The problem:

1. Musculoskeletal (MSK) conditions are a major cause of ill-health and disability worldwide, more prevalent in more deprived groups, with substantial impacts on quality of life and healthcare resource use.
2. The mainstay of UK National Health Service treatment for MSK conditions is supported self-management.  Evidence for effectiveness is limited because intervention development has overlooked low health literacy (HL) (affecting 43-61% of the English population). 
3. Patients with low HL have higher prevalence of osteoarthritis, lower physical function, higher pain intensity and lower pain-related self-efficacy including difficulties in managing medication, compared to patients with adequate HL, often struggling to understand key messages of self-management.

The approach

Mixed methods concurrent-sequential study design with four work-packages (WPs). WP1: secondary analysis existing data to identify potential targets (mediators, moderators and sub-groups) for intervention. WP2: evidence synthesis to assess likely effective components of supported self-management interventions taking into account varying levels of HL. WP3: views of community members and health care professionals (HCPs) on essential components. WP4: findings from WPs 1,2,3 synthesised to produce evidence tables: online modified Delphi approach with stakeholder group of HCPs and third-sector collaborators ranked importance of evidence presented to reach consensus on most important components of a logic model. 

Findings: Eight dimensions to the logic model were identified, each with their own domains: the problem, inputs, determinants, training and education (HCPs), intervention components, delivery modes, outputs and health outcomes. Determinants identified include: self-efficacy, illness perceptions, and an understanding of the MSK condition.  Components identified included information in diverse formats (e.g. audio, video and written materials) offered at specific times; action planning and goal setting; visual demonstrations of exercises. Support should be multi-professional using a combination of delivery modes including verbal, written and audio-visual. 

Conclusions: This research has developed a patient-centred model for a multi-disciplinary, multi-modal approach to supported self-management for patients with musculoskeletal pain and varying levels of health literacy. The model is evidence-based and acceptable to both patients and HCPs, with potential for significant impact on the management of musculoskeletal pain and for improving patient health outcomes. Further work is needed to establish its efficacy.