Background to the MOOC

The MOOC was 5 weeks in duration and ran between 7th November to 11th December 2022. It was free and provided in five different languages (English, Spanish, French, Portuguese and Chinese). It was intended for physiotherapy students or junior physiotherapists with little prior experience in the area of SCI. Participants were required to devote 5 h per week for 5 weeks to the MOOC (a total of 25 h). They were required to complete online lessons, engage with additional resources and contribute to an online discussion forum. They could do these activities at any time during the week. That is, participants were not required to be online together at particular times. Participants were also given access to a textbook that the MOOC was based upon [24]. Participants were given certificates of completion if they sat the final post-MOOC Knowledge Assessment. The MOOC was run in collaboration with the International Spinal Cord Society and based on similar MOOCs run by some of the authors in 2014, 2016 and 2018 [1, 2].

The MOOC was housed on a purpose-built website—www.SCIMOOC.org. This website provided all the objectives of the MOOC as well as the objectives for each lesson (see Supplementary File 1). It also outlined tasks for each week. Some of the tasks required participants to move across to physiotherapy-specific online lessons housed at www.elearnSCI.org (created by ISCoS). The lessons contain over 1500 screens and 150 videos. Each screen has a small amount of text with an accompanying image or video. Interspersed are screens with activities that require participants to answer questions or identify appropriate physiotherapy exercises for a particular problem. The screens were designed to encourage participants to repeatedly stop, think, do [something] and revise [what they had learnt]. The content was largely built around real-world case studies with videos of people with SCI and experienced SCI physiotherapists from countries around the world. Participants were frequently presented with different clinical problems and prompted to reflect on appropriate assessments and treatments. The elearn website also contains multiple-choice assessments at the end of each lesson that provide participants with an opportunity to test their knowledge.

Participants were encouraged to join and engage with their colleagues and course co-ordinators (teachers) on a closed Facebook (FB) group. There was one FB group for each of the four languages (English, French, Spanish and Portuguese) and a Weibo chat forum for Chinese participants (because FB is blocked in China). Each FB group had one or two language co-ordinators who oversaw the FB group and responded to participants’ posts. Two or three discussion threads were opened by the coordinators each week. These posed particular clinical scenarios or questions that related to the week’s learning content. Participants were encouraged to post to these open threads but they could not open new discussion threads of their own. The discussion threads were closed at the end of each week.

Participants were instructured on what to do each week through email. The instructions for each week were also posted on the FB groups and on the MOOC website. In addition, short videos were created in English and Portuguese at the beginning of each week for participants to view. These outlined the content for the week. These videos were not created in the other languages because of financial constraints.

The overall MOOC co-ordinators and the language coordinators were all senior physiotherapists with clinical experience in the area of SCI. Three of the co-ordinators held academic positions and regularly taught physiotherapy students and junior physiotherapists about the management of SCI. Each co-ordinator made a short video to introduce themselves to participants.

Assessing participant’s knowledge and seeking their feedback

Participants were asked to complete a pre- and post-MOOC Knowledge Assessment, and a post-MOOC Evaluation. The Knowledge Assessments consisted of 20 multiple choice questions. Prior to the commencement of the MOOC pairs of questions were prepared and then one question of each pair was randomly assigned to the pre-MOOC Knowledge Assessment and the other to the post-MOOC Knowledge Assessment. This was done to ensure that there were no systematic differences in the difficulty of the questions comprising the pre- and post-MOOC Knowledge Assessments. The score attained on the first attempt of the post-MOOC Knowledge Assessment was printed on the participants’ certificates of completion. The post-MOOC Evaluation asked participants to rate statements about the MOOC on a five-point scale ranging from “strongly disagree” to “strongly agree”. There were also open-ended questions in which participants could provide free text feedback.

The University of Sydney’s Ethics Committee approved this study and provided a waiver of consent on the basis that the study met the criterion for waiver of consent as articulated in The National Statement on Ethical Conduct in Human Research (pg 21) [25].

Data collection

Qualitative and quantitative data were collected to address the four posed questions captured by the themes: reach, effectiveness, reaction and behaviour. The data sources were participants’ registration details, the pre- and post-MOOC Knowledge Assessments, the post-MOOC Evaluation and the FB posts. In addition, online tracking was used to determine the number of hits or views of the websites, videos and emails that were part of the MOOC. The details are outlined below.

THE REACH: Who were the participants and were they engaged? The participants

Data were collected for each registered participant for each of the five languages in which the MOOC was run including their country and level of SCI experience (undergraduate student or postgraduate student or <1 year SCI experience or 2 to 5 years SCI experience of >5 years SCI experience).

Engagement

This was determined by looking at the number of people who accessed, completed or viewed different components of the MOOC including:

Pre- and post-MOOC Knowledge Assessments and the post-MOOC Evaluation: The number of participants who completed the pre- and post MOOC Knowledge Assessments and the post-MOOC Evaluation were counted (data sourced from the Content Management System of the www.SCIMOOC.org website).

Facebook or Weibo Group: The number of participants who joined each FB or Weibo Group, and posted comments or reacted to posts were counted (data sourced from FB or Weibo).

Emails: The number of instructional emails that were sent and opened were counted (data sourced from MailChimp).

Website hits on www.SCIMOOC.org: The number of page views of www.SCIMOOC.org were recorded (data sourced from Google analytics). This website contained the weekly instructions.

Website hits on www.elearnSCI.org: The number of page views of www.elearnSCI.org were recorded (data sourced from by Google analytics). This website contained most of the learning content.

Daily views of www.physiotherapyexercises.com: The number of page views of www.physiotherapyexercises.com were recorded over the duration of the MOOC although participants were only asked to use this website during the 4th week of the course to create exercise booklets for a patient (data sourced from Google analytics).

Attrition rate

This was estimated on the basis of the number of participants who completed the post-MOOC Knowledge assessment. It was also based on the change in the number of page views of www.SCIMOOC.org and the www.elearnSCI.org websites from the beginning to the end of the MOOC, and the drop in the number of comments posted to the threads each week on FB.

THE EFFECTIVENESS: Was there a short-term/immediate change in knowledge and/or confidence?

This was determined in the following ways:

Knowledge assessments

The median (interquartile range, IQR) change in scores from the pre-MOOC and post-MOOC Knowledge Assessments was determined in the sub-sample of participants who completed both Assessments.

Text analysis

The comments posted to three discussion threads on the FB Pages and the text responses received on the English version of the post-MOOC Evaluation were searched for the following terms—“learnt”, “learned”, “learn”, “did not know” and “understand” and “confidence”. Each mention was counted to gauge participants’ self-reported changes in knowledge and confidence.

REACTION: How did the participants react to the MOOC? Post-MOOC evaluation

The results of the post-MOOC Evaluation were used to gauge how participants reacted to the MOOC.

Text analysis

The comments posted to three discussion threads on the FB Groups, and the text responses received on the English version of the post-MOOC Evaluation were used to determine:

Participants’ overall impressions of the MOOC: The number of times positive words such as “amazing”, “awesome”, “brilliant”, “fantastic”, “great”, “superb” or “wonderful” were used to describe the MOOC were counted.

The topics that participants enjoyed or valued learning about: The FB threads and post-MOOC Evaluation asked participants to reflect on what they had learnt or enjoyed learning about. The leading 8 topics participants wrote about were identified and counted.

The aspects of the learning experience that participants valued and/or enjoyed: The number of times participants mentioned different aspects of the learning experience in the FB threads and post-MOOC Evaluation were identified and counted.

BEHAVIOUR: Will the participants change their clinical practice or teach others differently in response to the MOOC? Text analysis

The comments posted in the FB threads and post-MOOC Evaluation were used to determine participants’ intention to change clinical practice in response to the MOOC and to teach others differently.