In total, 2,532 individuals registered for the course. On average, a live session was attended by 993 people and 1,608 participants watched at least one live session. In the end, 987 participants received certificates (Table 3). Participants represented 72 countries. Many participants were from the U.S. (47.8%), where PIH is headquartered, and Rwanda (21.2%), where UGHE is located.
Table 3
Participant Session Attendance
Session
|
Live Viewers (zoom report tracking viewers)
|
Viewed Recording (self-reported in post session survey)
|
Successfully Completed Post Session Survey
|
Course completion rate
|
Session 1: Global Overview of COVID-19 and Health Equity
|
1,292
|
324
|
1,449
|
90%
|
Session 2: Contact Tracing and Equity: MA
|
1,002
|
332
|
1,116
|
84%
|
Session 3: COVID-19, Inequity and Racism in the U.S and How the Navajo National is fighting COVID-19
|
862
|
371
|
1,102
|
89%
|
Session 4: Equity and Innovation: The Response to COVID-19 in Rwanda
|
818
|
366
|
1,062
|
90%
|
Approximately 40% of participants were from different African countries. A range of professionals and students attended the sessions, 17% were public health implementers, 21% were medical professionals, 11% were public health leaders, and 27% were students (Fig. 2).
Within the medical professionals, 35% were physicians and 24% were nurses (Table 4). Survey data identified the motivation for attending the course, participants’ prior exposure to equity and racial dynamics, and areas of course success.
Table 4
Demographic characteristics of course participants (N = 1062)
Position
|
% of participants
|
Student (overall)
|
26.4%
|
Undergraduate
|
8.9%
|
Masters
|
8.0%
|
Medical School
|
6.7%
|
Doctoral
|
1.5%
|
Secondary School
|
1.3%
|
Other
|
23.5%
|
Medical Professional (overall)
|
20.8%
|
Physician
|
7.3%
|
Other
|
5.4%
|
Nurse
|
5.0%
|
Paramedic professional
|
1.6%
|
Clinical Officer
|
1.0%
|
Physician’s Assistant
|
0.4%
|
Implementer
|
17.2%
|
Public health leader
|
10.6%
|
Policy maker
|
1.4%
|
Source: self-reported on 4th session |
Motivation for attending
Immediate need for skills and information to address COVID-19 and explicit focus on an equity approach were the primary drivers of participant’s interest in this course, 44% and 27%, respectively.
Educational background on race & equity
When asked whether their undergraduate, graduate or health professional classes explicitly addressed issues of racism and equity, 29-35% agreed (lower for health professional training), 20-34% disagreed (lower for graduate studies), and 31-45% said not applicable (N/A) (highest for health professional studies). The largest numbers of participants were from the U.S. and Rwanda. A higher percentage of participants from the U.S. both agreed (40% vs. 34% of Rwanda participants) and disagreed (34% vs. 23% of Rwanda participants) that their undergraduate studies explicitly addressed issues of racism and equity. A higher portion of respondents from Rwanda said N/A (42% vs. 27% of U.S. participants). When asked whether their academic studies covered the social determinants of health, but stopped short of naming racism, a higher proportion (46%) agreed, 28% disagreed, and 25% said N/A.
Areas of course success
Three areas including high comprehension, use of acquired knowledge, alignment with the implementation, and smooth logistics were highlighted as the major areas of success.
High Content Comprehension: Overall, participants demonstrated a good understanding of course material. The average score for content related questions answered correctly was 82% for Session 1, 85% for Session 2, 88% for Session 3, and 86% for Session 4. Participants reported a good grasp on the learning objectives of each session. For Session 1 ~70% said their understanding was Excellent or Very Good, ~80% for Sessions 2 and 3, and ~90% for Session 4.
High Desire to Apply Knowledge: Participants reported that they are very likely (4.75 out of 5) to use the information, tools, or skills from the course in their work.
Implementation Team Alignment: There was strong alignment between the PIH and UGHE contributors, resulting in cohesive course themes, PPR resource sheets, web page resources, and social media content.
Course Logistics: When reflecting on the structure and logistics, the course implementation team found that positive aspects were Zoom as the webinar platform, the length of each session, the pre-readings, the dynamic exchange among panelists, and the opportunity for an extended discussion during Office Hours that directly followed panel discussions.
Qualitative findings highlighted practical application of the course, focusing on equity and racism, communication and community engagement, and supportive environment as emerging themes.
Practical application of the course
For many participants the most useful aspects of this course were the case studies and practical applications. Participants (N=225) noted either the case studies generally or a specific case study as the most useful aspect of the course.
A medical professional from the U.S. shared, “I liked hearing from leaders in Rwanda, where you can see the success that comes from focusing on vulnerable populations.” When asked how they would apply course learnings to their work or studies, respondents mentioned they would use learnings to implement best practices (N=122). However, some respondents (N=31) noted that a lack of funding or resources was a barrier to implementing the approaches discussed in the course. Participants (N=130) were interested in including more case studies generally, with an added focus on low-middle income country contexts (N=43). Many participants (N=57) also wanted more practical applications. One medical professional from the U.S. shared, “I would like to hear more about specific ways healthcare providers can create change in vulnerable communities” and a public health leader from Zimbabwe said, “[I would like to learn more about] practical and specific references to what low-income countries need to do within the available resources.”
Several participants noted that the course challenged them not only to reconsider approaches to PPR in their own contexts, but also to question their prior assumptions and cognitive framework. One participant shared: “I found myself thinking of ways to apply the mechanism of countries who invest more into their public health structure to my own community policies that specifically disproportionately affect those who are socioeconomically disadvantaged.” Another participant said, “I loved hearing [course faculty] Dr. Agnes' perspective and other global leaders in health equity as I have a narrowed U.S. perspective that operates in the systemic inequities built in the U.S.”. Similarly, a participant shared, “I also love understanding the pandemic from a different perspective; understanding that not all parts of the world have the level of healthcare inequity that the US has." Said another, "The cost of poor health system contributed more to my learning and awakened my mind to these problems.”
For many, the discussion of clinical and containment nihilism (views that efforts to either treat or contain the pandemic were pointless), strongly resonated. More than 50 participants commented on this. Said one: "I have been witnessing ‘containment nihilism’ for weeks, and this gave me a name for it, and a reminder to push back on that framework and fight for better.” Said another, “It gave me a great perspective and helped me to articulate my own experiences in a better way.” Equally appreciated was the clear definition of leadership as being accountable to the most vulnerable in society.
At a time when some of the world’s most prominent leaders were promoting disinformation, belittling science, callously disregarding the pandemic’s impact on the most vulnerable, and even contributing to increased violence against people of color through their rhetoric, the course and the panel discussions were able to present a fundamentally different vision of leadership and equity in PPR. Many participants expressed the relief and encouragement they experienced through their participation in the course.
Focus on equity and racism
Participants left this course with a deeper understanding of the importance of approaching PPR with an equity focus. When asked about the most useful or valuable aspects of the course, the equity focus (N=156) was frequently mentioned. A public health implementer from the U.S. shared, “I have a better understanding of the disparities around the world and also have acquired some language to talk about the impact on vulnerable communities, about what an equitable response might look like, and about why and how to invest in social, economic, and health systems.” A medical professional from Rwanda stated that, “[this course reinforced for me] the role and responsibilities of current and future leaders to eliminate social disparities in the context of pandemic preparedness response.”
When asked how they would apply course learnings to their work or studies, respondents mentioned they would use learnings to work toward social equity (N=162) and many respondents (N=129) commented that this course was a catalyst to continue personal reflection and education about health equity and pandemic response. A public health implementer from Malawi said this course reminded them of the need to “consider inherent inequalities when designing community responses to minimize propagating the inequality.” Some respondents (N=53) commented that a barrier to implementing equity-based approaches is their communities' lack of understanding about the need for an equity focus or willingness to take such approaches. A medical student from Germany shared, “a lack of understanding for the need to address social determinants will certainly pose a hindrance in implementing such measures in my future work setting,” but emphasized “I intend to always take a step back and consider the social determinants to make sure I am making equitable decisions and programming.”
One of the four course segments focused on the intersection of racism and the pandemic in the U.S. When asked about the most valuable aspects of this session, a public health leader in the U.S. wrote, “Having such an open discussion about equity and racism within the sphere of public health with such passionate public health professionals was empowering.” A Masters student of governance in Germany replied, “The ability…to explicitly address racism denial in health equity and understanding frameworks of racism on institutionalized, personally mediated, and internalized levels helped understanding … bias and privilege.” Hundreds of people expressed similar sentiments. Many commented on gaining a deeper understanding of racism, including “as a system of structuring opportunities based on social interpretation,” of a person’s value, and of racism as a public health crisis. Some participants from outside the US expressed surprise and concern. A public health worker in Zimbabwe wrote “Learning that racial inequalities still exist in developed countries like the U.S. was an eye opener as an implementer in Africa I always felt this is present only here and is fueled by corruption and mismanagement of public resources that widen disparities and leave the poor poorer and the rich better off.” Hundreds more wrote of how valuable they found the focus on the Navajo Nation’s experience of the pandemic. One U.S. public health implementer wrote: “Including the case study on the Navajo Nation was truly brilliant!! No matter how much I hate to admit it: how the reservation was fairing in the battle against Covid-19 never entered my mind.”
Communication and community
Participants benefited from the opportunity to hear the global perspectives of the panel and ask panelists questions directly. The panel discussion and Q&A were mentioned by many participants (N=157) as the most valuable aspect of the course. Additionally, participants mentioned the building of community solidarity (N=38) and opportunity to hear global perspectives (N=34). A participant from Senegal shared, “I loved how frank the discussion and presentations were. The speakers spoke from lived experiences and with passion about equity, not just as an academic topic, but something they actually believe in and advocate for.” A student from the U.S. shared, “I think it was extremely useful that we got to hear from people in different areas of the public health sector and how they've dealt with health equity wherever they may be globally.” Another student expressed, “Connecting with people [from] different countries who talk of their experience in this pandemic was great if one wants to adjust and explore different things that [one] can do to respond.” A student from the U.K. shared how meaningful it was to, “Finally be able to hear another perspective outside of the U.K., where I live, or the U.S.”
Students also noted the tenor of the conversation. Said one, “Being able to ask questions to the panelists and also hearing them ask questions to each other - it is amazing to see leaders also learning from their peers.” One student noted that the most valuable part of the course for her was, “Listening to the speakers discuss and qualify their positions with each other in a constructive and educational way, unlike what we unfortunately are hearing every minute of every day in the news.”
Participants (N=115) suggested future courses include more panelists who are frontline workers or beneficiaries of COVID-19 programs. In general, participants wanted even more time (N=147) and opportunities to interact and ask panelists questions directly (N=180). Respondents (N=110) gave feedback on the Q&A format, suggesting allowing participants to pre-submit questions, showing the questions being asked, and distributing a document after the session with responses to unanswered questions.
Many respondents indicated that they would share course learnings with others (N=118), and some emphasized they would try to increase collaboration in their work or studies (N=74). A public health implementer from Liberia stated that they plan to, “share acquired knowledge through practical demonstrations and also encourage and motivate others to emulate this.” Some respondents (N=21) expressed that obstacles to sharing course concepts included feeling unsure how to incorporate learnings into their work or discussions with colleagues. When asked about the greatest challenges to applying course learnings to their work or studies, respondents mentioned resistance from political leaders or the political system (N=36) and institutional barriers of their organizations or society in general (N=36). An implementer from Mexico shared that “[a challenge is the] governance and support from our government. It has been very challenging to collaborate, especially [with] the Ministry of Health.'' A public health leader from Nigeria anticipated the greatest challenge would be, “breaking institutional frameworks that aid this inequity.”
Supporting participant learning
Pre-Reading: For some participants (N=41) the pre-readings were an important aspect to introduce the topic and offer additional case study examples. One participant from Canada shared that “the pre-reading materials were great informational guides and provided well-needed context behind COVID-19.” Twenty respondents suggested more reading, as compared to only five respondents who recommended less pre-reading. Participants (N=21) advised further linking the panel discussion to the pre-reading. A public health leader from the U.S. proposed, “tying more of the readings into the slides or panel discussion.”
Visual Aids: Slides and graphics were identified by participants (N=75) as a useful tool for communicating information. A medical professional from Mexico suggested “having more visual aids” and a participant from the U.S. said, “I wish we had the slides in advance so we can take notes on/alongside them.” Respondents also indicated that their understanding would have been enhanced by a session summary, one participant commented, “maybe have a slide or two at the end with the key takeaways from the discussion.”
Technical & Logistical Aspects: Many respondents (N=155) mentioned technical challenges such as the lighting, framing, volume, sound quality of panelists, and video editing. Participants commented that accessibility could be improved by including the speaker's titles in their name banner, enabling closed captions for the live session and non-English subtitles for the recorded version, defining technical terminology, slowing the speed of conversation, and providing pre-readings as downloadable pdfs.
The landscape analysis showed that other courses and webinars on PPR and equity were offered by the American Public Health Association, Johns Hopkins University, Mass General Brigham, the New York Academy of Science, University of Houston, University of Michigan, and Washington University. However, most of these learning opportunities focused more on public health surveillance with limited emphasis on equity-based approaches to PPR.