The Development, Content Validity and Evaluation of an African-Contextual Back Pain Self-Management Model (AC-BP-SMM): The Delphi Technique

BackgroundBack pain is a leading occupational health problem among healthcare workers globally, with a disproportionately higher burden in low- and middle-income countries (LMICs). Existing theoretical models including the Fear-Avoidance Model, Biopsychosocial Model, and Patient Activation Theory originate from high-income country contexts and insufficiently represent the cultural, structural, and organisational realities of African healthcare settings. AimTo develop and evaluate the content validity of an African-Contextual Back Pain Self-Management Model (AC-BP-SMM) using a two-stage approach: a framework synthesis grounded in a 15-year programme of empirical research from Zambia, followed by content validity evaluation through the Delphi technique. MethodsStage 1 drew on 17 studies (N > 1,000 participants) conducted in Zambia between 2010 and 2025, comprising epidemiological surveys, qualitative research, psychometric validation, systematic reviews, and digital health intervention trials. The five analytical phases that guided model development were: data immersion and familiarisation, concept identification and preliminary framework development, systematic indexing of data, integration with existing theoretical frameworks, and model refinement. Stage 2 involved a two-round Delphi study with a purposively selected panel of 18 experts comprising physiotherapists, occupational health specialists, back pain researchers, and healthcare policy practitioners from 10 countries across Africa, Europe, and North America who rated each model component on relevance, clarity, and representativeness using a 4-point Likert scale. Content Validity Index (CVI) scores were calculated per item (I-CVI) and for the overall model (S-CVI/Ave); consensus was defined a priori as I-CVI [≥] 0.80. The framework synthesis identified five sequential model components -- Cultural and Occupational Context, Back Pain Beliefs, Coping Strategies, Participant Activation, and Self-Management Behaviours -- and a persistent knowledge-action gap (40-45 percentage points) where healthcare workers possess strong back-pain knowledge (78-85%) but cannot sustain self-management behaviours (35-42%). Four moderators (educational interventions, digital health tools, workplace culture, and system-level factors) influence pathway strength. The Delphi process achieved consensus across two rounds: the overall S-CVI/Ave was 0.93, with all 17 items achieving I-CVI [≥] 0.80 in the final round, and inter-rater agreement of {kappa} = 0.82 (95% CI 0.74-0.90). The AC-BP-SMM is the first empirically grounded, content-valid conceptual model tailored for back pain self-management in African healthcare settings. By foregrounding context as a primary determinant and operationalising the knowledge-action gap, the model provides a validated theoretical blueprint for culturally appropriate multi-component interventions targeting both beliefs and structural barriers, with implications for occupational health policy, digital health intervention design, and future implementation research.