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From Local Action to Global Policy: A Comparative Policy Content Analysis of National Policies to Address Musculoskeletal Health to Inform Global Policy Development

Background: Global policy to guide action on musculoskeletal (MSK) health is in a nascent phase. Lagging behind other noncommunicable diseases there is currently little global policy to assist governments to develop national approaches to MSK health. Considering the importance of comparison and learning for global policy development, we aimed to perform a comparative analysis of national MSK policies to identify areas of innovation and draw common themes and principles that could guide MSK health policy. Methods: Multi-modal search strategy incorporating a systematic online search targeted at the 30 most populated nations ; a call to networked experts; a specified question in a related eDelphi questionnaire; and snowballing methods.. Extracted data were organised using an a priori framework adapted from the WHO Building Blocks and further inductive coding. Subsequently, texts were open coded and thematically analysed to derive specific sub-themes and principles underlying texts within each theme, serving as abstracted, transferrable concepts for future global policy. Results: The search yielded 165 documents with 41 retained after removal of duplicates and exclusions. Only three documents were comprehensive national strategies addressing MSK health. The most common conditions addressed in the documents were pain (noncancer), low back pain, occupational health, inflammatory conditions, and osteoarthritis. Across eight categories, we derived 47 sub-themes with transferable principles that could guide global policy for: service delivery; workforce; medicines and technologies; financing; data and information systems; leadership and governance; citizens, consumers and communities; and research and innovation. Conclusion: There are few examples of national strategic policy to address MSK health; however, many countries are moving towards this by documenting the burden of disease and developing policies for MSK services. This review found a breadth of principles that can add to this existing work and may be adopted to develop comprehensive system-wide MSK health approaches at national and global levels.

leading cause of disability worldwide representing 17% of the global years lived with disability in 2019, global strategy and policy guidance lags behind that for other noncommunicable diseases (NCDs), particularly in low resource settings. [2][3][4] Global policy to guide action on musculoskeletal (MSK) health is in a nascent phase. There is currently little global policy or strategic direction that serves as technical guidance to assist national governments in developing whole-of-system approaches to MSK health. 5,6 Global policy serves to inform best-practice targets and provide guidance on the technical implementation of policies at local, national and regional levels. The development of global policy, however, evolves through a long process of agenda-setting, policy development, debate, legitimation and dissemination, with each stage entailing political, procedural and technical aspects. 6,7 The goal is the facilitation of policy learning; where unique experiences and local knowledge are observed, combined and analysed to provide a basis for globally-relevant learnings. The challenge is creating global policy that is grounded in local experience but interpreted into principles that find relevance and applicability across contexts. In recent years these development processes have been helpful for rapidly progressing global policy with respect to mental health 8 , NCDs 9 , antimicrobial resistance 10 , tobacco control and alcohol and other drugs. 9,[11][12][13] Despite the attributed high health and economic burden, MSK health receives little attention on the global stage, and has not featured prominently in recent global goal setting and consequently national policies on NCDs. 6 Despite overwhelming and increasing recognition of the burden of MSK disorders, 14 recent research has identified gaps in the evidence base in terms of effective policy solutions. 15 The purpose of this review is to extend this knowledge base and contribute to the feasibility and promise of global MSK policy. In acknowledging that the development of global policy is grounded in phases of policy comparison and learning from local experiences, we aimed to, 1) perform a comparative analysis of national MSK policies and develop a snapshot of current national MSK policy approaches and priorities; 2) collate themes covered from the combined content of existing national policies; and 3) draw key principles from the existing pool of local policies that can be used in policy learning.
This study was undertaken as part of a three-phase project that included key informant interviews with MSK policy experts and a global eDelphi to determine prioritised components for a global strategy for improving MSK health. [16][17][18] The goal of this paper is to provide the detailed findings from our policy analysis to assist policy makers at both national and international levels. We also aim to outline a detailed method for undertaking comparative policy content analysis for this purpose, in the hope that it can be useful for facilitating global policy learning for other vital health challenges.

Design
We undertook a systematic comparative policy content analysis of MSK heath policy documents adapted from the framework proposed by Arksey and O'Malley, 19 and used by Anderson et al, 20 for policy mapping.

Inclusion criteria: document types
Documents were included where they described national, sub-national or multi-national level health policies for a MSK health condition(s) that were government-issued -or cosponsored with government -labelled as 'policy', 'strategy', 'framework', 'action plan' or similar, consistent with definitions used previously. 3 Policies needed to focus on MSK health generally, MSK pain, or any specific MSK condition

Document collection
We conducted a broad search for national MSK policies via four search methods. Contacts from countries not included in the top 30 most populous nations were also asked to identify any potentially relevant documents.

Second, we identified policy documents via requests to the Global Alliance for
Musculoskeletal Health (G-MUSC) International Coordinating Council members and policy researchers (expert round), including those with access to raw data from an earlier integrated NCD policy review of OECD member states. 3 The request was deliberately broad to enable the collation of policies that could fit any of the potential criteria for inclusion.
Third, we extracted data from a related project that used an eDelphi method to collect information from the global MSK community on systems strengthening opportunities and priorities 17  Fourth, we examined all documents for reference to additional MSK policy documents following snowballing methods. All documents that were not originally in English or German were translated using an online document translator (https://www.onlinedoctranslator.com/en/) as previously. 3 3

Inclusion criteria (document content) and document selection
An initial review of documents included in the pool showed a wide variety of document reported for discussion to all authors. Sub-themes were refined, expanded or merged as necessary.

Interpretive analysis
To extract key principles underlying the meaning of texts, we read, discussed and interpreted underlying meanings from across multiple texts within each category, reflecting on position, overarching goals, common linguistic patterns and purpose of texts. 17 Principles were developed to represent the common underlying purpose of a policy action for achieving policy goals. Abstracted principles were presented at working group and project group meetings and discussed with all authors and refined for internal validity and consistency purposes.

Ethical Issues/Statement
This study did not include any human or animal participants.

Overview of included policies
From an initial yield of 165 documents, 6 were excluded as duplicates. A further 7 documents were excluded as falling outside of the specified date range and 111 documents did not meet the criteria of being a policy document or did not have a substantial MSK component. It is notable that while our search was not designed to capture clinical and treatment guidelines, or reports on MSK burden and risk factors, we identified a far greater number of these than we did policy documents in our final yield. These peripheral documents also came from a greater range of high, low-and middle-income countries (LMICs) (see Table 1 Table 1). Of the 118 documents excluded after removal of duplicates, most were classified as clinical guidelines (n=56), government reports on burden of disease

Policy characteristics
The documents we analysed varied greatly in form and purpose (see Table 2). Documents ranged from book-length reviews of the current health system, MSK services disease burden and future reform initiatives (for example, documents USA 1 and Belgium 1), to stand-alone tables of goals, target roles and responsibilities but without guiding text (for example, document Columbia 1).
Although the documents varied in form and even target condition, there was a commonality in purpose across most documents to improve understanding and awareness of the conditions they addressed and reduce disease burden.   To continue and strengthen the policy initiated for more than 10 years to improve pain management.  Green=Primary condition targeted in document; Yellow=Condition is addressed as a major theme in document; Orange=Condition mentioned as a minor or incidental target in document; Red: Condition not addressed in document.

Policy content
Across the 8 policy categories, we inductively derived 47 sub-themes. Understanding service availability and moving towards an increased number of citizens that can access MSK services when they are needed.

Improve patient outcomes
Understanding and improving MSK health following diagnosis.

Knowledge, awareness and outcomes
Improving knowledge of MSK conditions, how they can be prevented and when to take action among the general population as well as health care providers.

Improve quality of care
Understanding and improving the quality of MSK services 6. Target priority populations Understanding who is at risk of MSK disorders and establishing systems to reach those populations.

Research and investment
Funding to improve knowledge and understanding of MSK prevention and treatment 8. Cost-efficiency Calculating the broader costs of MSK disorders and the benefits of early detection and treatment. individual-level assessment and tailored treatment. We drew a total of 9 sub-themes and transferrable principles from the documents as they relate to service delivery.
The second most broadly addressed major category in the documents was centred around the health workforce. This is unsurprising considering the close connection between health services and human resources required for care delivery. Furthermore, with MSK being one of the most common reasons people seek primary care, and the recognized lack of primary care availability in many parts of the world by their own governments, particularly in underserved communities, this makes sense to be one of the more common themes. The need for formal and continuing education, as well as workforce planning and support tools were the most frequent sub-themes. In total, we found 8 distinct sub-themes and transferrable principles with respect to the MSK health workforce.
The next two most broadly raised categories in the texts related to "financing" and "medicines and technologies". The place of pharmacological and biological treatment in multidisciplinary care, medical education and knowledge for citizens; and the appropriate use, in particular concerning opioid medications, dominated texts around medicines. We determined 6 distinct sub-themes concerning medicines and technologies. Given the prevalence of texts around the appropriate use of opioid medication, we determined this warranted a separate distinct sub-theme.
There were very few documents that covered in-depth how MSK services, models of care or other activities addressing MSK health should be financed. We relied on smaller text excerpts from the breadth of documents to draw 6 distinct sub-themes and abstracted principles related to this category. Where financing was discussed, texts focused on ensuring that systems of risk pooling, public funding, safety nets, and reducing out-ofpocket costs should be in place for enabling affordable access to health services.
Almost all documents contained policy statements concerning data monitoring and information systems; with a considerable number of common themes and underlying principles. Ensuring that the quality of services and outcomes are measured, and building systems to collate data through standardized processes were key features in most policies.
We determined 5 distinct sub-themes and transferrable principles related to data and monitoring.
We also found 5 sub-themes in texts related to leadership and governance, although this was not commonly addressed specifically as an area for action. Rather we found a reference to the roles and responsibilities allocated to organisations and individuals within the system, as well as the decision-making structures that have been, or will be, established to govern MSK health. We also found a single reference to the roles that non-government organisations play in MSK health, particularly in agenda-setting and as issue-area champions.
Finally, we drew 4 distinct sub-themes in each of the inductively coded analysis categories.
With respect to citizens, consumers and communities, most policies contained strategies or goals to educate and empower citizens with better knowledge of MSK health for both prevention and treatment. Policies also focused on reaching priority populations, either through screening, planning or by developing culturally sensitive models of care.
Policy documents that were comprehensive strategies targeting whole-of-systems approaches included calls for increased research and innovation for improving MSK health.   In the few countries where a system-wide overarching policy and strategy to guide MSK health has been developed, such as England, Turkey and Switzerland, this is likely to have been the product of particular policy entrepreneurship and a facilitating policy context. We propose further research into the history of the development of these policies to determine facilitating factors would be important to understand historical context and to inform prospective policy evolution and evaluation. 6,62 This approach has been used to better understand policy and global priority evolution related to NCDs generally. 63 However, even among these few national-level strategies, the variation in format and nature and depth of content, indicates that we are still firmly in a phase of sharing policy experiences and tools, with a focus on engaging in policy learning, rather than supporting widespread implementation and monitoring. Global technical advice to support the establishment of MSK policy has been lacking but could contribute to increased efficiency in the development of MSK policies at the national level, and indeed, an empirically-derived strategic framework has been developed recently for this purpose, as well as more nuanced and context-specific recommendations for low and middle-income settings. 2,17,18 There are opportunities for policy entrepreneurs, from government, industry or civil society sectors to draw on the principles itemized in this review to drive MSK policy evolution locally. This is especially the case in countries that have already invested in monitoring and recording of MSK burden -and we found many examples of this as an incidental finding in our document collection -as well as countries where population health monitoring of MSK health is absent or emerging. 64 Indeed, as the burden attributed to MSK health impairment becomes more widely recognised and countries move towards arresting this burden, as This may be a more feasible approach to developing MSK policy than a single strategy in some settings; while in others an integrated single strategy may be more resource efficient. 67 Another example is dispersing responsibility and authority for policy development. In some countries, notably Australia and, Canada, MSK policies were also authored by nongovernment organizations (including consumer advocacy and professional societies) and research institute with expertise in specific MSK conditions; with a mix of funding, endorsement or co-production with government. The relationship between peak bodies, national research institutes and governments differs from country to country but could also provide important resources and capacity in the development of new policy and system strategies.
As mentioned above, based on our operational definition, we identified a far greater number of clinical guidelines for MSK health, or reports on MSK disease burden, than we did policy documents. This is despite our search not targeting this type of document specifically. Importantly, similar burden of disease documents were also identified from LMICs, potentially pointing to emergent activity for health systems strengthening in these countries, despite a recognised lack of local MSK population health surveillance. 64,69 Most documents were also dominated by goals, targets, service provision and strengthening the workforce, with considerably less focus on governance, technologies and workforce and only a few documents included aspects of monitoring, innovation and community engagement.
Apart from a few, we also noted that most policies did not frame discussions around a life course approach or address MSK health in children. This is unusual for policies addressing an NCD where a life course approach is typically a guiding principle, the strong association between disease expression and life course behaviours, and that MSK impairments are common in children. Across all major themes, there is considerable potential for further policy learning and related system strengthening contextualised for country-specific purposes.
While we identified many national clinical guidelines and reports of national MSK disease burden, there were few system-level policies, strategies or action plans. This suggests that while there has been positive progress in recognizing burden of disease and articulating approaches for clinical management, system-level strengthening is rarely purposively and strategically developed in current policy. We found only 3 documents that could be considered system-wide strategy or policy for MSK health conditions at the national level 46,47,49 and two at the international level 59,61 .
Collectively, the pool of documents contained a breadth of key issues, themes and principles. The content analysis of the policies triangulated closely with independently collected data from aligned mixed-methods research in our broader program of work on empirically deriving a co-designed health systems strengthening response for MSK health. 16,17 This close alignment between independently collected and analysed data validates the concurrent and construct validity of our findings. Importantly, the priorities and strategies articulated by key informants and the global MSK community sampled in our aligned work 18 are also reflected closely in national policy documents, suggesting an evolution of policy that is reflective of community expectations.

Strengths and Limitations
This comparative policy analysis was the first to provide a comprehensive global search through multiple data collection steps, including networks facilitating the collection of documents in multiple languages combined with a global. Our refinement of categories enabled comparisons across a wide range of document types; enabling collation, analysis and extraction of principles in a policy field where complete, comprehensive national strategies were almost non-existent. The use of interpretive analysis methods enabled the extraction of principles that can be interpreted and applied across contexts, while maintaining the policy learning from original local country-level experience. This work was also strengthened by parallel work undertaken within a wider project that included eDelphi expert panel views on key themes and principles thereby enabling concurrent validation. 17 We excluded documents addressing road traffic injury and injury through violent trauma and acknowledge these policy areas as critical for MSK health. We only included policy documents addressing NCDs if there was explicit and substantial inclusion of MSK policy, strategy, or targets, and acknowledge the close interplay between other NCDs and MSK health, and the common shared risk factors.
While our initial web-based search focused on the 30 most populous countries; and was then supplemented by an expert round and responses to an e-Delphi with participants from 72 countries, it is possible that our search failed to uncover all relevant documents, particularly those from less populated countries.

Conclusions
The development and use of national policies for MSK health is still in its infancy. Very few national policies covered multiple MSK conditions; nor did many documents in our analysis cover all health system building blocks or supplementary categories of MSK policy interest.
However, the collective pool of documents contained a breadth of key issues, themes and principles and collated and grouped this content covered key principles and abstract key principles that can helpfully guide policy sharing and learning. Future global guidance to assist countries to develop their own MSK policies and strategies can draw on implemented principles across the health system building blocks, including service delivery, workforce, medicines and technologies, financing, data and information systems, and governance.
Existing policy also embody underlying principles of action with respect to citizens, These collective key issues, themes and principles may be helpful in informing the development of a global policy and technical guidance on action to improve MSK health that is grounded in local experiences.

Source(s) of support
This project was funded by a grant awarded by the Bone and Joint Decade Foundation with additional funding provided by Curtin University, Australia, and guided by an international external steering group of experts in the field of musculoskeletal health.