵ This indicator shows that there is interest in the topic of LGBTI+ population and health in Brazil. ^16,17 The overall success and the interest of a young audience in this MOOC ¹⁸ can be attributed to the convenience of distant education and the role it plays in students' motivation, and to the usage of a variety of innovative educational resources. Literature has shown that flexibility of MOOC and capacity of the learner to check the content in diverse forms are some potentials for the conclusion of the process. ¹⁹ The creation of this MOOC considered as base rule the multipossibility of choosing the contents in the multiplatform interface used by UFRGS, including modalities like videos and podcasts.

This pioneering endeavor of using MOOC in Brazil will possibly support the telemedicine strategies that are already consolidated in the country, while also contributing in the short term to the training of teleconsultants regarding the topics studied. ²⁰ We believe that the form of organization of the contents of this MOOC, with organic discussions that actually give materiality to the health practices of intersectionality about race, gender, and sexual diversity, increases the interest of health professionals because it addresses inequities in a cross-sectional perspective and according to international guidelines. ²¹

The capillarity of this MOOC can be seen on the map that shows how students who completed the course are spread throughout Brazil (Fig. 1), especially in states along the coastline. The sprawled out and widely distributed points in the states of São Paulo and Rio de Janeiro (Southeast) and Rio Grande do Sul (South) can be explained by the social, economical, cultural, and historical connection of these regions, which result in a faster flow of information and, therefore, make these areas more prone to the spread of MOOCs and their reproduction on local networks (e.g., friends and colleagues connected by digital social networks). The map also indicates that the MOOC was an effective strategy for the inland expansion of this knowledge and was not restricted to the southern Brazilian axis, but rather encompassed various points in Brazil, such as the Northeastern region of the sertão and parts of the Northern region. Brazil is a country with continental dimensions, therefore the inland expansion of training processes is a major challenge. Consequently, the results of our study show that the MOOC strategy is capable of facing this challenge, allowing for the multiplication of contents in the most far-off places of the country.

The relatively low cost of producing an MOOC and its potential for disseminating knowledge in a complex geographical scale are essential for making this tool an important element for optimizing public services and improving public policies. Improvements in equity policies emanating from the federal administration must be supported by high-impact, low-cost strategies (e.g., MOOCs) to train health professionals and professionals from other areas, such as social assistance, education, and public security. Spreading technical and scientific knowledge across multiple languages and access formats such as MOOCs and improving the quality of public policies are ways of enhancing professional qualification and social control inside SUS.

This analysis will open the way for new proposals on how to promote strategies on social networks to widen the public and the number of people who complete this MOOC. This could include adopting educational strategies such as reorganizing contents and formats, implementing debate forums, and monitoring evasion in the first few weeks after enrollment. ^22,23

Conclusions

Professionals from the whole country showed a high level of interest in the health of the LGBTI+ population. The demand came from a variety of groups and was not restricted to health professionals. It also included cities from the countryside, which demonstrates the capillarity and potency of distant training promoted by MOOCs.

The MOOC format was successful and reliable in enabling the teaching-learning process.