Literature ReviewImplementing the evidence for preventing falls among community-dwelling older people: A systematic review Victoria Goodwina,⁎ , Tracey Jones-Hughesb, Jo Thompson-Coona,
Trang 1Literature Review
Implementing the evidence for preventing falls among community-dwelling older people: A systematic review
Victoria Goodwina,⁎ , Tracey Jones-Hughesb, Jo Thompson-Coona, Kate Boddya, Ken Steina,b
a
PenCLAHRC, Peninsula College of Medicine and Dentistry, University of Exeter, Veysey Building, Salmon Pool Lane, Exeter, UK, EX2 4SG
b PenTAG, Peninsula College of Medicine and Dentistry, University of Exeter, Veysey Building, Salmon Pool Lane, Exeter, UK, EX2 4SG
a b s t r a c t
a r t i c l e i n f o
Article history:
Received 30 September 2010
Received in revised form 13 July 2011
Accepted 28 July 2011
Available online 10 November 2011
Keywords:
Falls prevention
Implementation
Older adults
Evidence-based practice
Systematic review
Problem and objective: The translation of the evidence-base for preventing falls among community-dwelling older people into practice has been limited This study systematically reviewed and synthesised the effective-ness of methods to implement falls prevention programmes with this population Methods: Articles published between 1980 and May 2010 that evaluated the effects of an implementation strategy No design restrictions were imposed A narrative synthesis was undertaken Results: 15 studies were identified Interventions that involved the active training of healthcare professionals improved implementation The evidence around changing the way people who fall are managed within primary care practices, and, layperson, peer or com-munity delivered models was mixed Impact on industry: Translating the evidence-base into practice involves changing the attitudes and behaviours of older people, healthcare professionals and organisations However, there is a need for further evaluation on how this can be best achieved
© 2011 National Safety Council and Elsevier Ltd All rights reserved
1 Introduction
Falls are an increasing public health concern, affecting a third of
peo-ple aged 65 and over It has been estimated that even if age-adjusted
in-cidence rates remain stable, the number of hip fractures worldwide will
climb from 1.66 million in 1990 to 6.26 million in 2050 (Sambrook &
Cooper, 2006) This rising trend exists despite many high quality
re-views and clinical guidelines providing evidence for the prevention of
falls among community-dwelling older people (American Geriatrics
Society and the British Geriatrics Society, 2010; Gillespie et al., 2009;
National Institute for Health Clinical Excellence, 2004) However, on
closer examination it is apparent that this evidence base has not
neces-sarily been transferred into clinical practice (Royal College of Physicians,
2007; Tinetti, Gordon, Sogolow, Lapin, & Bradley, 2006) As such, falls
and fall-related injuries continue to escalate (Department of Health,
2009) with a less than optimal provision of evidence-based healthcare
(Goodwin et al., 2010)
One aspect of this problem originates from the lack of understanding
on how to effectively implement the evidence-base, particularly where
routine practice may be in contrast to the experimental conditions
ob-served in the original research (Roen, Arai, Roberts, & Popay, 2006)
For example, clinicians and patients may be required to change behavior
and adopt new practices; and organizations may be required to develop
alternative systems of working across professional and organizational boundaries (Rose, Alkema, Choi, Nishita, & Pynoos, 2007; Tinetti et al.,
2006) Known barriers to implementation of falls prevention strategies include (Tinetti et al., 2006):
• Time;
• Lack of knowledge and skills;
• Complex health and social issues;
• Service organization issues, such as fragmentation or a lack of co-ordination; and
• Financial issues
Facilitators of successful implementation are (Ganz, Alkema, &
Wu, 2008; Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004):
• Effective leadership and collaboration;
• Strategies adopting simpler interventions;
• Benefits of the intervention to be observable by those intending to adopt the intervention; and
• An approach which can be adapted to meet the needs of organiza-tions and practitioners
We therefore performed a systematic review of studies in which the implementation of a falls prevention strategy has been evaluated
We identify and explore the existing evidence base, and attempt to identify key factors for successful implementation of falls prevention strategies
⁎ Corresponding author Tel.: +44 1392 262745; fax: +44 1392 421009.
E-mail address: victoria.goodwin@pms.ac.uk (V Goodwin).
0022-4375/$ – see front matter © 2011 National Safety Council and Elsevier Ltd All rights reserved.
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Trang 22 Methods
The systematic review was conducted according to a predefined
protocol that was developed following consultation with experts in
thefield and is available from the authors on request
2.1 Literature search and eligibility criteria
By analysis of key studies, we devised a search strategy to identify
relevant papers capturing the process of implementation in the
manage-ment of accidental falls among older people (Fig 1) No methodsfilter
was applied The master search strategy was adapted and run in the
fol-lowing electronic databases from 1980 to May 2010: AMED and CINAHL
(Using the EBSCO interface); Cochrane Database of Systematic Reviews;
CENTRAL; Medline; Embase and Psychinfo (Using the OVID interface);
and the Social Sciences Citation Index We scrutinized the bibliographies
of included studies and of other identified relevant review papers in the
search for additional articles
Studies were included if they reported the evaluation of an
imple-mentation strategy for the prevention of falls among
community-dwelling older adults Outcomes could include, for example, behavior
change, attitudes, and uptake of recommendations Studies were
ex-cluded if they only reported health outcomes, such as fractures or
healthcare utilization There were no restrictions on study design
Ed-itorials, opinion papers, and studies reported only as conference
ab-stracts were excluded Only papers published in the English
language were included in the review
Two reviewers independently screened all titles and abstracts Full
text manuscripts of any relevant titles/abstracts were obtained and
the relevance of each study was assessed according to the inclusion
and exclusion criteria Studies that did not fulfill the criteria were
ex-cluded and their bibliographic details listed with the reason for
exclu-sion Any discrepancies were resolved by consensus and, where
necessary, a third reviewer was consulted
2.2 Data extraction and quality assessment
Data were extracted from included papers independently by two
reviewers using a standardized, piloted data extraction form The
fol-lowing data were extracted: study location and setting, study design,
implementation method, fall prevention intervention, study
popula-tion, outcomes and follow up, analysis and results
The quality of individual studies were assessed independently by
two reviewers using the Cochrane risk of bias tool (Higgins & Green,
2009) The tool includes six key criteria against which potential risk
of bias is judged These being:
• Was the allocation sequence adequately generated and described to
enable the assessment of whether it would produce comparable
groups following randomization?
• Was the allocation adequately concealed and described in enough detail
to determine whether allocation of research participants could have
been predicted before or during recruitment by research personnel?
• Were participants, personnel or outcome assessors adequately
blinded to allocation during the study, what methods were used
and were they successful?
• Were incomplete outcome data, such as exclusions, attrition, or missing
data reported, with reasons and how these were dealt with in analyses?
• Was the study free of suggestion of selective outcome reporting (e.g., by
pre-specifying outcomes and analyses of interest and reporting these)?
• Was the study apparently free from other problems that could put it
at risk of bias, such as study design, extreme baseline imbalances?
The results were tabulated by individual reviewers for each study
and compared Disagreements were resolved through consensus
in-volving a third reviewer where necessary
2.3 Data synthesis
To determine whether effective methods of implementation were consistent across studies, data were summarized using evidence ta-bles and synthesized using a narrative approach Where data allowed, relationships and differences between studies were identified based
on factors such as healthcare system, professions involved, or the na-ture of the implementation method
3 Results
3.1 Search results and study characteristics
A total of 3,638 unique titles and abstracts were identified from the search following removal of duplicates (Fig 2); 3,530 studies were ex-cluded following a review of titles and abstracts as not meeting the inclu-sion criteria A full-text assessment of 108 articles resulted in the exclusion of 93 studies (7 did not target community-dwelling older peo-ple; 76 did not evaluate implementation; 6 were opinion papers, 3 were only available as abstracts, and 1 paper was not available in English) The remaining 15 studies met the selection criteria and were included
in the review
Six studies were undertaken in the United States (Baraff, Lee, Kader, & Penna, 1999; Brown, Gottschalk, Van Ness, Fortinsky, & Tinetti, 2005; Fortinsky et al., 2008; Healy, Haynes, McMahon, Botler, & Gross, 2005; Shah, Maly, Frank, Hirsch, & Reuben, 1997; Wenger et al., 2009), four in Australia (Barnett et al., 2004; Deery, Day, & Fildes, 2000; McClure et al., 2010; Stackpool, 2006), and one each in Canada (Scott, Votova, & Gallagher, 2006), New Zealand (Gardner, Robertson, McGee, & Campbell, 2002), Sweden (Larsson, Hägvide, Svanborg, & Borell, 2010), Belgium (Milisen, Geeraerts, & Dejaeger, 2009), and Hong Kong (Sze, Lam, Chan, & Leung, 2005) A variety of study designs were utilized in-cluding a non-randomized controlled trial (n=1), cross-sectional studies (n =3), cohort studies (n =4), surveys (n =5), process evaluation (n =1), and a case series (n =1)
3.2 Assessment of study quality When examining the quality of each study (Table 1), all were found to be at a high risk of bias In terms of blinding, six studies
1 Accidental Falls/
2 (fall or falls or faller$1 or fallen).ti,ab.
3 1 or 2
4 exp Aged/
5 (senior$1 or elder* or older or old or oldest).ti,ab.
6 4 or 5
7 3 and 6
8 (prevent* or reduce* or manage*).ti,ab.
9 7 and 8
10 Program Evaluation/
11 Information Dissemination/
12 Barrier*.ti,ab.
13 evaluat*.ti,ab.
14 translat*.ti,ab.
15 feasibility.ti,ab.
16 integrat*.ti,ab.
17 implement*.ti,ab.
18 disseminat*.ti,ab.
19 adopt*.ti,ab.
20 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19
21 9 and 20
22 limit 21 to yr="1980 -Current"
Fig 1 Master search strategy written for Medline (OVID) and adapted for different databases.
Trang 3(Deery et al., 2000; McClure et al., 2010; Scott et al., 2006; Shah et
al., 1997; Sze et al., 2005; Wenger et al., 2009) did not provide a
clear indication as to whether participants or outcome assessors
were blinded As all but one study (Wenger et al.) did not include
a comparator group, participants were aware of the intervention
and, where outcomes were self-reported, this may result in
poten-tial reporting bias In most cases, we were unable to ascertain
whether all collected outcome data were reported Only one study
(McClure et al.) was considered to be free from other sources of
bias such as baseline imbalance between groups
3.3 Implementation methods and their effects
Table 2describes each individual study with the corresponding
re-sults presented inTable 3 Implementation methods included training
of healthcare professionals (n = 6), changes to primary care/general
practice management (n = 3), peer or lay volunteer-delivered
pro-grams (n = 3), and community awareness propro-grams (n = 3) The
level of description of the implementation strategies was mixed,
with some studies providing only brief details
3.3.1 Training of health care professionals
Six studies (Baraff et al., 1999; Brown et al., 2005; Fortinsky et al.,
2008; Larsson et al., 2010; Milisen et al., 2009; Scott et al., 2006)
uti-lized training and dissemination of evidence to healthcare
profes-sionals For those that reported the duration of training, it varied
from 30 minutes to one day, targeting a range of staff including
doctors, nurses, physical and occupational therapists, and healthcare support workers
Two of the studies (Brown et al., 2005; Fortinsky et al., 2008) reported on a comprehensive approach to implementation as part of the Connecticut Collaboration for Falls Prevention (CCFP) This pro-gram incorporated training and dissemination of evidence-based falls prevention interventions using behavior change strategies, opin-ion leaders, media awareness campaigns, outreach visits to older peo-ple, and patient and provider materials This collaborative approach resulted in improvements in fall-prevention assessment and manage-ment among physical therapists, community-based rehabilitation therapists, and nurses Thirty-eight percent of physical therapists reported almost always using falls prevention strategies six weeks following training, compared with 14% before training; 68% increased their use of falls prevention strategies in practice with 7% decreasing use in practice A year after training, more than 70% of community based practitioners reported undertaking assessments of balance, mobility and postural hypotension, with around half assessing home hazards and poly-pharmacy Around half of home health agencies (HHA) had 100% of their clinical staff following the recommended falls assessment and management strategies for mobility, postural hypotension, polypharmacy, home hazards, and balance management
Three (Baraff et al., 1999; Milisen et al., 2009; Scott et al., 2006) of the remaining four studies using training explicitly evaluated their implementation methods in terms of changing clinical practice be-haviors Baraff et al (1999) trained medical and nursing staff in
Number of records identified through database searching
n=3701
Number of records screened after duplicates removed n=3638
Number of records excluded
n=3530
Number of full-text articles searched for eligibility n=108
Number of papers selected for
inclusion n=15
Number of full-text articles excluded n=93 Reason for exclusion:
-Full-text not available in English (n=1)
-Abstract only (n=3) -Opinion paper (n=6) -Did not address falls prevention in community-dwelling older people (n=7)
-Did not evaluate implementation (n=76)
Trang 4emergency departments (ED) in a locally developed guideline and
reported improvements in documentation for some aspects of history
taking, assessment, and actions When examining issues around the
implementation of a falls prevention guideline with
community-based healthcare staff,Milisen et al (2009)reported that 88% of
prac-titioners considered falls prevention important However, there was
some disagreement between professions regarding responsibility for
the assessment and management of fall risk factors and how best to
implement the guideline in practice Only half of nurses thought it
would be feasible to implement guidelines into practice compared
with between 71% and 89% of GPs, physiotherapists, and occupational
therapists Barriers to implementation were identified as time
invest-ment withoutfinancial compensation, poor patient and family
motiva-tion, and a lack of communication/collaboration between professionals
Scott et al (2006)reported a 25% increase in the fall-related knowledge
among healthcare support workers following training delivered by
nurses and therapists, although it is unclear as to the nature of this
knowledge Using the Falls Prevention Checklist and Action Plan© the
uptake of recommendations by clients was low to moderate, for
exam-ple, only 30% who had difficulties balancing whilst in the shower took
action to reduce the risk
3.3.2 Changes to primary care management
A total of three studies (Gardner et al., 2002; Shah et al., 1997;
Wenger et al., 2009) evaluated changes to the management of falls
within primary care organizations as a result of the implementation
of a falls prevention strategy Two of these studies (Shah et al.,
1997; Wenger et al., 2009) did so as part of a transformation of the
way in which common problems experienced by older people were
assessed and managed The conditions included urinary incontinence,
depression, cognitive impairment, and functional limitations.Wenger
et al (2009)reported improvements in achieving quality indicators
for falls, including history-taking, physical assessments, and
interven-tions Adherence to specialist recommendations by primary care
phy-sicians and patients was examined in one study byShah et al (1997),
although only 11% (15/139) of individuals required
recommenda-tions for falls This study reported that recommendarecommenda-tions were
imple-mented by general practitioners in six out of nine cases Among the
seven patients receiving self-care recommendations, three adhered
The study byGardner et al (2002)evaluated the implementation of
primary care practice nurse training to deliver exercise interventions,
in terms of identifying older people for the exercise program and
up-take A perception of an inability to take part in an exercise program
was indicated by both general practitioners and older people Reasons
for participation included perceived potential benefits in terms of health and well being
3.3.3 Peer or lay-volunteer training to implement programs Three studies (Deery et al., 2000; Healy et al., 2005; Sze et al.,
2005) delivered training to peers (n = 1) or lay-volunteers (n = 2)
in order to deliver health promotion messages, relating to falls preven-tion, to older people.Deery et al (2000)used peers to deliver educa-tional sessions to groups of older people, although it is unclear as to the duration or content of their training The training of lay-volunteers
to advise and promote fall-related behavior change among older people was undertaken in two studies (Healy et al., 2005; Sze et al., 2005) with training lasting from 90 minutes to two days These three studies exam-ined changes in fall-related knowledge, attitudes, and behaviors and, in the main, these outcomes improved in the short and longer term, with the exception ofDeery et al (2000)where control group participants had greater falls prevention knowledge at three months, although at
12 months the reverse was observed
3.3.4 Community awareness programs Three studies undertaken in Australia used community programs
to raise awareness about falls and promote falls prevention activities among the population, although each of these were evaluated differ-ently (Barnett et al., 2004; McClure et al., 2010; Stackpool, 2006)
Barnett et al (2004)assessed recall and current falls prevention prac-tices of healthcare staff and councils following the four year‘Stay on your Feet’ program Five years after the commencement of the pro-gram, the 321 healthcare staff (GPs, pharmacists, community nurses, occupational therapists, physiotherapists and health promotion staff) took part in a survey From this, 50% (70/139) of GPs and 30% (16/53)
of pharmacists thought the program influenced their practice Among the 129 community staff completing the survey, 48% had been involved
in the program, although many activities had been discontinued (such
as medication checks and exercise classes) Reasons included time limited resources and a lower priority Sustainability of activities was reported to have been helped by the adoption of activities as part of nor-mal work, resources, and compatibility with other projects A follow on from this study, byMcClure et al (2010), was undertaken to examine whether less resource intensive methods would be effective Although they reported an increased awareness of falls and associated behavior change among the older population, no improvements were found in terms of fall-related injuries and hospitalization
The health promotion program utilized byStackpool (2006)using community collaboration to promote physical activity among older
Table 1
Quality Assessment of Included Studies using the Cochrane Risk of Bias Tool.
generation
Allocation generation
Blinding Incomplete
outcome data
Selective outcome reporting
Other sources
of bias
Yes = adequately addressed
No = inadequately addressed
Trang 5people found a 19% increase in the number of available physical activity
classes for older people and a 16% increase in attendance by older
peo-ple over three years
4 Discussion
There is some evidence to show that the implementation of falls
prevention programs into practice can be successful Although we
identified a total of 15 studies, heterogeneity in terms of study design,
implementation methods and outcomes has limited the extent to
which the identified data could be synthesized The level of
descrip-tion of the implementadescrip-tion strategies included in this review was
often limited For example, the papers that report an aspect of the
CCFP program had clearly described implementation methods, but
the study by Deery and colleagues failed to describe how the
peer-delivered model was developed, and omitted details such as how
peers were identified and trained, and the content of the training
This is in agreement with a review of complex interventions in
work-place settings performed byEgan, Bambra, Petticrew, and Whitehead
(2009), who found that implementation was frequently referred to
but was poorly described A clear description of an intervention, albeit
a treatment or implementation method, is essential for study
replica-tion, whether to inform further research or to utilize thefindings in
clinical practice Context is also an important factor to describe as
dif-ferent healthcare systems and cultural considerations may impact on
whether translating evidence is applicable or feasible
Successful programs generally included some aspect of training of
healthcare professionals in order to change clinical practice behaviors
that have been reported to be a key aspect of implementation (Bero et
al., 1998; Tinetti et al., 2006) Peer or lay delivered programs speci
fical-ly aimed at changing knowledge, attitudes, and fall-related behaviors of
older people demonstrated some improvements, often related to
avoid-ing or removavoid-ing environmental hazards and extrinsic fall-risk factors
However, none of the non-professionally delivered programs included
training in exercise provision, a key element of effective falls prevention
strategies (Gillespie et al., 2009; Sherrington et al., 2008) There is
cur-rently a trial underway in the UK comparing the effectiveness of usual
care with a peer-delivered home exercise program, and with a group
exercise intervention delivered by a qualified exercise instructor (Iliffe
et al., 2010)
Evidence on changing clinical practice within primary care was
mixed This may be due to competing priorities with other conditions
Community awareness programs appeared diverse in terms of
out-comes and provided no clear picture in terms of the effectiveness of
this method of implementation Furthermore, one of the studies
(Shah et al., 1997) evaluating impact in this area was published
prior to 2000 when the evidence for falls prevention interventions
was less well established Falls therefore carried a relatively low priority
within healthcare
There is no general consensus with regards to which outcomes
should be used to examine the impact of implementation, possibly
due to differing interpretations as to what implementation is Within
the RE-AIM framework,Glasgow, Vogt, and Boles (1999)suggest the
evaluation of implementation programs refers to thefidelity and
ad-herence to a program, whereas,Rabin, Glasgow, Kerner, Klump, and
Brownson (2010)suggest that evaluation requires a variety of
out-comes that should be examined, from those at an individual level
(e.g., behavior change of patients or professionals), to organizational
level data, (e.g., healthcare costs) Policymakers and service
commis-sioners are interested in improved outcomes, such as fall-related
inju-ries or hospital admissions, which require effective falls prevention
interventions and effective implementation (FPG Child Development
Institute, 2011) The CCFP program was based upon an effective
multi-factorial intervention (Tinetti et al., 1994) that has also been
shown to result in a 9% (95% confidence interval [CI] 6 to 12%)
reduction in serious fall-related injuries and an 11% (95% CI 8 to 14%) reduction in medical service use (Tinetti et al., 2008)
To our knowledge, this is thefirst systematic review that has evalu-ated implementation strategies in relation to falls prevention among older people We conducted an extensive literature search in a range
of electronic databases and included a range of study designs as we recognize that traditional randomized controlled trials are less feasible and may not be appropriate when evaluating implementation into clini-cal practice (Medical Research Council, 2000; Rabin et al., 2010) There are a number of limitations of this review Firstly, although
we were able to identify a reasonable number of relevant papers, po-tential risk of bias was generally high or unclear (Higgins & Green,
2009) This was linked to the fact that most study methods did not in-corporate a control element and some studies used surveys Although evidence suggests that the failure to report key quality indicators may indicate bias, the extent of the size and direction of the impact of this bias is not always clear The quality assessment of studies designed to evaluate the implementation of evidence into practice has not been well researched and there are no guidelines to assist in the reporting
of this type of evaluation The Cochrane risk of bias tool may not be the most appropriate tool for evaluating quality in studies of this type and there may be additional issues such as social desirability bias that have not been addressed either in the publications or in the assessment of their quality Appraising evaluations of implemen-tation is a relatively new area and further work is required to develop appropriate methods (Egan et al., 2009) Secondly, we included only papers that were available in English, although based on information provided in the abstracts it is unlikely that the non-English language papers identified in the search would have met the other selection criteria Thirdly, we did not include grey literature, defined as litera-ture not published in journals, such as conference abstracts and unpublished theses (Higgins & Green, 2009), which may have highlighted further studies and reports, andfinally, we were unable
to undertake meta-analyses due to heterogeneity in all aspects of the included studies
A small number of studies in this review employed mixed methods Implementation research is particularly ripe for such an approach in which evidence of qualitative change can be set along-side elucidation of the reasons for such change The fact that the ma-jority of papers in our review were restricted to quantitative enquiry means that the influence on implementation efforts at individual (clinician or patient) and organizational levels is constrained
In summary, there is evidence to support active training and support of healthcare professionals in order to implement falls preven-tion evidence into clinical practice The evidence around changing the way people who fall are managed within primary care practices is mixed, as is the use of community awareness programs and peer or lay-delivered falls prevention programs Nevertheless, questions remain about the methods used to report, evaluate, and appraise imple-mentation research, such as developing effective search strategies and quality appraisal methods The relative importance of thisfield needs to be promoted alongside evidence for effective healthcare inter-ventions in terms of funding if evidence is to be translated into policy and clinical practice
5 Impact on industry The implementation of falls prevention research into practice in-volves changing the attitudes and behaviors of older people, healthcare professionals, and organizations However, there is a need for further evaluation on how this can be best achieved
Acknowledgement This work was funded by the National Institute for Health Re-search (NIHR) This report/article presents independent reRe-search
Trang 6Table 2
Description of Study Characteristics, Stratified by Type of Implementation Method.
intervention
evaluating implementation
Follow up
Training of healthcare professionals
Baraff et al.
(1999)
measures, cohort study
To assess impact of practice guideline on process of care
Training of physicians (2 hours) and nurses (30 minutes)
Medication management, vaccinations and ophthalmology referral
(> 65 years) attending ED
Documentary evidence of history taking, physical examination and action taken
1 year
Brown et al.
(2005)
therapy practices
Survey To describe physical
therapists knowledge, attitudes and behaviours relating to fall prevention
CCFP programme comprising training of physical therapists (1 hour)
Multi-factorial 94 physical therapy providers
from 119 organisations
falls prevention strategies and change in practice.
6 weeks
Fortinsky et
al (2008)
implementation of EBP by nurses and therapists
CCFP programme comprising training (90 minutes) of home health care staff
Multi-factorial 184 nurses and rehabilitation
therapists from 19 home health agencies (HHA)
prevention assessment and management practice
1 year
Larsson et al.
(2010)
Sweden Community Repeated
measures, cross-sectional study
To evaluate the impact of the programme on injury rates
Training of community practitioners (half day);
Media campaign 2006/7
Unclear 32 community practitioners;
82 members of public
21,898 people aged
> 55 years
Awareness of campaign; use of a hazard reporting telephone line
1 year
Milisen et al.
(2009)
Belgium Community Survey To test feasibility of
implementing a falls prevention guideline
Staff training (2 hours) Multi-factorial 23 GPs, 34 nurses, 25 PTs,
17 OTs
feasibility and practicality of guideline.
Unclear
Scott et al.
(2006)
Canada Community Repeated
measures, cohort study
To evaluate the impact of training on knowledge, practice, falls and related injuries
Training of community healthcare support workers (1 day)
Multi-factorial 57 community healthcare
support workers
87 people requiring home help support
Change in knowledge, uptake of
recommendations
Six months
Changes to primary care practices
Gardner et al.
(2002)
New
Zealand
Primary care
Process and impact evaluation of
a non-randomised trial
Applicability and feasibility of a primary care nurse-delivered exercise programme
balance training
61 general practitioners in
36 practices;
3 nurses
330 exercise participants aged
> 80 years
Recruitment issues;
fidelity and adherence
1 year
Shah et al.
(1997)
care practices
Case series To examine
implementation of CGA recommendations
Communication between geriatrician, primary care physician and patient
Multi-factorial (individually tailored)
with urinary incontinence, falls, depression or
Physician implementation and patient adherence rates
3 months
Trang 7Study Country Setting Study design Study purpose Implementation strategy Falls prevention
intervention
evaluating implementation
Follow up
Wenger et al.
(2009)
care practices
Non-randomised trial
To examine effect of ACOVE-2 intervention on process of care
Changes to practice processes and training of primary care physicians (3 hours)
Unclear 2 practices;40 physicians 644 people aged
>70 years experiencing falls, urinary incontinence
or cognitive impairment
% of quality indicators satisfied
13 months
Peer or lay volunteer delivered programmes
Deery et al.
(2000)
Australia Community Matched
cohort with repeated measures
To assess impact of peer education on fall-related knowledge, attitudes and behaviours
Peer-presented education sessions.
Training of peers unclear.
aged > 60 years (education) and 174 age and sex matched controls
Fall-related attitudes, knowledge and behaviours
3 and
12 months
Healy et al.
(2005)
measures, cohort study
To examine whether a CBT programme ‘a Matter of Balance’ can be effectively delivered by volunteers
Training of lay volunteers (2 days) Risk behaviour
change
(51–95 years)
Fidelity to the programme;
changes in fall-related self-efficacy and behaviours.
6 weeks,
6 months,
1 year
Sze et al.
(2005)
Hong
Kong
Community Survey To evaluate impact of an
education and training programme on awareness and knowledge of fall prevention
Training programme-community centre staff and lay volunteers (90 minutes); Educational seminar for older people;
Education and home hazard modification
34 staff and 312 volunteers
5114 older people Knowledge and
awareness regarding falls prevention
Unclear
Community awareness programmes
Barnett et al.
(2004)
Australia Community Surveys To assess sustainability of a
community SOYF falls prevention programme
Awareness raising, community education, policy development, engaging health professionals (1992
to 1996)
Multi-factorial 321 healthcare
professionals); 9 shire councils and 8 shire access committees
80,000 people aged
>60 years
Recall of SOYF, involvement and current falls prevention activities
5 years
McClure et al.
(2010)
Australia Community Repeated
measures, cross-sectional study
To evaluate whether a population based programme reduces falls and injuries
(a) Peer health promotion of falls prevention activities, or (b) health promotion officers delivering and supporting physical activity 2002 to 2006.
Multi-factorial 1,600 older people (a) 43,821, (b) 58,722 Fall-related
behaviour change
4 years
Stackpool
(2006)
Australia Community Repeated
measures, cross-sectional study
To establish viability of collaborative model to promote physical activity among older people
Collaborative management model (2000 to 2003)
Physical activity 6 area Health Promotion units Not reported Availability and
uptake of physical activity programmes
3 years
ED Emergency Department; CFFP Connecticut Collaborative Falls Prevention; CGA Comprehensive Geriatric Assessment; ACOVE-2 Assessing Care of Vulnerable Elders; CBT Cognitive behavioural therapy; SOYF Stay of your Feet
Trang 8commissioned by the NIHR The views expressed in this publication
are those of the author(s) and not necessarily those of the NHS, the
NIHR or the Department of Health
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Table 3
Individual Study Results, Stratified by Implementation Method.
Study Results
Training of healthcare professionals
Baraff et al.
(1999)
Improvement in 6 out 10 items on history taking; 2 out of 4 items on physical examination; 2 out of 6 items on actions taken
Brown et al.
(2005)
Most physical therapists reported an increased use of falls prevention strategies in practice.
Fortinsky et al.
(2008)
Most community healthcare staff used recommended guidance for assessment and management of falls in practice
Larsson et al.
(2010)
Low awareness of campaign in the community (20%); 72% of fall prevention agents aware 29 reports of community hazards in 6 months
Milisen et al.
(2009)
Disagreement between different professionals as to feasibility and roles in using falls prevention guideline.
Scott et al.
(2006)
Increased knowledge of staff, high use of checklist and action plan by staff, mixed uptake of recommendations by clients.
Changes to primary care practices
Gardner et al.
(2002)
Reasons for exclusion: being medically unwell; physical frailty; considered incapable of exercise Reasons for participation: doctor recommendation, health/ functional benefits, prevent falls Reasons for declining: already active, too frail/unwell, commitment too long; not interested.
Shah et al.
(1997)
6/9 physician recommendations implemented and all adhered to by patients 3/7 self-care recommendations adhered to
Wenger et al.
(2009)
44% of intervention group and 23% controls met quality indicator for falls.
Peer or lay volunteer programmes
Deery et al.
(2000)
Greater changes in attitude reported for intervention group; Intervention group has lower knowledge at 3 months but greater at 12 months compared with controls; intervention group made more environmental changes and changed behaviour at 3 and 12 months.
Healy et al.
(2005)
Significant improvements in self-efficacy and fall management.
Sze et al.
(2005)
Older people and volunteers reported gaining knowledge about falls prevention Almost all community centre staff had set up falls prevention activities.
Community awareness programmes
Barnett et al.
(2004)
Culprit medication checked by more than half of GPs/Pharmacists most of time.Around half of community staff ran exercise classes No councils had a comprehensive falls prevention policy No access committees maintained falls prevention activities.
McClure et al.
(2010)
Increased awareness of falls Behaviour change of older people in relation to falls prevention.
Stackpool
(2006)
Increase in availability of exercise classes and enrolment.
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Victoria Goodwin, PhD, is a Senior Research Fellow for PenCLAHRC (Peninsula Col-laboration for Leadership in Applied Health Research and Care) at the University of Exeter, UK and a physiotherapist for Torbay Care Trust She has recently completed a doc-torate evaluating an exercise intervention to reduce falls among people with Parkinson's disease She is involved with the British Geriatrics Society specialist section for Falls and Bone Health and is former national chair of AGILE (Chartered Physiotherapists working with Older People) Her research interests are the rehabilitation of older people and those with long term conditions.
Tracey Jones-Hughes, PhD, is an Associate Research Fellow for PenTAG (Peninsula Tech-nology Assessment Group), currently working on Health TechTech-nology Assessment She has
a diverse background, ranging from nursing to earning a PhD in environmental chemistry
at Plymouth University However, more recently she became involved in project facilita-tion for PenCLAHRC, focusing on translafacilita-tion of research into clinical practice Linking with the varied nature of her career, Tracey's current research interests include systematic re-views of environment and human health related issues.
Jo Thompson-Coon, PhD, is a Research Fellow for PenCLAHRC as part of the evidence synthesis team Her background is in pharmacology and she has worked in the respira-tory and complementary medicine fields Her current role involves identifying and prioritising potential local research projects and producing systematic reviews to in-form evidence-based practice.
Kate Boddy, MSc, is an Information Specialist at PenCLAHRC where she has been work-ing since 2009 She has been workwork-ing in health services research since 2004 and re-ceived her MSc in Library and Information Management from the University of the West of England in 2009 She has worked on numerous systematic reviews providing information support and has a particular research interest in the ways in which differ-ent search interfaces can affect search results.
Ken Stein, MD, is Professor of Public Health with a background as a physician in general practice He directs a multi-disciplinary research group which undertakes evidence syn-theses and economic evaluation on a wide range of health technologies and is deputy di-rector of the PenCLAHRC which aims to improve the influence of research on NHS practice
in the UK.