Journal of Safety Research 42 (2011) 443–451 Contents lists available at SciVerse ScienceDirect Journal of Safety Research journal homepage: www.elsevier.com/locate/jsr Literature Review Implementing the evidence for preventing falls among community-dwelling older people: A systematic review Victoria Goodwin a,⁎, Tracey Jones-Hughes b, Jo Thompson-Coon a, Kate Boddy a, Ken Stein a, b a b PenCLAHRC, Peninsula College of Medicine and Dentistry, University of Exeter, Veysey Building, Salmon Pool Lane, Exeter, UK, EX2 4SG PenTAG, Peninsula College of Medicine and Dentistry, University of Exeter, Veysey Building, Salmon Pool Lane, Exeter, UK, EX2 4SG 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 a b s t r a c t 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 effectiveness 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 community 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 Introduction Falls are an increasing public health concern, affecting a third of people aged 65 and over It has been estimated that even if age-adjusted incidence 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 reviews 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 necessarily 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 observed 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 ⁎ Corresponding author Tel.: + 44 1392 262745; fax: + 44 1392 421009 E-mail address: victoria.goodwin@pms.ac.uk (V Goodwin) 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 coordination; 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 organizations 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 0022-4375/$ – see front matter © 2011 National Safety Council and Elsevier Ltd All rights reserved doi:10.1016/j.jsr.2011.07.008 444 V Goodwin et al / Journal of Safety Research 42 (2011) 443–451 Methods The systematic review was conducted according to a predefined protocol that was developed following consultation with experts in the field 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 management of accidental falls among older people (Fig 1) No methods filter was applied The master search strategy was adapted and run in the following 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 implementation strategy for the prevention of falls among communitydwelling older adults Outcomes could include, for example, behavior change, attitudes, and uptake of recommendations Studies were excluded if they only reported health outcomes, such as fractures or healthcare utilization There were no restrictions on study design Editorials, opinion papers, and studies reported only as conference abstracts 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 excluded and their bibliographic details listed with the reason for exclusion Any discrepancies were resolved by consensus and, where necessary, a third reviewer was consulted 10 11 12 13 14 15 16 17 18 19 20 21 22 Accidental Falls/ (fall or falls or faller$1 or fallen).ti,ab or exp Aged/ (senior$1 or elder* or older or old or oldest).ti,ab or and (prevent* or reduce* or manage*).ti,ab and Program Evaluation/ Information Dissemination/ Barrier*.ti,ab evaluat*.ti,ab translat*.ti,ab feasibility.ti,ab integrat*.ti,ab implement*.ti,ab disseminat*.ti,ab adopt*.ti,ab 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 and 20 limit 21 to yr="1980 -Current" Fig Master search strategy written for Medline (OVID) and adapted for different databases 2.3 Data synthesis To determine whether effective methods of implementation were consistent across studies, data were summarized using evidence tables 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 nature of the implementation method 2.2 Data extraction and quality assessment Results Data were extracted from included papers independently by two reviewers using a standardized, piloted data extraction form The following data were extracted: study location and setting, study design, implementation method, fall prevention intervention, study population, 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: 3.1 Search results and study characteristics • 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? A total of 3,638 unique titles and abstracts were identified from the search following removal of duplicates (Fig 2); 3,530 studies were excluded following a review of titles and abstracts as not meeting the inclusion criteria A full-text assessment of 108 articles resulted in the exclusion of 93 studies (7 did not target community-dwelling older people; 76 did not evaluate implementation; were opinion papers, were only available as abstracts, and 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 including 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 The results were tabulated by individual reviewers for each study and compared Disagreements were resolved through consensus involving a third reviewer where necessary 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 V Goodwin et al / Journal of Safety Research 42 (2011) 443–451 (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 potential 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 describes each individual study with the corresponding results presented in Table Implementation methods included training of healthcare professionals (n = 6), changes to primary care/general practice management (n = 3), peer or lay volunteer-delivered programs (n = 3), and community awareness programs (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) utilized training and dissemination of evidence to healthcare professionals 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 program incorporated training and dissemination of evidence-based falls prevention interventions using behavior change strategies, opinion leaders, media awareness campaigns, outreach visits to older people, and patient and provider materials This collaborative approach resulted in improvements in fall-prevention assessment and management 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 behaviors 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=108 445 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) Number of papers selected for inclusion n=15 Fig Flow diagram for study selection 446 V Goodwin et al / Journal of Safety Research 42 (2011) 443–451 Table Quality Assessment of Included Studies using the Cochrane Risk of Bias Tool Study Sequence generation Allocation generation Blinding Incomplete outcome data Selective outcome reporting Other sources of bias Baraff et al (1999) Barnett et al (2004) Brown et al (2005) Deery et al (2000) Fortinsky et al (2008) Gardner et al (2002) Healy et al (2005) Larsson et al (2010) McClure et al (2010) Milisen et al (2009) Scott et al (2006) Shah et al (1997) Stackpool (2006) Sze et al (2005) Wenger et al (2009) No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No Unclear Yes Yes No Yes Unclear No Unclear Unclear Yes Unclear Unclear Yes No Unclear No No Unclear No Unclear Yes No Unclear No Yes Unclear Unclear Yes Unclear Yes No Yes Unclear Unclear No Unclear Unclear Unclear Unclear Yes Unclear Unclear No Unclear No No Unclear Unclear No No Yes No Unclear No Unclear No No Yes = adequately addressed No = inadequately addressed emergency 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 communitybased healthcare staff, Milisen et al (2009) reported that 88% of practitioners 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 investment without financial compensation, poor patient and family motivation, 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 example, 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 interventions Adherence to specialist recommendations by primary care physicians and patients was examined in one study by Shah et al (1997), although only 11% (15/139) of individuals required recommendations for falls This study reported that recommendations were implemented by general practitioners in six out of nine cases Among the seven patients receiving self-care recommendations, three adhered The study by Gardner 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 uptake 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 prevention, to older people Deery et al (2000) used peers to deliver educational 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 examined changes in fall-related knowledge, attitudes, and behaviors and, in the main, these outcomes improved in the short and longer term, with the exception of Deery 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 differently (Barnett et al., 2004; McClure et al., 2010; Stackpool, 2006) Barnett et al (2004) assessed recall and current falls prevention practices of healthcare staff and councils following the four year ‘Stay on your Feet’ program Five years after the commencement of the program, 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 normal work, resources, and compatibility with other projects A follow on from this study, by McClure 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 by Stackpool (2006) using community collaboration to promote physical activity among older V Goodwin et al / Journal of Safety Research 42 (2011) 443–451 people found a 19% increase in the number of available physical activity classes for older people and a 16% increase in attendance by older people over three years 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 description of the implementation 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 peerdelivered 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 workplace settings performed by Egan, 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 replication, whether to inform further research or to utilize the findings in clinical practice Context is also an important factor to describe as different 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 specifically aimed at changing knowledge, attitudes, and fall-related behaviors of older people demonstrated some improvements, often related to avoiding or removing 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 currently 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 outcomes 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 the fidelity and adherence to a program, whereas, Rabin, Glasgow, Kerner, Klump, and Brownson (2010) suggest that evaluation requires a variety of outcomes 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 commissioners are interested in improved outcomes, such as fall-related injuries 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] to 12%) 447 reduction in serious fall-related injuries and an 11% (95% CI to 14%) reduction in medical service use (Tinetti et al., 2008) To our knowledge, this is the first systematic review that has evaluated 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 clinical 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, potential risk of bias was generally high or unclear (Higgins & Green, 2009) This was linked to the fact that most study methods did not incorporate 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 implementation 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 literature not published in journals, such as conference abstracts and unpublished theses (Higgins & Green, 2009), which may have highlighted further studies and reports, and finally, 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 alongside elucidation of the reasons for such change The fact that the majority 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 prevention 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 implementation research, such as developing effective search strategies and quality appraisal methods The relative importance of this field needs to be promoted alongside evidence for effective healthcare interventions in terms of funding if evidence is to be translated into policy and clinical practice Impact on industry The implementation of falls prevention research into practice involves 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 Research (NIHR) This report/article presents independent research 448 Table Description of Study Characteristics, Stratified by Type of Implementation Method Study Country Setting Brown et al (2005) USA Physical therapy practices Study purpose Implementation strategy Falls prevention intervention Sample Population Outcomes evaluating implementation Follow up Repeated measures, cohort study To assess impact of practice guideline on process of care Training of physicians (2 hours) and nurses (30 minutes) Not reported 3843 older people (> 65 years) attending ED Documentary evidence of history taking, physical examination and action taken year Survey To describe physical therapists knowledge, attitudes and behaviours relating to fall prevention To describe extent of implementation of EBP by nurses and therapists CCFP programme comprising training of physical therapists (1 hour) Medication management, vaccinations and ophthalmology referral Multi-factorial CCFP programme comprising training (90 minutes) of home health care staff Multi-factorial 184 nurses and rehabilitation therapists from 19 home health agencies (HHA) - 94 physical therapy providers from 119 organisations Self-reported use of weeks falls prevention strategies and change in practice year Self-reported falls prevention assessment and management practice year Awareness of campaign; use of a hazard reporting telephone line Fortinsky et USA al (2008) Community Survey Larsson et al (2010) Sweden 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 Milisen et al (2009) Belgium Community Repeated measures, crosssectional study 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 - 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 Strength and balance training 61 general practitioners in 36 practices; nurses 330 exercise participants aged > 80 years Recruitment issues; year fidelity and adherence Multi-factorial (individually tailored) Not reported 150 people >65 years with urinary incontinence, falls, depression or functional impairment Physician implementation and patient adherence rates Changes to primary care practices Gardner et al New Primary (2002) Zealand care Shah et al (1997) USA Primary care practices Process and impact evaluation of a nonrandomised trial Case series Nurse training (1 week) Applicability and feasibility of a primary care nurse-delivered exercise programme To examine implementation of CGA recommendations Communication between geriatrician, primary care physician and patient Importance, feasibility and practicality of guideline Change in knowledge, uptake of recommendations Unclear Six months months V Goodwin et al / Journal of Safety Research 42 (2011) 443–451 Training of healthcare professionals Baraff et al USA ED (1999) Study design Table (continued) Study Country Setting Study design Study purpose Implementation strategy Falls prevention intervention Sample Population Outcomes evaluating implementation Follow up Wenger et al (2009) USA Primary care practices Nonrandomised 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 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 Australia Community Matched (2000) 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 Education Not reported 361 people aged > 60 years (education) and 174 age and sex matched controls 349 older adults (51–95 years) Fall-related attitudes, knowledge and behaviours and 12 months Fidelity to the programme; changes in fallrelated self-efficacy and behaviours Knowledge and awareness regarding falls prevention weeks, months, year Recall of SOYF, involvement and current falls prevention activities Fall-related behaviour change years USA Community Repeated measures, cohort study To examine whether a CBT Training of lay volunteers (2 days) programme ‘a Matter of Balance’ can be effectively delivered by volunteers Risk behaviour change Not reported 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 321 healthcare professionals); shire councils and shire access committees 80,000 people aged >60 years 1,600 older people (a) 43,821, (b) 58,722 Community awareness programmes Barnett et al Australia Community Surveys (2004) McClure et al Australia Community Repeated (2010) measures, crosssectional study Stackpool Australia Community Repeated (2006) measures, crosssectional study Multi-factorial To assess sustainability of a Awareness raising, community education, policy development, community SOYF falls engaging health professionals (1992 prevention programme to 1996) To evaluate whether a population based programme reduces falls and injuries To establish viability of collaborative model to promote physical activity among older people Multi-factorial (a) Peer health promotion of falls prevention activities, or (b) health promotion officers delivering and supporting physical activity 2002 to 2006 Collaborative management model Physical activity (2000 to 2003) area Health Promotion units Not reported Availability and uptake of physical activity programmes Unclear years years V Goodwin et al / Journal of Safety Research 42 (2011) 443–451 Healy et al (2005) 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 449 450 V Goodwin et al / Journal of Safety Research 42 (2011) 443–451 Table Individual Study Results, Stratified by Implementation Method Study Results Training of healthcare professionals Baraff et al Improvement in out 10 items on history taking; out of items on physical examination; out of items on actions taken (1999) Brown et al Most physical therapists reported an increased use of falls prevention strategies in practice (2005) Fortinsky et al Most community healthcare staff used recommended guidance for assessment and management of falls in practice (2008) Larsson et al Low awareness of campaign in the community (20%); 72% of fall prevention agents aware 29 reports of community hazards in months (2010) Milisen et al Disagreement between different professionals as to feasibility and roles in using falls prevention guideline (2009) Scott et al Increased knowledge of staff, high use of checklist and action plan by staff, mixed uptake of recommendations by clients (2006) Changes to primary care practices Gardner et al Reasons for exclusion: being medically unwell; physical frailty; considered incapable of exercise Reasons for participation: doctor recommendation, health/ (2002) functional benefits, prevent falls Reasons for declining: already active, too frail/unwell, commitment too long; not interested Shah et al 6/9 physician recommendations implemented and all adhered to by patients 3/7 self-care recommendations adhered to (1997) Wenger et al 44% of intervention group and 23% controls met quality indicator for falls (2009) Peer or lay volunteer programmes Deery et al Greater changes in attitude reported for intervention group; Intervention group has lower knowledge at months but greater at 12 months compared with (2000) controls; intervention group made more environmental changes and changed behaviour at and 12 months Healy et al Significant improvements in self-efficacy and fall management (2005) Sze et al Older people and volunteers reported gaining knowledge about falls prevention Almost all community centre staff had set up falls prevention activities (2005) Community awareness programmes Barnett et al 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 (2004) comprehensive falls prevention policy No access committees maintained falls prevention activities McClure et al Increased awareness of falls Behaviour change of older people in relation to falls prevention (2010) Stackpool Increase in availability of exercise classes and enrolment (2006) commissioned 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 References American Geriatrics Society and the British Geriatrics Society (2010) Clinical practice guideline: Prevention of falls in older persons New York: Author Baraff, L J., Lee, T J., Kader, S., & Penna, R D (1999) Effect of a practice guideline on the process of emergency department care of falls in elder patients Academic Emergency Medicine, 6, 1224–1231 Barnett, L M., Van Beurden, E., Eakin, E G., Beard, J., Dietrich, U., & 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management: challenges to adopting geriatric care practices The Gerontologist, 46, 717–725 Wenger, N S., Roth, C P., Shekelle, P G., Young, R T., Solomon, D H., Kamberg, C J., Chang, J T., Louie, R., Higashi, T., Maclean, C H., Adams, J., Min, L C., Ransohoff, K., Hoffing, M., & Reuben, D B (2009) Practice-based intervention to improve primary care for falls, urinary incontinence and depression Journal of the American Geriatrics Society, 57, 547–555 451 Victoria Goodwin, PhD, is a Senior Research Fellow for PenCLAHRC (Peninsula Collaboration 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 doctorate 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 Technology Assessment Group), currently working on Health Technology 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 facilitation for PenCLAHRC, focusing on translation of research into clinical practice Linking with the varied nature of her career, Tracey's current research interests include systematic reviews 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 respiratory and complementary medicine fields Her current role involves identifying and prioritising potential local research projects and producing systematic reviews to inform evidence-based practice Kate Boddy, MSc, is an Information Specialist at PenCLAHRC where she has been working since 2009 She has been working in health services research since 2004 and received 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 different 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 syntheses and economic evaluation on a wide range of health technologies and is deputy director of the PenCLAHRC which aims to improve the influence of research on NHS practice in the UK