Introduction
Since their inception just over a decade ago, Massive Open Online Courses have become a popular means of promoting knowledge and understanding of research, both to the general public and to professional communities, around the globe. In comparison to face-to-face taught courses, there are no limits on numbers and participants are free to pursue the course at their own pace and at a time which suits them.
Many platforms provide access to content for free, albeit usually for a limited period and with a charge levelled for a course completion certificate. While this ‘freemium’ model undoubtedly increases accessibility, some hurdles to participation do remain, most notably having the skills and equipment to navigate the internet. The evidence points to the majority of individuals taking MOOCs as being from more affluent backgrounds (Zawacki-Richter, 2018; Rasheed, 2019, 124811; Blum, 2020, p. 2) and MOOCs are most popular in wealthier Western countries, including the UK and US. Nevertheless there are many subscribers in developing countries and the availability of courses at no, or minimal, cost creates much needed opportunities for training and learning in resource-poor organisations and settings. In all professional settings, MOOCs arguably offer an effective means of supplementing face-to-face teaching, though it is suggested further research is needed to firmly establish and optimize their efficacy in healthcare contexts (Rowe, 2019).
About our MOOC
‘Introduction to Behavioural Activation’ was created by members of the Department of Health Sciences at the University of York, the Hull York Medical School (HYMS) and the Tees Esk and Wear Valleys NHS Foundation Trust, including Professor Lina Gega, Professor Najma Siddiqi, Professor David Ekers, Karen Coales and Philip Kerrigan. Professors Ekers, Gega and Siddiqi all have extensive experience in designing and delivering research programmes involving Behavioural Activation. The multimedia content was funded by the Improving Outcomes in Mental and Physical Multimorbidity and Developing Research Capacity (IMPACT) in South Asia project and ‘in kind’ support for the development and review of the course materials and the course moderation came from IMPACT, the Developing and evaluating an adapted behavioural activation intervention for people with depression and diabetes in South Asia’ (DIADEM) programme, and the Community-based Behavioural Activation Training for Depression in Adolescents (ComBAT) project.
The aim of the course is to introduce the principles and practices of behavioural activation (BA) as a treatment for depression. The content is divided over three weeks each consisting of a number of steps grouped under three-four themed sections. Each week starts with an introductory video outlining what will be covered in the week and ends with a summary of the material covered that week, a brief quiz and the opportunity for learners to share what they found most helpful and provide feedback. The content for the individual steps can take several forms, including expository pieces, case study illustrations, subjects for discussion, activities to try, videos and even polls.
The first week offers an introduction to depression, how this differs from normal variation in mood, how it can be screened and the main different ways in which it can be treated. The second week explores the relationship between mood and behaviour, using the ABC (antecedent-behaviour-consequence) theory, and explores the vicious cycle that perpetuates depression and how this can be broken by identifying and engaging in activities that are purpose-driven and emotionally rewarding. The final week looks at how behavioural activation works in practice, covering a number of core techniques including functional analysis, activity scheduling, goal prevention and relapse prevention. It also summarises the evidence base for the effectiveness of BA, including with people of different ages and cultural backgrounds.
Demographics
The course is aimed at anyone interested in helping others with brief psychological interventions including members of the public, educators, mental health and social care professionals, and community workers.
As of the start of June 2022, almost 4,000 have enrolled with 1834 (66%) having posted at least one comment in the discussion and therefore qualifying as ‘active learners’. This percentage of active learners is extremely high – more than twice what has been identified as the usual maximum level of 25% (Almatrafi, 2019, p. 418). Although the level of fall-off in participation is quite sharp with 35% of learners completing half of all the steps and 25% completing more than 90% of the steps, these statistics compare favourably with the average retention figure of 10% that is widely cited (Rasheed, 2019, 124820). The low completion rate for MOOCs may be in part because of the low financial barriers to entry – having to pay for something means that it is more likely you will persevere with it in order to get your money’s worth. On the other hand, it is possible that some people join who would not have otherwise and then go on to complete the course.
In the first step of our course, we ask learners to introduce themselves briefly in the discussion: to state what they do, where they are from, and to explain why they have chosen the course and what they hope to get out of it. According to the responses to date, the majority of joiners have been non-professionals who either stated that they themselves were experiencing depression or knew family members, friends, co-workers who were. In either case they were hoping to learn new techniques for combating depression. A significant number of health professionals – doctors, psychologists and psychotherapists, people in counselling roles and people working in mental health support roles in schools, social care and the voluntary sector – have also taken part.
So far there has been a good age-range spread, from young people in the UK in their A-level year, planning to go on to study Psychology at University, to several individuals in their eighties. Interestingly enrollment steadily increased by age bracket from 8% in 18-25 year old’s to 20% for those over 65 years.
There is equally a pleasing geographical spread across 138 countries with the majority of participants from outside the UK. The below table shows the top ten countries for enrollments.
Enrolments by country
| United Kingdom | 34% |
| India | 7% |
| Pakistan | 5% |
| United States of America | 4% |
| Australia | 4% |
| Nigeria | 2% |
| Canada | 2% |
| Brazil | 1% |
| Ireland | 1% |
| Italy | 1% |
| South Africa | 1% |
| 129 other countries | 28% |
| Unknown | 10% |
Engagement with learners
One of the challenges with a MOOC is to make the course as interactive, personal and supportive as a face-to-face learning experience can be. Future Learn, as with most platforms, makes the discussion board, to which all participants can freely contribute and exchange ideas and reflections, a core feature. There is also a moderation period when the course is first launched, during which those who put together the course review the discussion and welcome joiners, acknowledge contributions, answer queries and intervene if any contentious points are raised.
Our course was moderated by all of the course creators plus several members of IMPACT based in South Asia – Sarmad Ali, Rubab Ayesha and Najma Hayat for the first three weeks following its launch: 10-31 January 2022. The moderators spent approximately 1-2 hours each day, reading through and responding to comments and questions submitted by learners. Feedback, both in the discussion and in the end of course survey, demonstrates that this engagement was much appreciated by the majority of learners. Comments reveal that it helped to make the learning experience feel more personal and friendly, and to aid engagement and motivation to complete the content and associated activities for the week.
Throughout the course, we strongly promote the active engagement of learners by inviting them to reflect on the concepts, illustrations, examples and allied questions that we pose and then to post these reflections in the discussion. Learners are nonetheless advised to exercise discretion and not to include any very personal or potentially identifying information in their posts. They are also encouraged to be sensitive in responding to other’s comments, especially where they hold strong views on a topic and disagree with what is written. Generally participants have appeared very comfortable in relating what they were learning to their own situation. One learner’s comment that they did not mind talking about themselves because they ‘believe there’s freedom to be gained when stigmas are challenged’ received the highest number of likes for the step.
Many individuals gave examples that other learners found helpful – for instance ways in which they had managed to break out of a depressive cycle by engaging in an activity and/or changing their perspective. Where people posted about their ongoing struggles, other participants would invariably add supportive comments and suggestions. Appreciation for the supportive nature of the learning community was a repeated theme in the feedback on people’s overall experience of the course.
The discussion gave learners the opportunity to request further information and/or clarification on certain topics, for instance with regard to the assertion made in the text ‘that antidepressant drugs are not addictive’ and about the precise nature of negative reinforcement. Members of the moderating team looked out for these questions and answered them as they arose, pointing to further sources of reliable information on the web.
Many learners expressed their appreciation of these links to further information about depression and its treatment (e.g. NHS sites, and charities, including the Mental Health Foundation). Some learners in turn posted links to other external websites. There was some concern in the moderating team about the potential for people to point to inappropriate sources of information but this has not happened to date and it was agreed that, if it did, a respectful advisory comment would be added by a team member.
Case studies
There was very good engagement with the several fictitious case studies that appear in the videos. These were informed by clinical experience of working with people with depression and were designed to demonstrate several characteristic experiences of depression in adults of different ages and in different cultural settings. Each of the three fictional characters – Suhana, Deepak and Sarah – describes their situation and feelings in a ‘talking head’ monologue. This was recorded by a voice-actor, and is presented in the video with complementary images. Many of the learners expressed empathy for the situations of the characters – ‘my heart goes out to him/her’ was a common expression used. Several learners described the example of Sarah, an older woman living on her own and struggling with her mood, energy levels and managing her diabetes, as particularly powerful and affecting.
Two of the characters, Suhana and Deepak, are encountered again undertaking a therapy session with a professional using behavioural activation techniques. The approach of Suhana’s support worker drew some criticism. In the case study, Suhana is a young Indian woman experiencing pronounced post-partum depression following a difficult birth. Her husband and parents-in-law do not appear to fully understand her situation and so are quite critical of what they see as her neglect of her house duties and appearance. When her support worker explores with Suhana what she might do that she would find rewarding, Suhana replies that she would like to start cooking again. A number of learners however did not find Suhana’s response persuasive and stated that the therapist should have probed further what might really matter to her and also help her to stand up to the demands of her husband and in-laws. This is perhaps however to misunderstand Suhana’s situation and to project a Western perspective of what should happen onto a rather different cultural context. A more practical alternative was also suggested of further breaking down the activity of cooking a meal into – choosing the recipe, buying the ingredients, preparing the meal etc. With respect to both Suhana and Deepak, the suggestion was made of ending on an even more positive note by adding a further video showing how the use of BA techniques is aiding their recovery.
The first week
The invitation in the first week to discuss to what extent ‘self-help’ techniques might be beneficial and for which groups in particular, garnered a lot of engagement. The consensus was that they were potentially helpful but most suitable for those with milder forms of depression and who had some insight into their condition and were already motivated to get better. It was generally agreed that those with more severe depression would need external support, ideally from a professional with the appropriate expertise and objective distance. There was recognition too that self-help materials offered a treatment route to those who did not wish to discuss their depression with others but that, at the same time, reaching out to others is a key part of the recovery process and that a failure to confide in others can perpetuate the emotional isolation that sustains depression.
A poll which asked learners to consider the merits of using medication and talking therapies for depression, resulted in a large majority – 77% – specifying that combining both approaches may be best, with 20% contending that talking therapies may be more effective and only 2% that medication may be more effective. A number of learners however would have liked to have seen an additional option in the poll which stated that medication may be best for some and talking therapies more helpful for others. Some individuals expressed strong views here and elsewhere about the merits of one approach against the other and these usually triggered equally strong statements from those with the opposing viewpoint. Nevertheless the results of the poll and the majority of comments would suggest that attitudes are not generally polarised. A popular opinion also was that antidepressants could help get the depressed individual to a state of mood where they are more capable of talking through their depression with a professional and addressing the circumstances, thoughts and behaviours driving it. A couple of remarks to the effect that some people may need to take antidepressants long-term because of more persistent physical problems with neurotransmitter regulation equally attracted a lot of likes.
The second and third weeks
An explicit focus on behavioural activation and its constituent methods was left for the final week. Some learners fed back that they found the first week’s material about depression and how it is commonly identified and treated too simplistic and would have preferred had we launched straight into a discussion of BA. For many others however week one served as an accessible introduction to the subject or a helpful way of refreshing their memory. The exploration of the links between mood and behaviour and the explanation of the ‘ABC’ and reinforcement theories of behaviour in week 2 were also appreciated in clarifying why and how behavioural activation works.
There was a high level of engagement with the accompanying discussion exercises which asked learners to think of examples from their own experience to match the theory. Without exception, people equated low mood in their own experience with low energy and motivation levels and behaviours characterised by avoidance (of people, of situations, of active pursuits), distraction (through comfort eating, alcohol, or television bingeing) and rumination. The more practical exercise of creating positive memory cards to make the most of good feelings was also well received. A number of learners particularly applauded, what they saw as, the straightforward eloquence of the concept of ‘purpose’ rather than ‘mood’-driven behaviour, or as it is framed in the take-away message for week 2: ‘we don’t have to wait till we feel better in order to do something rewarding; we can do something rewarding in order to feel better’.
Learners equally appreciated the practical nature of the Behavioural Activation techniques; including scheduling rewarding activities and then reflecting on and scoring these, and creating an individualised relapse prevention plan. The approach of grading activity, that is starting off gradually with easier challenges over shorter periods and building up as confidence, energy and mood levels increase was stated by several as being particularly helpful. A couple of learners shared what they considered to be similar or allied techniques – including combining an activity that you find difficult or off-putting e.g. riding an exercise bike with something pleasurable e.g. watching a favourite TV programme at the same time; also drawing up a list of healthier alternative activities to troublesome or unhelpful activities. These two examples attracted a large number of likes.
Overall feedback
The feedback on the course, both in the discussion and in the end of course survey, has been overwhelmingly positive. 84% of participants polled that they were happy with the first week’s content, increasing to 93% for the second week. 49% of participants completing the post course survey stated the course exceeded their expectations, 95% declared that they had gained new knowledge or skills, 75% that they had already applied their learning and 61% that they had shared their learning.
Many of the learners shared that they were beginning to apply BA techniques in their own day-to-day lives and were already starting to reap the benefits in terms of increased confidence, energy and mood. A number of the professionals stated that they would employ the principles and techniques they have learnt in their practice. Several participants remarked on the value of the course in promoting awareness and understanding of depression given there is still much misunderstanding about the condition in societies across the world. Finally however, while acknowledging the strength of the evidence base for the efficacy and cost effectiveness of behavioural activation across age groups and different cultures, a couple of learners cautioned that it might not always be the optimal treatment and that it is important to recognize the individuality of the patient and their circumstances and work out the most effective approach accordingly.
References
- Almatrafi, O. and Johri, A. Systematic Review of Discussion Forums in Massive Open Online Courses (MOOCs) (2019). IEEE Transactions on Learning Technologies, 12(3), 413-428. https://doi.org/10.1109/TLT.2018.2859304
- Blum, E. R., Stenfors, T., & Palmgren, P. J. (2020). Benefits of Massive Open Online Course Participation: Deductive Thematic Analysis. Journal of medical Internet research, 22(7), e17318. https://doi.org/10.2196/17318
- Meet, R. K., & Kala, D. (2021). Trends and Future Prospects in MOOC Researches: A Systematic Literature Review 2013–2020. Contemporary Educational Technology, 13(3), ep312. https://doi.org/10.30935/cedtech/10986
- Rasheed, R.A., Kamsin, A., Abdullah, N.A., Zakari, A. & Haruna, K. (2019). A Systematic Mapping Study of the Empirical MOOC Literature. IEEE Access, 7, 124809-124827. https://doi.org/10.1109/ACCESS.2019.2938561
- Rowe, M., Osadnik, C.R., Pritchard, S. et al. (2019). These may not be the courses you are seeking: a systematic review of open online courses in health professions education. BMC Med Educ, 19, 356. https://doi.org/10.1186/s12909-019-1774-9
- Zawacki-Richter, O., Bozkurt, A., Alturki, U., & Aldraiweesh, A. (2018). What Research Says About MOOCs – An Explorative Content Analysis. The International Review of Research in Open and Distributed Learning, 19(1). https://doi.org/10.19173/irrodl.v19i1.3356
- Zhu, M., Sari, A.R. & Lee, M.M. (2020). A comprehensive systematic review of MOOC research: Research techniques, topics, and trends from 2009 to 2019. Education Tech Research Dev, 68, 1685–1710. https://doi.org/10.1007/s11423-020-09798-x