One of the greatest challenges that will face health systems globally in the twenty-first century will be the increasing burden of chronic diseases. Despite the clinical differences across these chronic conditions, each illness confronts patients and their relatives with the same spectrum of needs: to alter their behaviour; to deal with the social and emotional impacts of symptoms, disabilities, to take medicines; and to interact with medical care over time. Chronic illness requires complex models of care, involving collaboration among professions and institutions that have traditionally been separate. Yet, healthcare still builds largely on an acute, episodic model of care that is ill equipped to meet the long-term and fluctuating needs of those with chronic illness. In order to provide better support for patients, health professionals, policy makers and institutions are increasingly recognizing the need to respond to those with complex health needs and are initiating new models of service delivery designed to achieve better coordination of services across the continuum of care. The aim of this project is to gain deeper insight into causal mechanisms operant within the process of chronic disease management. Special attention is paid to the factors closely related to patient’s self-management such as noncompliance, socio-economic inequalities, ethnicity, ageing, social participation and coping.The main aim of this multidisciplinary project is to gain knowledge in the field chronic disease management by disentangling routes of causal influence. Self-reinforcing feedback loops will be identified and related to lack of specific types of intra-individual and extra-individual resources. The outcomes of causal modelling are empirical evidence that will facilitate decision-making concerning improved models of healthcare delivery in the chronically ill.