The global burden of MSK impairments

MSK conditions such as low back pain, arthritis and other MSK conditions account for the largest contribution to disability among the NCDs.1 In the context of injury, most non-fatal injuries affect the MSK system, such as strains and fragility fractures.2 3 Box 1 outlines key facts and figures related to the global burden of MSK health impairment.

A systems strengthening strategy is needed for MSK health

MSK health is not prioritised in national health plans or policy for NCDs in many countries.4–9 While there is a myriad of reasons for this, a fundamental reason is the lack of prioritisation globally due to the current SDG 3.4 indicator.8–10 The indicator positions action towards NCDs associated with premature mortality. This is an appropriate global health goal given the burden of NCDs,11 12 and a critical target for low-income and middle-income countries (LMICs) in particular, where an increasing contribution of NCDs to the total disease burden has been observed.1 13 However, the emphasis on premature mortality reduction alone disregards the imperative to concurrently address disability attributed to NCDs and injury, largely driven by MSK impairments. Disability accounts for an increasingly larger proportion of the total disease burden attributed to NCDs and injury.14 For example, an increasing disability contribution to the total burden of NCDs and injury was observed in all but two countries from 1990 to 2019.1 Without explicitly addressing the disability contribution to the total burden of disease imposed by NCDs, in particular disability-related to MSK health impairment, a lost opportunity to improve global health will persist.

Insights: how to cocreate a systems strengthening response for an overlooked NCD

Experience from the Bone and Joint Decade 2000–2010 suggests that simply stating the size of the MSK burden of disease is insufficient to catalyse system-level change.15 Therefore, considerable time and effort was invested in planning and deriving a systems strengthening response to ensure it was data driven, codesigned, acceptable, viable and representative of the global community’s perspectives. We established an international consortium, supported by G-MUSC, to undertake a phased research programme over 2020–2022. The programme was underpinned by a genuine cocreation approach to derive a roadmap of actions to strengthen health systems (the ‘Roadmap’).10 16 17 A series of projects were undertaken to empirically derive 59 systems strengthening actions organised around eight priority pillars (online supplemental file S1). The research programme included a qualitative study of 31 international key informants from 20 countries (40% LMICs),8 a content analysis of 41 health policies from 22 countries6 and a global e-Delphi consisting of 674 panellists from 72 countries (46% LMICs).10 Recognising the critical importance of understanding context in LMICs,18 we undertook further work to explore opportunities for systems strengthening in MSK health in LMICs.4 The cocreators of the Roadmap overwhelmingly agreed or strongly agreed it was valuable and credible (97.6% and 94.8%, respectively; n=426 respondents), irrespective of the economic development of their country of residence, whether they were individuals or organisation-level respondents, or whether they were clinicians or non-clinician respondents.10

Insights: approaching dissemination

We approached dissemination of the Roadmap with two key strategies: translation into non-English languages and development of a comprehensive dissemination plan.

1. Translation. To support advocacy and health systems strengthening efforts in LMICs in the regions of Africa, Asia and Latin America, the Roadmap was translated into six non-English languages (Arabic, Simplified Chinese, Hindi, Brazilian Portuguese, Latin American Spanish and Swahili) in 2022.

2. Dissemination plan. Using the translated Roadmap reports as the dissemination product, a multimodal dissemination plan was developed to maximise reach with specific emphasis on the regions of Africa, Asia and Latin America. These regions were chosen as they represent the largest volume of LMICs. To balance resource limitations with maximising reach into target regions, we engaged with peak global or regional civil society and clinical organisations with reach/membership in the regions of Africa, Asia and Latin America and a scope of interest, activity or influence in MSK health, pain, injury and trauma, rehabilitation or a lifecourse focus (ageing or child and youth). The project team participated in an organisation mapping exercise to identify relevant organisations meeting these criteria, supported by a systematic desktop Internet search, consistent with previous methods (online supplemental file S2).6 10 We harnessed existing relationships with organisations to initiate engagement or established new connections with organisational leaders. We invited each organisation to become a ‘dissemination partner’ and supported the invitation with a suite of engagement and dissemination resources (box 2, figure 1).

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Figure 1

Examples of Twitter posts in Arabic (A), Simplified Chinese (B), Hindi (C), Brazilian Portuguese (D), Latin American Spanish (E) and Swahili (F).

Evaluation design

We designed a formative evaluation of (1) dissemination reach, (2) user experience and (3) early adoption over 6 months. The design was anchored to the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework; the most widely used framework for evaluating uptake of public health interventions.19 Table 1 outlines the evaluation questions, methods and outcomes.

Public and patient involvement

The original Roadmap was codesigned with genuine public and patient involvement from inception and throughout all stages (design through to completion).10 The current evaluation was cocreated by the project team, with 8 (53%) team members from LMICs. Collecting views of people with lived experience was explicitly included as part of the evaluation design.

Reach by dissemination partners

We identified 42 potential dissemination partners, of which 22 (52%) agreed to support dissemination and 17 (40%) confirmed activities in active dissemination efforts (online supplemental file S3). Dissemination partners predominantly used Twitter (88%) to disseminate the Roadmap (40 unique posts; 12 reposts), with fewer partners using email (71%), Facebook (65%; 19 unique posts; 2 reposts) and Instagram (41%; 12 unique posts; 0 reposts). English was the most commonly language used for posting on Twitter, followed by Arabic, Simplified Chinese and Hindi (online supplemental file S4).

Reach to end users

Over the evaluation period, there were 2195 visitors to the G-MUSC website where the Roadmaps were published (19% repeat visitors) from 109 countries, representing all geographic regions and levels of economic development (41.7% high-income countries (HICs), 25% upper- middle-income countries, 25.9% lower-middle-income countries, 7.4% low-income countries). Comparatively, less reach was observed in Africa and Central Asia (figure 2). Among the visitors, 93% were active on the website (ie, activity beyond a page load), including 829 downloads (138/month) of a Roadmap report (69.2% English, 13.6% Latin American Spanish, 12.9% Brazilian Portuguese, 1.6% Simplified Chinese, 1.5% Arabic, 1.0% Swahili and 0.2% Hindi). We restricted reach evaluation to Twitter, since it was the most used social media platform. The highest median count of impressions and engagements with Twitter posts across organisations were recorded for posts in Brazilian Portuguese (n=1608 impressions) and English (n=21 engagements). Across all languages, mean impressions per day were at least 5 (range 1–157) while mean engagements per day exceeded 1 (range 1–7) for English and Hindi only (online supplemental file S4).

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Figure 2

Heat map of total end users (n=2195) across 109 countries over 6 months (September 2022 to March 2023). Darker blue shading reflects a greater frequency of users. Map powered by Microsoft Bing (Microsoft, Redmond, Washington, USA).

What did we find?

The evaluation highlighted a wide geographic reach, high levels of acceptability and support, and promising early adoption of the Roadmap, irrespective of national economic development. Importantly, the evaluation sample represented all geographic regions and levels of economic development. We interpret, therefore, that the codesigned pillars and actions described in the Roadmap have global applicability. This helps position the Roadmap as a viable health systems strengthening response for MSK health globally. Findings highlight that as adoption activities extend, there is a need to focus efforts towards implementation support, particularly in LMICs where resources are limited, and the priority status of MSK health is typically low.4 This transitional approach from strategy development to implementation support also aligns with the evolution of other health systems strengthening initiatives, such as the WHO Integrated Care for Older People (ICOPE) approach and the WHO Rehabilitation 2030 initiative.21 22

Notably, respondents from LMICs expressed a stronger intention for adoption than respondents from HICs in phase 1, which may suggest a stronger appetite for an MSK-focused health systems strengthening response in LMICs. This also resonates with findings at the cocreation stage of the Roadmap, where more of the codesigned actions were deemed essential for health systems in LMICs, compared with HICs.10 In phase 2, we observed some self-reported early adoption among stakeholders and strong future adoption intentions, with a signal of greater adoption intent from respondents from LMICs. This is unsurprising in light of evidence for limited system-level responses to the burden of MSK impairments among LMICs.4 6 23 24

Across all economies, respondents expressed the highest importance for health systems strengthening actions related to public health and community awareness of MSK health (Pillar 1); policy responses relevant to MSK health (Pillar 2) and accessible health services for people with MSK health conditions (Pillar 4). These priorities resonate with what is commonly observed across communities and health systems: a lack of understanding of, and recognition for, the burden of MSK health impairments; inadequate or absent policy responses; and inequitable access to high-value health services for people living with MSK health impairments.8 24–26 The relative deprioritisation of population health surveillance (Pillar 7) is understandable on a background of a history of limited system-level (macro) and service-level (meso) reform activities for MSK health in most countries. This may necessitate more urgent attention to pillars of the Roadmap that target community perceptions, policy responses and service delivery, consistent with findings from aligned research.24 Nonetheless, the lower priority assigned to population health surveillance may limit action on other pillars. Without population health data on prevalence and burden, local advocacy and data-driven policy responses become less achievable—the problem of ‘no data’ inferring ‘no disease’. Indeed, aligned research has identified a lack of national-level population health surveys for MSK conditions and global health estimates for MSK conditions lack primary data for many nations, in particular from LMICs.27–29

Insights

We invested resource into the dissemination strategy anchored to a partnership model, on the premise that the potential reach using a global network of dissemination partners would be superior to what the project team could achieve alone. We also adopted this model with the intention to build awareness, genuine engagement and promotion among the network of dissemination partners. We interpret that the creation of bespoke dissemination assets (box 2) was a key factor to successful engagement with dissemination partners and ultimately to reaching end users. More than half of the evaluation sample represented the key regions we targeted—Africa, Asia and Latin America—suggesting the multifaceted dissemination plan was effective and could continue to be used for similar dissemination efforts.

Using Google Analytics and Twitter Analytics tools enabled tracking of end user interactions with the Roadmap; data we considered critical to evaluate reach and user engagement. Twitter was the most widely used platform to disseminate information about the Roadmap, consistent with observations around the choice of social media platforms for disseminating health information,30 and the platform of choice by global health agencies such as the WHO. Recent research suggests that the construction of tweets about global health information influences their diffusion.31 This highlights the importance of attention to tweet construction attributes in future dissemination initiatives, and the important role of partnering with health communication experts.

The collection of case studies allowed unique insight into early adoption practices in different contexts, settings and health system levels. The diversity in adoption examples suggests that the Roadmap has value and adoption potential at multiple touch points within health systems. We infer that it may contribute to systems strengthening responses in different ways; in our examples, from informing organisational strategic directions on MSK health, to building workforce capacity, to service delivery and to national policy response, among others.24 32 The collection of case studies also allows for deeper insights into adoption practices and sharing of experiences. This approach, commonly used for health systems strengthening evaluations,24 33 34 provides context that would not be ascertainable from survey methods.

Lessons and future directions

Although we observed wide reach and end user interaction with the Roadmap, we cannot speculate on the nature of these interactions and broader perceptions owing to the limited available metrics. Further, the sample that participated in the survey phases was modest, especially in phase 2 where the response rate was low, and therefore, the findings may not be generalisable. One interpretation here is that end users were interested in receiving information about the Roadmap and accessing it, but not interested in participating in further evaluation.

A key challenge in sampling was recruitment of participants outside health professionals, educators and researchers. We observed over-representation from these sectors which may reflect the stakeholder networks of our dissemination partners, yet we did reach people with lived experience (19%) at a proportion comparable to an earlier review.35 In future evaluation cycles, targeting a more diverse sample, including a sample outside the MSK sector, will be important. A critical future direction in evaluation, and ultimately implementation, will be to understand the integration potential of the Roadmap with systems strengthening initiatives for other NCDs, especially among policy-makers, service managers and other civil society organisations.