Osteoporosis is a major global health issue, affecting approximately 200 million people worldwide and resulting in over 8.9 million fractures annually, or 1 fracture every 3 seconds [1,2]. With the global population aging, this burden is expected to increase significantly in the coming decades, with projections suggesting an up to 310% rise in hip fractures for men and a 240% increase for women by 2050, compared to 1990 rates [3-5]. In Australia, the total annual costs of osteoporosis and osteopenia management in Australians aged ≥50 years were estimated at $4.8 billion (~US $3.4 billion) in 2023 and projected to increase to >$8.3 billion (>US $~5.9 billion) by 2033 [6]. Despite the rising prevalence and the significant morbidity, mortality, and economic burden caused by fragility fractures, there remains a substantial gap in the effective implementation of interventions aimed at fracture prevention [3,7,8]. Although diagnostic tools such as dual-energy X-ray absorptiometry (DXA) and fracture risk assessment tools such as FRAX [9,10] are available, and medications exist to reduce fracture risk, only 20%‐30% of individuals who sustain fragility fractures receive care based on established guidelines [3,6,11]. For instance, despite changes in reimbursement guidelines, there has been a plateau in subsidized bone density testing for Australians aged ≥70 years, despite the aging population [12,13].

Hospital-based fracture liaison services (FLSs) are a cost-effective model for secondary fracture prevention and represent an exemplary standard of postfracture care. They provide a multidisciplinary, patient-centered approach that systematically identifies, assesses, and manages individuals following a fragility fracture through coordinated input from multiple specialists and are internationally recognized as the most effective strategy for preventing subsequent fractures in patients with osteoporosis [14,15]. However, fractures that do not require hospital care, such as many vertebral or radial fractures, are often managed solely in primary care clinics, where patients may miss out on these services [16,17]. Additionally, recent modeling has suggested that expanding hospital-based FLS would only moderately reduce fracture incidence in older adults and at a high financial cost, underscoring the need for alternative, community-based strategies [18]. Therefore, adapting hospital-based fracture prevention efforts for use in primary care represents a rational and potentially scalable approach. Unlike hospital-based models that rely on coordinators, community-based prevention places full responsibility on primary care physicians (PCPs) to identify, investigate, and manage osteoporosis [19]. Notably, the translation of evidence into clinical practice remains low among PCPs in Australia and other countries, leading to suboptimal care for many at-risk individuals [11,20-22]. While hospital FLS programs focus on secondary prevention, PCPs are uniquely positioned to also address primary prevention and reduce long-term fracture risk [23].

PCPs face significant challenges in managing multiple chronic health conditions within the constraints of limited consultation time, requiring continuous knowledge expansion to ensure evidence-based practices are applied [24,25]. As a result, there is an increasing reliance on online resources for continuing professional development [16,17,26], offering a flexible, time-efficient alternative to traditional learning methods. Social media tools and virtual communities of practice (VCoPs) have become popular platforms for collaborative learning in health care, particularly since the COVID-19 pandemic, as they allow health care professionals to overcome barriers such as geography, time, and cost [27-29]. VCoPs have been shown to alleviate professional isolation, improve retention, foster interprofessional collaboration, and provide a risk-free environment for active participation [30,31]. Despite the potential benefits, only a few studies, including our Community Fracture Capture (CFC) Learning Hub pilot [32], have explored the role of internet-based learning activities in addressing the osteoporosis care crisis, maximizing health care resources, and delivering accessible skeletal health care at reduced costs [33,34].

Given the potential of VCoPs to offer a flexible and accessible way to enhance PCPs’ knowledge and confidence in osteoporosis management, and the current lack of studies evaluating their effectiveness, this study is guided by the following research question: “How do PCPs engage with a VCoP to build knowledge and confidence in osteoporosis care?” and “How can their engagement be improved?” This study will address the research question by evaluating PCPs’ engagement with an innovative VCoP, the CFC Learning Hub.

Our CFC Learning Hub served as an interactive, case-based, small-group online learning platform with flexible, tailored modules designed to address the fracture treatment gap in the community, promote current bone health practices for PCPs, and support the expansion of the e-learning hub and fracture liaison models at the primary care level, both in Australia and globally [35]. The quantitative evaluation of the program provided strong positive feedback, with 82% of participants reporting satisfaction with the program content and 89% indicating that they were likely to recommend it to their colleagues, suggesting that it is tailored to address the challenges faced by PCPs and could also be relevant in diverse health-related and other fields [36]. A qualitative analysis of the CFC model offers valuable insights into how learners interact with and experience such a novel learning model, complementing quantitative findings by adding context and depth to the interpretation of observed outcomes.

In addition to the insights gained from the quantitative analysis of the CFC Learning Hub, a qualitative evaluation of this innovative tool provides crucial information to assess the effectiveness of the model in delivering professional training to Australian PCPs and helping to bridge gaps in community-based fracture treatment. Qualitative inquiry explores the “how” and “why” behind decision-making, providing an in-depth and personalized understanding of PCPs’ behaviors, experiences, and real-world environments [37]. For instance, a recent study used qualitative analysis to investigate health practitioners’ perceptions of web-based learning to support patient behavior change [38]. Our study aims to identify themes related to barriers and facilitators of online learning, PCPs’ perceptions of the program, and challenges in osteoporosis management in general practice. We propose that the CFC Learning Hub can serve as a peer-to-peer platform providing up-to-date fracture prevention knowledge to PCPs of diverse backgrounds and experience levels, while also enhancing their confidence and motivation in osteoporosis care, as measured using analytics tools.

Participants stressed that a well-designed online learning platform is essential for improving their user experience, especially given their limited time. They noted that features such as intuitive navigation, easy access to resources, and responsive support are crucial. They also mentioned that minimizing complexity and ensuring key information is accessible helps them engage effectively with the content, thereby supporting their professional development. Based on the data collected for this theme, this theme was further divided into 3 subthemes.

Some participants mentioned encountering challenges with interface design. The issues reported included difficulty in finding specific information among a vast amount of reference material, leading to time consumption, and confusion about the setup of tiles under the education tab and the main page. While acknowledging that the course materials were helpful, they highlighted that the navigation and organization of information were not as streamlined or intuitive as needed, pointing to a need for improved clarity and usability in the system’s design to enhance user efficiency and reduce the learning curve.

One participant from cycle 1 mentioned:

Another participant from cycle 2 highlighted facing problems with flow between the program components:

It is notable that after the initial cycles, improvements such as the provision of more detailed and advanced platform induction and changes to content layout were made to ensure an improved user experience. In the following cycles (cycles 3 and 4), no similar comments regarding the need for improvements were made.

Many participating PCPs indicated that minimizing separated sections within the online learning platform significantly enhances their user experience by creating a more cohesive and streamlined learning environment. They noted that when content is organized in a unified manner rather than fragmented across multiple sections, learners can more easily navigate through materials and maintain focus. According to them, this integration reduces cognitive load, allowing users to connect concepts more effectively and progress more smoothly through their courses. They reported feeling frustrated and disoriented, struggling to connect concepts and maintain their focus when navigating through fragmented and disjointed sections.

One participant of cycle 2 mentioned:

Another cycle 2 participant suggested that reducing separated sections would enhance the learning experience:

Similar to the “Flow Between Different Components of the Program’ subtheme, no comments regarding section separation were made in cycles 3 and 4. This followed changes to the program format that reduced content separation and included a detailed navigation session in the Week 1 webinar.

A considerable proportion of cycles 1, 2, and 3 suggested that having clear navigation options on an online learning platform enhances their overall user experience. Many of them mentioned that clarity of navigation options allowed them to easily find and access various sections of the course, reducing frustration and saving time, and helped learners to focus on the material without getting lost or overwhelmed by the platform’s structure. Several participating PCPs highlighted that, with intuitive navigation, learners can quickly locate specific content, track their progress, and seamlessly transition between modules.

One cycle 1 participant expressed frustration over the unclear platform navigation options:

Another cycle 2 participant highlighted facing difficulties due to unclear navigation mapping throughout the platform:

As with the previous 2 subthemes, no comments regarding issues with unclear navigation options were received in cycles 3 and 4, following changes to the platform layout that provided a clearer map of the platform and the inclusion of a navigation session early in the program.

Participants mentioned that a well-structured course that connects practice-based case studies with core papers can greatly improve learning. They also suggested that the provision of regular summaries can help to reinforce key information and prevent cognitive overload, while after-activity quizzes can serve to continuously assess and deepen program understanding. They noted that this integrated approach fosters a more coherent and impactful learning experience, facilitating both comprehension and retention of the material. This theme, based on the data collected, was further categorized into 3 subthemes.

Several participants emphasized the need for connections between case studies and foundational knowledge papers to be made explicit and easily accessible. They highlighted that clear, direct links between practical examples and theoretical content would enhance their understanding and application of the material. Additionally, they mentioned that ensuring these connections are readily accessible and well-defined would improve navigation and reinforce learning by helping participants link theoretical concepts to their application in real-world scenarios.

A cycle 1 participant suggested:

A cycle 4 participant expressed confusion:

The observations from these quotes indicate a need for improved integration and navigation within the online learning platform. The feedback suggests that enhancing the course structure could improve user experience by making transitions between case studies and foundational knowledge papers smoother and more intuitive.

Some participants highlighted a consistent desire for clearer, more accessible summaries and highlights throughout the course. They expressed a need for concise summaries that clearly outline the knowledge and management expectations for participating PCPs, as well as key points and reference tools. They also suggested incorporating bullet-point summaries and providing weekly overviews or links to resources to better track and review the learning content.

A cycle 2 participant added:

A cycle 4 participant proposed:

These suggestions point to a need for enhanced clarity and organization to ensure that crucial information is not lost in complex discussions and that learners can easily access and review essential material.

Some members reported concerns about the quizzes used in the program, highlighting issues with their difficulty and alignment with the course material. They found the quizzes challenging, with questions that were hard to answer based on the provided resources.

A cycle 1 participant mentioned:

A cycle 4 participant highlighted:

Overall, these observations suggest a need for improving quiz design and content alignment to better match the course content and enhance learner engagement and assessment accuracy.

While our program supported the learners in a less directive learning style, PCP participants in the CFC Learning Hub exhibited varying interests in diverse learning styles, such as synchronous interactions, self-study, didactic sessions, and online discussions. For those interested in different learning styles, the program aimed to accommodate varied learning approaches by offering a range of instructional methods. The program supported real-time engagement through live sessions, provided flexibility for independent study, incorporated structured didactic content for foundational knowledge, and fostered collaborative learning through interactive discussions. Additionally, in later cycles (ie, cycles 3 and 4), prerecorded short video discussions were included in each week of the cycle to engage learners preferring one-way direction education. Further, we updated our communications with content that encouraged participation in other learning styles, such as peer-to-peer discussion. This approach aimed to ensure that learners could engage with the material in ways that aligned with their individual learning styles, enhancing overall effectiveness and satisfaction. However, it is important to address that there is no one-size-fits-all approach to learning styles, as various methods will appeal differently to various learners.

The learners’ different styles and preference themes were further broken down into 6 subthemes.

Some members of the program expressed their preference for live, interactive elements in online learning. Specifically, they expressed their desire for regularly scheduled virtual meetings or webinars that facilitate real-time discussions, enable immediate question-and-answer sessions, and enhance their engagement. This cohort of participants believed that live interactions, as opposed to asynchronous messaging or comment posting, foster more effective and dynamic conversations. According to their perspectives, live webinars with interactive features, such as live chat and question-and-answer, tend to generate greater participation and maintain interest better than asynchronous communication methods.

A cycle 2 participant mentioned:

Also, a cycle 4 member commented:

Overall, these learners expressed their inclination toward incorporating more video and live discussion formats to improve their learning experience.

Several members highlighted positive aspects of the program experience and its support for a self-study learning style. Participants demonstrated an impression with the quality of feedback provided by both PCP and specialist moderators, suggesting that the level of support and interaction was highly valued. They also appreciated the overall style and structure of the course, finding it enjoyable and effective.

A cycle 2 participant said:

A cycle 4 member mentioned:

According to this cohort of CFC Learning Hub members, the learning style providing flexibility to navigate between different episodes or sessions was noted as a strong feature, ensuring easy access for learners.

Some participants preferred a more didactic and directive learning experience. They desired a consistent instructional approach, with a clear progression from didactic lectures to case presentations and interactive sessions, rather than self-studying the provided resources. Additionally, they asked for an increased use of structured and concise video discussions, avoiding open-ended conversations that can disrupt the flow of their learning.

A cycle 1 participant mentioned:

A cycle 4 participant recommended:

In summary, these observations highlight a desire among some members for a more structured learning environment with well-organized content delivery and focused discussions.

Some CFC members highly valued the exchange of diverse perspectives, practical suggestions, and collaborative discussions. They appreciated hearing various management viewpoints, acknowledged the practical advice on clinical practice, and expressed appreciation for the knowledge shared by moderators and colleagues. Additionally, they gave positive feedback on engaging and helpful discussions, indicating that the collaborative and interactive elements of the learning experience are particularly beneficial.

A cycle 1 participant mentioned:

In another comment, the same participant mentioned:

Overall, the observations reveal that some participants valued the exchange of diverse viewpoints, appreciated practical suggestions and expert input, and responded positively to collaborative discussions.

Learners preferring interactions reflected a strong appreciation for the educational content, effective communication, and supportive interactions provided throughout the learning sessions. Those participants frequently expressed gratitude for the helpful and engaging nature of the educational materials, case study discussions, and presentations. There was also recognition of the value of the collaborative efforts of moderators, specialists, and the IT team in making the sessions informative and engaging. Many specifically commended moderators for their comprehensive answers, concise presentations, and overall contributions, noting that these addressed their questions and enhanced their learning experience.

A cycle 2 participant expressed gratitude:

One cycle 4 participant commented:

In summary, feedback from these interaction-seeking learners highlights a high level of satisfaction with the educational activity and a deep appreciation for the support and knowledge shared.

Many participants highlighted a preference for interactive questioning and active dialogue as key components of their learning process, demonstrated by asking more questions. Additionally, when participants asked questions, they contributed to a collaborative environment in which knowledge was coconstructed through shared inquiry and discussion, as their questions encouraged other members and moderators to engage interactively and contribute further to the conversation.

Below are some examples of questions asked by engaged participants throughout the program’s different cycles.

A cycle 1 participant commented and asked:

A cycle 2 participant asked:

This dynamic of asking questions fostered a richer, more interactive learning experience, enhancing both individual comprehension and collective knowledge.

Some participants shared their thoughts on the program content, offering valuable feedback that can lead to actionable improvements. Their reflections provide useful insights into how the content may be enhanced in future cycles and how the program may continue to support members even after the cycle ends. The program content is further divided into 2 subthemes: Topic Suggestions and Reinforcement and Long-Term Knowledge Retention.

Participants across all cycles suggested a range of additional topics to include in the program, highlighting a desire for both broad and detailed topics. These included practical topics such as managing common day-to-day PCP presentations, understanding government-subsidized vs nonsubsidized treatment approaches under national health care reimbursement schemes (eg, Australia’s Pharmaceutical Benefits Scheme and Medicare Benefits Schedule), and incorporating content aimed at preventing morbidity and mortality. Participants also expressed interest in more detailed clinical content, including management across different case scenarios, selection of drugs in osteoporosis treatment, and recent breakthroughs in the field. Additionally, suggestions were made to expand the scope of the program to include women’s health, pediatrics, and information on menopausal hormone therapy and premenopausal osteoporosis.

In response to this feedback, later program cycles were adapted to include more case-based discussions related to suggested topics, along with more detailed treatment guidance. Broader topics such as women’s health and pediatrics were acknowledged as valuable and noted for future inclusion beyond the current scope of the program.

In summary, this subtheme suggests a need for the program to incorporate a diverse array of topics, addressing both practical concerns and emerging advances to better meet participants’ varied learning needs.

Several participants in the program valued opportunities for ongoing learning and reinforcement of the program material. Many expressed a desire for periodic refreshers or updates to help retain and apply their knowledge over time. Suggestions included offering brief annual refresher programs, updates on osteoporosis, and the ability to revisit core content. Some participants specifically noted the need to review studies cited in the educational material and to have continued access to resources such as the national health care reimbursement schemes, including Pharmaceutical Benefits Scheme eligibility criteria, acknowledging the challenge of recalling detailed information after the initial delivery of the program.

These observations suggest that incorporating regular review sessions and updates into the program could enhance its effectiveness and support long-term learning for participants.