Actions towards the health-related Sustainable Development Goal 3.4 typically focus on non-communicable diseases (NCDs) associated with premature mortality, with less emphasis on NCDs associated with disability, such as musculoskeletal conditions—the leading contributor to the global burden of disability. Can systems strengthening priorities for an underprioritised NCD be codesigned, disseminated and evaluated? A ‘roadmap’ for strengthening global health systems for improved musculoskeletal health was launched in 2021. In this practice paper, we outline dissemination efforts for this Roadmap and insights on evaluating its reach, user experience and early adoption. A global network of 22 dissemination partners was established to drive dissemination efforts, focussing on Africa, Asia and Latin America, each supported with a suite of dissemination assets. Within a 6-month evaluation window, 52 Twitter posts were distributed, 2195 visitors from 109 countries accessed the online multilingual Roadmap and 138 downloads of the Roadmap per month were recorded. Among 254 end users who answered a user-experience survey, respondents ‘agreed’ or ‘strongly agreed’ the Roadmap was valuable (88.3%), credible (91.2%), useful (90.1%) and usable (85.4%). Most (77.8%) agreed or strongly agreed they would adopt the Roadmap in some way. Collection of real-world adoption case studies allowed unique insights into adoption practices in different contexts, settings and health system levels. Diversity in adoption examples suggests that the Roadmap has value and adoption potential at multiple touchpoints within health systems globally. With resourcing, harnessing an engaged global community and establishing a global network of partners, a systems strengthening tool can be cocreated, disseminated and formatively evaluated.
- Health policy
- Health systems
- Health systems evaluation
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
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In response to musculoskeletal (MSK) health being underprioritised relative to other non-communicable diseases (NCDs), a ‘roadmap’ for strengthening health systems to improve prevention and control of MSK health impairment was codesigned by the global community and launched in 2021.
A global network of partners supported by resources (particularly multilingual translations of the Roadmap and social media assets) was key to disseminating the Roadmap and ensuring its reach across the target regions of Africa, Asia and Latin America.
Social media analytics and Google Analytics enabled evaluation of geographic reach and stakeholders’ interactions with the Roadmap, while collection of user experience measures and real-world adoption case studies provided insights into the value and adoption potential of the Roadmap.
Findings highlight the strong endorsement of the Roadmap as a systems strengthening tool with a clear indication that implementation products and supports are now needed, especially in low-income and middle-income countries.
Investing in non-English translations, establishing a global network of dissemination partners, harnessing analytics potential of social media platforms and Google Analytics, collecting quantitative and qualitative user experiences, and collecting case studies of real-world adoption provide multidimensional insights into how a systems strengthening tool for an underprioritised NCD can be codesigned, disseminated and evaluated in a real-world context.
In this practice paper, we describe our experiences and insights in developing and disseminating a systems strengthening strategy for musculoskeletal (MSK) health. We describe a formative evaluation of its reach, end-users’ perceptions and adoption, interpretation of the evaluation findings and how these might inform future directions for systems strengthening efforts. This work is relevant to non-communicable diseases (NCDs) that are afforded a lower priority status (eg, MSK conditions) than those NCDs more closely aligned with the targets of the health-related Sustainable Development Goal (SDG) 3.4.
The need to address the burden MSK health impairment
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.
Key facts and figures related to the global burden of musculoskeletal (MSK) health impairment
Musculoskeletal conditions consistently feature in the top three conditions contributing to the greatest disability burden across most countries, irrespective of economic development.1
A greatest number of people likely to benefit from rehabilitation interventions are those living with MSK conditions, currently estimated at 1.71 billion people.40
For the poorest billion people globally, MSK conditions are among the leading health conditions accounting for the majority of disease burden related to non-communicable diseases and injuries.13
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.
Creating a roadmap to strengthen health systems for MSK health
Recognising the gap between the increasing burden of disease attributed to MSK health impairment and policy/systems strengthening responses globally and nationally, the Global Alliance for Musculoskeletal Health (G-MUSC) called for development of a strategy to inform a global response. The call encompassed the prevention and control of MSK conditions, MSK pain, and MSK injury and trauma.
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.
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.
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).
Resources to support organisation-level active dissemination
The following dissemination resources were provided to each organisation:
Briefing document outlining the background to the Roadmap, its relevance to each organisation and an invitation to become a ‘dissemination partner’.
YouTube explanatory video link outlining the background to the Roadmap.
Curated and adaptable email templates in seven languages (Arabic, Simplified Chinese, English, Hindi, Brazilian Portuguese, Latin American Spanish and Swahili) inviting individuals to download the Roadmap from the Global Alliance for Musculoskeletal Health (G-MUSC) website in their preferred language and respond to a short survey in their preferred language.
Curated social media packs for three social media platforms, including: Twitter (rebranded to ‘X’ in July 2023), Facebook and Instagram in seven languages (Arabic, Simplified Chinese, English, Hindi, Brazilian Portuguese, Latin American Spanish and Swahili). Each pack contained text and graphics tailored to the posting requirements of each social media platform (image size and orientation, character limits), directing followers to access the Roadmap from the G-MUSC website in their preferred language and respond to a short survey in their preferred language (figure 1).
Instruction manual about how to post content on social media. Organisations were also encouraged to use other platforms, where this was preferred (eg, LinkedIn, TikTok).
Project officer support to assist with dissemination, where required.
Evaluation of reach, perceptions and adoption
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.
Evaluation question 1: what reach was achieved for the suite of Roadmap reports within the first 6 months of their publication?
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).
Evaluation question 2: what was the user experience of the Roadmap within the first 6 months of publication?
Among 373 unique respondents, 254 (68%) provided at least one valid data point for the phase 1 user experience survey. Demographic characteristics are summarised in table 2.
Respondents predominantly represented health workers, educators/researchers and people with lived experience. We collected responses from people across 63 countries representing all geographic regions. More than 50% of respondents represented the target regions of Africa, Asia and Latin America. Further, more than 50% of the countries represented and respondents were in the low-income or middle-income economic classification. Across the four user experience domains,20 respondents ‘agreed’ or ‘strongly agreed’ the Roadmap was valuable (88.3%), credible (91.2%), useful (90.1%) and usable (85.4%) (figure 3). Most (77.8%) agreed or strongly agreed they would adopt the Roadmap in some way. A significantly larger proportion of respondents from LMICs (84%) agreed or strongly agreed they would adopt or use the Roadmap in some way, compared with respondents from HICs (70%). Among the 61 free-text comments received, the main themes related to:
Identification of the Roadmap as a valued tool for health systems strengthening: ‘All I can say is: ‘It’s about time’ we see NCD and MSK concerns taking the centre field with the WHO and many National and non-government organisations (NGO) organizations interested in more cost-effective and outcome-based results in MSK care’.
Need to transition to implementation support, particularly for influencing priorities for national health: ‘How the strategies and blueprint developed could be practically incorporated will be of value.’
Need for adaptation and support in LMICs where MSK health is not a priority condition: ‘This report is very important. But there is no money in Africa to implement this report. … There is practically no funding for musculoskeletal research, education or advocacy in Africa. Musculoskeletal diseases are foreign language to the African government[s] and health authorities. Musculoskeletal NGOs in Africa are left by donors to bark like toothless dogs’.
See online supplemental file S5 for more detail on content analysis of the free-text outcomes.
Evaluation question 3: is there any evidence of early adoption of the Roadmap?
Eighty-nine individuals responded to the phase 2 follow-up survey in June 2023 (table 2). Forty-one (46.1%) indicated they had adopted the Roadmap in some way, with no differences observed between respondents in HICs compared with LMICs. Respondents reported they shared it with other people/organisations (70.7%), discussed it with other people/organisations (63.4%) and referred to/promoted it in reports or presentations (51.2%). Seventy-four (83.1%) indicated their intention to use the Roadmap in some way. Although not statistically significant, a larger proportion of respondents from LMICs (92.5%) indicated planned adoption, compared with respondents from HICs (78.7%). Respondents intended to share the Roadmap with other people/organisations (71.6%), discuss it with other people/organisations (68.9%) and refer to/promote it in reports or presentations (64.9%). Considering the importance of the eight pillars, mean rank was highest for Pillar 1 (Engaging, empowering and educating communities), followed by Pillar 2 (Leadership, governance and shared accountability) and Pillar 4 (Service delivery), with the lowest rank assigned to Pillar 7 (Population health surveillance). Mean ranks of these pillars were consistent across respondents from HICs and LMICs (online supplemental file S6). Translations were judged to be very or highly useful by 44.6% of respondents.
We identified three examples of early adoption of the Roadmap. Two included adoption by organisations with a global reach, where the Roadmap had informed organisation-level strategic planning (box 3). The third case describes adoption context within a lower-middle-income country with plans for national-level adoption (box 4).
Adoption case studies 1 and 2—global organisation-level adoption
Following publication of the Roadmap, World Physiotherapy (WP) and the manual/musculoskeletal group of WP (The International Federation of Orthopaedic Manipulative Physical Therapists—IFOMPT) reviewed the actions underpinning the eight pillars. WP and IFOMPT considered: (1) how their current portfolio of activities supported the pillars; (2) what further activities WP and IFOMPT need to consider to support implementation of the Roadmap; and (3) how such activities could be achieved by two global organisations made up of national professional organisations. A recent editorial outlines the organisations’ actions against pillar 1 (‘Engaging, empowering and educating communities’).42 Pillar 1 was chosen as the ‘test case’ for strategic mapping since it was considered to be closely aligned to the purpose of both organisations and it contains the greatest number of essential actions.
The International Federation of Musculoskeletal Research Societies (IFMRS) is an umbrella organisation of MSK research societies. The IFMRS launched its Education in Musculoskeletal Research Global Action Plan in March 2023, which provides a framework for tackling some of the biggest challenges facing the MSK community and captures key recommendations relevant to all sectors of the global MSK community. The Action Plan is the result of several virtual round tables and discussions over 2 years, involving a wide range of stakeholders from all parts of the MSK community globally. The Roadmap provided a powerful point of reference to inform these discussions, in particular Pillar 8 (‘Research and innovation’). Adoption of the Roadmap enabled the IFMRS to anchor its vision and recommendations and underlined how the solutions proposed around research and education are part of a much broader suite of necessary system reform actions for improving MSK health globally.
Adoption case study 3—Organisation-level adoption with planned national system-level adoption
Pakistan is a densely populated (>240 million people) lower-middle-income nation with low healthcare expenditure (US$38 per capita in 2020) relative to gross domestic product (GDP) (2.95% of GDP).43 Historically, MSK health has not been a public health priority in Pakistan. In 1996 for a population 137 million, the MSK workforce comprised only of eight rheumatologists. Advocacy for increasing the prioritisation of MSK health and building capacity in the rheumatology workforce was augmented when the Arthritis Care Foundation (ACF) was established in 2010.
Working collaboratively with the national and subnational government and rheumatology experts, ACF adopted actions under select pillars of the Roadmap to inform its future strategic priorities. Specifically, the ACF has undertaken and will continue to undertake activities related to public awareness (Pillar 1), engagement with government and supporting national leadership activities (Pillar 2), facilitating service delivery (Pillar 4), contributing towards provision of essential diagnostics and therapies (Pillar 5) and engaging in workforce training (Pillar 6). To further support national adoption, ACF is working closely with national academia and the WHO country office to elevate the priority of MSK health and initiate planning for national systems strengthening activities in Pakistan. Specifically, an expert advisory group is being established to elevate MSK health to a national priority agenda. This will inform development of a national strategy to improve MSK health for Pakistan.
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
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.
The Roadmap builds on decades of advocacy since the Bone and Joint Decade to elevate the priority status of MSK health within the global health agenda. The Roadmap is the first globally focused and cocreated product that outlines acceptable and feasible actions in systems strengthening. Nonetheless, we predict that raising awareness and supporting adoption and implementation will remain challenging, since in many HICs,5 most LMICs,4 23 and globally,7 8 MSK health has not been a health priority area. Recent global responses from the WHO, such as the Rehabilitation 2030 products and ICOPE,22 36 position MSK health with a higher priority, creating a unique window of opportunity for accelerating health systems strengthening responses—an area where the Roadmap can meaningfully contribute.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Patient consent for publication
This study involves human participants and was approved by the Human Research Ethics Committee of Curtin University, Australia, granted approval to collect individual-level outcomes data (HRE2022-0404). Participants gave informed consent to participate in the study before taking part.
We gratefully acknowledge Adrienne Sycamore (Linguistico, Sydney, Australia) for providing translation services and Nicole Melbourne (Nikki M Group, Melbourne Australia) for design and typesetting of the translated Roadmap reports. We also acknowledge our dissemination partner organisations: Academic Consortium for Integrative Medicine & Health; African League Against Rheumatism (AFLAR); AO Alliance Foundation; Arab League of Associations for Rheumatology (ArLAR); Asia Pacific Fragility Fracture Alliance (APFFA); Asia Pacific League of Associations for Rheumatology (APLAR); Asia Pacific Research Network on Ageing (APPRA); Asian and Oceanic Society of Regional Anaesthesia and Pain Medicine (AOSRA-PM); Foro Internacional de Medicina Interna; Fragility Fracture Network (FFN); Global Alliance for Musculoskeletal Health (G-MUSC); International Association for the Study of Pain (IASP); IASP Global Alliance of Partners for Pain Advocacy Presidential Task Force; International Federation of Musculoskeletal Research Societies (IFMRS); International Federation of Orthopaedic Manipulative Physical Therapists Incorporated (IFOMPT); International Society of Physical and Rehabilitation Medicine (ISPRM); Osteoarthritis Foundation International; Paediatric Taskforce, Global Alliance for Musculoskeletal Health; Pan American League of Associations for Rheumatology (PANLAR); Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT); World Federation of Chiropractic (WFC); World Physiotherapy and regional chapters (Africa, South America, Asia).
Handling editor Seye Abimbola
Twitter @AndrewMBriggs, @JasonYYChua, @MSKHealthGlobal, @LaurafinucaneB, @lynmarch1, @felipereisifrj, @link_physio
Contributors AMB, JC, MC, SAH, AAK, LM, SSharma, ERS and HS conceived and designed the evaluation AMB, JC, MC, FJJS and HS led the data collection NMA, LF, FM, SSarfraz contributed data AMB, JC and MC led data analysis AMB drafted the manuscript. All authors contributed to revising the manuscript and approved the final version for submission.
Funding Funding to undertake this work was provided through unrestricted grants from the AO Alliance; Asia Pacific League of Associations for Rheumatology; Australian Rheumatology Association; Curtin University; Pan American League of Associations for Rheumatology; and the World Federation of Chiropractic. MC receives funding from the Bone and Joint Decade Foundation (Global Alliance for Musculoskeletal Health).
Disclaimer The funding agencies had no role in the design of the project or influence on interpretation of the outcomes.
Map disclaimer The inclusion of any map (including the depiction of any boundaries therein), or of any geographic or locational reference, does not imply the expression of any opinion whatsoever on the part of BMJ concerning the legal status of any country, territory, jurisdiction or area or of its authorities. Any such expression remains solely that of the relevant source and is not endorsed by BMJ. Maps are provided without any warranty of any kind, either express or implied.
Competing interests AMB reports grant income from AO Alliance, Asia Pacific League of Associations for Rheumatology, Australian Rheumatology Association, Curtin University, Pan American League of Associations for Rheumatology, and World Federation of Chiropractic related to the current work. AMB reports grant funding from the Australian Government, Department of Health; Medical Research Future Fund (Australian National Health and Medical Research Council); Western Australian Government Department of Health; Bone and Joint Decade Foundation; Curtin University; Institute for Bone and Joint Research (Australia); Canadian Memorial Chiropractic College; and Arthritis and Osteoporosis Western Australia outside the submitted work. AMB reports consultancy fees and travel support from the WHO and speaker fees from the American College of Rheumatology outside the current work. JC: reports personal income from Curtin University related to the current work. MC: reports institutional income from the Bone and Joint Decade Foundation related to the current work; and Royalties from Up-to-Date unrelated the current work. NMA: nothing to disclose. LF: reports leadership roles with World Physiotherapy and the International Federation of orthopaedic Manipulative Physical Therapists. SAH: nothing to disclose. MJ: reports a leadership role with AO Alliance and personal fees. AAK: nothing to disclose. LM: reports institutional income from the Bone and Joint Decade Foundation related to the current work. LM reports grant income from Janssen Australia, NHMRC Australian Government CREE for Inflammatory Arthritis, MRFF Australian Government Adult Arthritis Biologic Tapering Trial, and MRFF Australian Government Juvenile Arthritis Biologic Tapering Trial outside the current work. LM reports data safety monitoring (unpaid) on an Australian Government funded trial for opioid medicines. LM reports leadership positions with the Global Alliance for Musculoskeletal Health and the Australian Rheumatology Association. FM: reports a leadership position with the International Federation of Musculoskeletal Research Societies. FR: nothing to disclose. SSarfraz: nothing to disclose. SSharma: reports fellowship funding from the International Association for the Study of Pain (IASP) and speaker fees and travel support from the IASP unrelated to the current work. SSharma reports leadership positions with the IASP. ERS: reports income from PANLAR, Abbvie, Elea and Pfizer outside the current work; testimony fees from Abbvie, Amgen, BMS, Glaxo, Janssen, Lilly, Novartis, Pfizer, Sandoz, UCB; and support for attening meetings from Abbvie, Janssen, Pfizer, UCB, Amgen. HS: reports grant income from AO Alliance, Asia Pacific League of Associations for Rheumatology, Australian Rheumatology Association, Curtin University, Pan American League of Associations for Rheumatology, and World Federation of Chiropractic related to the current work. HS reports grant funding from the Australian Government, Department of Health; Medical Research Future Fund (Australian National Health and Medical Research Council); Western Australian Government Department of Health; Bone and Joint Decade Foundation; Curtin University; Institute for Bone and Joint Research (Australia); and Canadian Memorial Chiropractic College outside the submitted work. HS reports travel support from the Australian Pain Society to attend a scientific meeting.
Provenance and peer review Not commissioned; externally peer reviewed.
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