When evidence is not enough: the challenge of implementing fall prevention strategies

Supporting Physical Activity Maintenance in Older Adults Following Supervised Group Exercise: A Mixed-Methods Study Among Culturally Diverse Older Adults

Physical activity (PA) is important for prevention of falls and chronic disease in older adults. We aimed to examine the interrelated influences upon PA in culturally diverse older adults who completed a short-term exercise program, to inform maintenance strategies, using a mixed-methods design. Eighty-two past participants from the "Stepping On"© program were surveyed examining ongoing participation, social and cognitive determinants of PA, mental and physical functioning, and fear of falls. Semi-structured interviews were undertaken with 34 respondents regarding enablers and barriers, cultural factors, and preferences for PA. Data were collected in English, Chinese, Arabic, Punjabi, or Hindi. Cultural factors minimally affected PA participation. There was low perceived availability of PA opportunities. Health difficulties not only discouraged but also motivated participation. Social connection was a facilitator and could be used to support maintenance. Older adults may benefit from assistance in accessing PA opportunities and clinical guidance about the benefits of ongoing PA.

Facilitators and barriers in interprofessional collaboration around physical activity on prescription-a focus group study in a Swedish school setting

In Swedish school health services, local initiatives have been taken to use physical activity on prescription (PAP) to encourage physically inactive children to become more active. Previous research shows that interprofessional collaboration plays a crucial role in promoting physical activity in children, as well as in promoting health in schools. However, there is a lack of knowledge about PAP for children in the school setting, including how medical and educational staff can work together to encourage children who have been recommended PAP. Therefore, this study aims to explore the perceived facilitators and barriers concerning interprofessional collaboration regarding physical activity on prescription in the school setting, as viewed from the professionals' perspectives. Semi-structured interviews were conducted with 21 professionals who work with the method in school settings. The data were analyzed using Reflexive Thematic Analysis. The results reveal both barriers and facilitators for interprofessional collaboration on PAP in the school setting, as perceived by professionals. Organizational and structural obstacles within school institutions hinder collaboration, while a shared commitment to PAP, characterized by consensus-building, acts as a facilitating factor. PAP for children in a school setting is still an unexplored area and further research is required.

The Belgian physiotherapy reimbursement criteria for fall prevention fails in screening appropriately fall-prone community-dwelling older adults

OBJECTIVES

The incidence of falling in older adults has remained unchanged over the past decades, despite evidence-based prevention initiatives. Therefore, it is appropriate to reflect on the current screening approach for preventive initiatives. The objective of this study was to determine whether the multifactorial algorithm proposed by Lusardi et al. (2017) exhibits superior predictive validity compared to the currently employed algorithm by the Belgian National Institute for Health and Disability Insurance (NIHDI).

METHODS

The current study includes a secondary analysis of data collected from a falls-related study in the Department of Rehabilitation Sciences at Ghent University to compare the predictive validity of the two algorithms. Sensitivity, specificity, positive and negative predictive value and area under the curve (AUC) were calculated to ascertain which algorithm is more accurate.

RESULTS

The database included a total of 94 community-dwelling older adults (mean age 76 years ±7.4, 35% male). Thirty-nine participants experienced at least one fall in the 8 month follow up. Lusardi's approach has a higher sensitivity score (89.7% compared to 10.3%) and negative predictive value (89.9% compared to 61.1%), but a lower specificity score (61.8% compared to 100%) and positive predictive value (62.2% compared to 100%) than the NIHDI approach. The AUC is 0.76 for Lusardi's approach and 0.55 for the NIHDI approach.

CONCLUSION

The use of the multifactorial algorithm proposed by Lusardi et al. may be significant and more accurate in identifying adults at risk to falls. Further research is needed particularly with a larger, more heterogenous group of older adults.

Process evaluation of an implementation intervention to facilitate the use of the Swedish Physical Activity on Prescription in primary healthcare

BACKGROUND

The Swedish Physical Activity on Prescription (PAP-S) is a method for healthcare to promote physical activity for prevention and treatment of health disorders. Despite scientific support and education campaigns, the use has been low. The aim of this study was to perform a process evaluation of an implementation intervention targeting the use of the PAP-S method in primary healthcare (PHC). Specifically, we wanted to evaluate feasibility of the implementation intervention, and its effect on the implementation process and the outcome (number of PAP-S prescriptions).

METHODS

This was a longitudinal study using the Medical Research Council guidance for process evaluation of a 9-month implementation intervention among healthcare staff at three PHC centres in Sweden. Data was collected by: participatory observations of the implementation process; questionnaires to the staff before, after and 6 months after the implementation intervention; interviews after the implementation intervention; and number of PAP-S prescriptions.

RESULTS

During the implementation intervention, the workplaces' readiness-to-change and the healthcare staff's confidence in using the PAP-S method were favourably influenced, as was the number of PAP-S prescriptions. After the implementation intervention, the number of PAP-S prescriptions decreased to about the same number as before the implementation intervention, at two out of three PHC centres. Four of the six implementation strategies appeared to impact on the implementation process: external facilitation; leadership engagement by a committed workplace management; local PAP-S coordinator taking a leading role and acting as local champion; educational outreach concerning how to use the PAP-S method.

CONCLUSION

The implementation intervention was not sufficient to produce sustained change of the healthcare staff's behaviour, nor did it achieve favourable long-term outcome on the number of PAP-S prescriptions. The healthcare staffs' sparse knowledge of the PAP-S method prior to the implementation intervention hampered the implementation. More hands-on education in how to use the PAP-S method introduced early in the implementation process is imperative for successful implementation of the PAP-S method. The findings also suggest that committed workplace management and local PAP-S coordinators, taking leading roles and acting as local champions, need to be firmly established at the PHC centres before the external facilitator withdraws.

TRIAL REGISTRATION

Registered in the ISRCTN registry with study registration number: ISRCTN15551042 (Registration date: 12/01/2016).

Contextual determinants influencing the implementation of fall prevention in the community: a scoping review

Background

Successful implementation of multifactorial fall prevention interventions (FPIs) is essential to reduce increasing fall rates in community-dwelling older adults. However, implementation often fails due to the complex context of the community involving multiple stakeholders within and across settings, sectors, and organizations. As there is a need for a better understanding of the occurring context-related challenges, the current scoping review purposes to identify what contextual determinants (i.e., barriers and facilitators) influence the implementation of FPIs in the community.

Methods

A scoping review was performed using the Arksey and O'Malley framework. First, electronic databases (Pubmed, CINAHL, SPORTDiscus, PsycINFO) were searched. Studies that identified contextual determinants that influence the implementation of FPIs in the community were included. Second, to both validate the findings from the literature and identify complementary determinants, health and social care professionals were consulted during consensus meetings (CMs) in four districts in the region of Utrecht, the Netherlands. Data were analyzed following a directed qualitative content analysis approach, according to the 39 constructs of the Consolidated Framework for Implementation Research.

Results

Fourteen relevant studies were included and 35 health and social care professionals (such as general practitioners, practice nurses, and physical therapists) were consulted during four CMs. Directed qualitative content analysis of the included studies yielded determinants within 35 unique constructs operating as barriers and/or facilitators. The majority of the constructs (n = 21) were identified in both the studies and CMs, such as "networks and communications", "formally appointed internal implementation leaders", "available resources" and "patient needs and resources". The other constructs (n = 14) were identified only in the .

Discussion

Findings in this review show that a wide array of contextual determinants are essential in achieving successful implementation of FPIs in the community. However, some determinants are considered important to address, regardless of the context where the implementation occurs. Such as accounting for time constraints and financial limitations, and considering the needs of older adults. Also, broad cross-sector collaboration and coordination are required in multifactorial FPIs. Additional context analysis is always an essential part of implementation efforts, as contexts may differ greatly, requiring a locally tailored approach.

Using an academic-community partnership model to deliver evidence-based falls prevention programs in a metropolitan setting: A community case study

Background

Prevention is an effective approach for mitigating the negative health outcomes associated with falls in older adults. The Administration for Community Living (ACL) has sponsored the implementation of evidence-based falls prevention programs (EBFPPs) across the United States through cooperative agreement grants to decrease the health and economic burden of falls. Marymount University received two of these grants to deliver three EBFPPs into the northern Virginia region. This community case study describes the development of a collaboration between a university and community-based organizations to adopt and implement multiple evidence-based programming in an area where none previously existed.

Methods

Through an academic-community partnership, EBFPPs were introduced to and implemented by senior-focused organizations. Target adopters were senior and community centers, multi-purpose senior services organizations, recreational organizations, and residential facilities serving older adults. The three EBFPPs were (1) Stay Active and Independent for Life (SAIL), (2) a Matter of Balance (MOB) and (3) Otago Exercise Program (OEP). Key interdependent project elements included: (1) fostering ongoing community organization collaboration, (2) introducing programs in the community, (3) growing and sustaining delivery sites, (4) preparing trained program leaders, and (5) building community demand for the programs.

Results

From August 2016–June 2022, 5,857 older adults participated in one of the three EBFPPs. SAIL classes were offered at 33 sites and MOB workshops at 31 with over 70% of them occurring at community or senior centers. OEP was offered at 4 sites. Factors that influenced the implementation of these programs included having: key advocates at host organizations, programs embedded into site workflows, sufficient capacity and workforce, engaged invested partners, and flexibility in working with a complex set of agencies and systems with different administrative structures.

Conclusion

By connecting academic faculty with various community members from multiple sectors, new initiatives can be successfully implemented. Results from this ACL-funded project indicate that using an academic-community partnership model to build relationships and capacity for ongoing delivery of health promotion programming for older adults is feasible and effective in delivering EBFPPs. In addition, academic-community partnerships can develop a strong network of invested partners to foster continued support of fall prevention activities.

Effectiveness of Self-guided Tailored Implementation Strategies in Integrating and Embedding Internet-Based Cognitive Behavioral Therapy in Routine Mental Health Care: Results of a Multicenter Stepped-Wedge Cluster Randomized Trial

BACKGROUND

Internet-based cognitive behavioral therapy (iCBT) services for common mental health disorders have been found to be effective. There is a need for strategies that improve implementation in routine practice. One-size-fits-all strategies are likely to be ineffective. Tailored implementation is considered as a promising approach. The self-guided integrated theory-based Framework for intervention tailoring strategies toolkit (ItFits-toolkit) supports local implementers in developing tailored implementation strategies. Tailoring involves identifying local barriers; matching selected barriers to implementation strategies; developing an actionable work plan; and applying, monitoring, and adapting where necessary.

OBJECTIVE

This study aimed to compare the effectiveness of the ItFits-toolkit with implementation-as-usual (IAU) in implementing iCBT services in 12 routine mental health care organizations in 9 countries in Europe and Australia.

METHODS

A stepped-wedge cluster randomized trial design with repeated measures was applied. The trial period lasted 30 months. The primary outcome was the normalization of iCBT delivery by service providers (therapists, referrers, IT developers, and administrators), which was measured with the Normalization Measure Development as a proxy for implementation success. A 3-level linear mixed-effects modeling was applied to estimate the effects. iCBT service uptake (referral and treatment completion rates) and implementation effort (hours) were used as secondary outcomes. The perceived satisfaction (Client Satisfaction Questionnaire), usability (System Usability Scale), and impact of the ItFits-toolkit by implementers were used to assess the acceptability of the ItFits-toolkit.

RESULTS

In total, 456 mental health service providers were included in this study. Compared with IAU, the ItFits-toolkit had a small positive statistically significant effect on normalization levels in service providers (mean 0.09, SD 0.04; P=.02; Cohen d=0.12). The uptake of iCBT by patients was similar to that of IAU. Implementers did not spend more time on implementation work when using the ItFits-toolkit and generally regarded the ItFits-toolkit as usable and were satisfied with it.

CONCLUSIONS

The ItFits-toolkit performed better than the usual implementation activities in implementing iCBT services in routine practice. There is practical utility in the ItFits-toolkit for supporting implementers in developing and applying effective tailored implementation strategies. However, the effect on normalization levels among mental health service providers was small. These findings warrant modesty regarding the effectiveness of self-guided tailored implementation of iCBT services in routine practice.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03652883; https://clinicaltrials.gov/ct2/show/NCT03652883.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-020-04686-4.

Using the RE-AIM framework to evaluate physical activity-based fall prevention interventions in older adults with chronic conditions: A systematic review

Falls are a serious public health problem, especially for older adults with chronic conditions. The purpose of this systematic review was to evaluate the translational potential of physical activity-based balance interventions for older adults with common chronic conditions guided by the Reach, Effectiveness/Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework. Databases were searched (2011-2021) to identify studies with physical activity-based fall prevention interventions for older adults with chronic conditions. Data were collected using the RE-AIM coding guide and Mixed Methods Appraisal Tool for evidence quality. The search yielded 122 articles, of which 14 distinct studies were included. The most reported RE-AIM dimensions across the studies were Reach (46.2%) and Implementation (40.5%), with Effectiveness/Efficacy (29.4%), Adoption (2.0%), and Maintenance (5.4%) being the least reported. Studies were largely conducted in controlled research environments with minimal staff involvement and without long-term follow-up periods. While studies found that physical activity-based programs were effective in improving balance, information on representativeness and adoption/maintenance of programs was lacking. Studies included sufficient details about the intervention (content, dosage, progression). External validity RE-AIM indicators were reported less frequently than internal validity indicators. The studies were of moderate quality overall. Studies often lacked information on indicators critical for understanding how to implement these programs. This review signals the need to investigate the translation of these interventions from controlled research settings to clinical settings to improve the public impact of fall prevention for this population.

A qualitative examination of barriers and facilitators of pediatric enhanced recovery protocol implementation among 18 pediatric surgery services

Background

Enhanced recovery protocols (ERPs) are an evidence-based intervention to optimize post-surgical recovery. Several studies have demonstrated that the use of an ERP for gastrointestinal surgery results in decreased length of stay, shortened time to a regular diet, and fewer administered opioids, while also trending toward lower complication and 30-day readmission rates. Yet, implementation of ERPs in pediatric surgery is lagging compared to adult surgery. The study’s purpose was to conduct a theory-guided evaluation of barriers and facilitators to ERP implementation at US hospitals with a pediatric surgery service.

Methods

We conducted semi-structured interviews at 18 hospitals with 48 participants, including pediatric surgeons, anesthesiologists, gastroenterologists, nurses, and physician assistants. Interviews were conducted online, audio-recorded, and transcribed verbatim. To identify barriers and facilitators to ERP implementation, we conducted an analysis using deductive logics based on the five Active Implementation Frameworks (AIFs).

Results

Effective practices (usable innovations) were challenged by a lack of compliance to ERP elements, and facilitators were having standardized protocols in place and organization support for implementation. Effective implementation (stages of implementation and implementation drivers) had widespread barriers to implementation across the stages from exploration to full implementation. Barriers included needing dedicated teams for ERP implementation and buy-in from hospital leadership. These items, when present, were strong facilitators of effective implementation, in addition to on-site, checklists, protected time to oversee ERP implementation, and order sets for ERP elements built into the electronic medical record. The enabling context (teams) focused on teams’ engagement in ERP implementation and how they collaborated to implement ERPs. Barriers included having surgical team members resistant to change or who were not bought into ERPs in pediatric practice. Facilitators included engaging a multi-disciplinary team and engaging patients and families early in the implementation process.

Conclusions

Barriers to ERP implementation in pediatric surgery highlighted can be addressed through providing guidelines to ERP implementation, team-based support for change management, and protocols for developing an ERP implementation team. Future steps are to apply and evaluate these strategies in a stepped-wedge, cluster randomized trial to increase the implementation of ERPs at these 18 hospitals.

A Collaborative Implementation Strategy to Increase Falls Prevention Training Using the Age-Friendly Health Systems Approach

Falls in the home and in community environments are the leading cause of injuries and long-term disabilities for the aging population. The purpose of this study was to examine outcomes of a partnership among an academic institution, government agency, community organizations, and emergency management services to implement a falls prevention training program using an Age-Friendly Health Systems approach. In this prospective study, partners identified gaps in services and targeted and non-targeted delivery areas for implementation of an evidence-based falls prevention intervention addressing the 4Ms of Age-Friendly Health Systems—Mobility, Medications, Mentation, and What Matters. Descriptive statistics were calculated for program implementation and participant demographic variables, and paired t-test analysis compared scores for self-assessed general health and falls efficacy prior to and after program participation. Twenty-seven falls prevention classes were implemented, with over half (52%) in targeted areas. A total of 354 adults aged 50 and older participated, with N = 188 participants (53%) completing the program by attending at least five of eight sessions. Of completers, 35% resided in targeted areas. The results showed a statistically significant improvement in falls efficacy by program completers in targeted and non-targeted areas. However, there was no statistically significant difference in self-rated health. Overall, the findings of this study indicate that collaboration to deliver falls prevention training can be effective in reaching at-risk older adults. By mobilizing collaborative partnerships, limited resources can be allocated towards identifying at-risk older adults and improving community-based falls prevention education.

Knowledge, Attitude, and Practice of Nursing Home Staff Regarding Physical Restraint in China: A Cross-Sectional Multicenter Study

Background

Restraint is widely used in nursing homes to address safety concerns. However, many studies have shown that improper restraint can lead to many adverse outcomes. Nursing staff are the main practitioners of physical restraint in nursing homes and play an important role in restraint decision-making and management. In China, there is still a lack of large-scale surveys on the current situation regarding the use of restraint. This study aimed to identify this situation and the influencing factors of the knowledge, attitude, and practice of nursing staff regarding physical restraint in elderly care institutions.

Methods

A cross-sectional multicenter descriptive study was conducted. A total of 311 staff in 25 elderly care institutions in Zhejiang Province were recruited using a quota sampling method. A homemade questionnaire was administered to collect general information and information on knowledge, attitude and practice regarding physical restraint.

Results

The average scoring rates of the knowledge and attitude dimensions of the 311 staff were 48.7 and 75.6%, respectively. The average scoring rate of the practice dimension of 140 staff who implemented restraint was 80.1%. Educational background and training experience were the influencing factors of restraint knowledge. Training experience, educational background and professional title were the influencing factors of restraint attitude. Restraint knowledge and length of service were the influencing factors of restraint practice.

Conclusions

Knowledge of physical restraint among nursing staff is not promising. Their attitude toward restraint was inappropriate or irresponsible in some aspects. Restraint practice is not sufficiently standardized. It is necessary to strengthen restraint training for nursing staff to improve their overall level of restraint knowledge, attitude and practice.

Proof of Concept of Novel Visuo-Spatial-Motor Fall Prevention Training for Old People

Falls in the geriatric population are one of the most important causes of disabilities in this age group. Its consequences impose a great deal of economic burden on health and insurance systems. This study was conducted by a multidisciplinary team with the aim of evaluating the effect of visuo-spatial-motor training for the prevention of falls in older adults. The subjects consisted of 31 volunteers aged 60 to 92 years who were studied in three groups: (1) A group under standard physical training, (2) a group under visuo-spatial-motor interventions, and (3) a control group (without any intervention). The results of the study showed that visual-spatial motor exercises significantly reduced the risk of falls of the subjects.

Strategies to Prevent Serious Fall Injuries: A Commentary on Bhasin et al. A Randomized Trial of a Multifactorial Strategy to Prevent Serious Fall Injuries. N Engl J Med. 2020;383(2):129-140

Every second of every day, an older adult suffers a fall in the United States (>30 million older adults fall each year). More than 20% of these falls cause serious injury (e.g., broken bones, head injury) and result in 800,000 hospitalizations and 30,000 deaths annually. Bhasin and colleagues recently reported results from a pragmatic, cluster-randomized trial designed to evaluate the effectiveness of a multifactorial intervention to prevent fall injuries. The intervention did not result in a significantly lower rate of a first adjudicated serious fall injury among older adults at increased risk for fall injuries as compared with enhanced usual care. In this commentary we briefly review and highlight these recent findings. Additionally, we argue that the findings should not be discounted just because of the lack of statistical significance. The approximately 10% reduction compared to enhanced usual care is, arguably, meaningful at both the individual and public health level, especially when one considers that the control group had better outcomes than expected based on prior work. Moreover, we encourage future research as well as practitioners to give strong consideration to the nuances of the exercise interventions for reducing falls and fall-related injuries particularly as it relates to exercise programming specifics, namely intensity and volume, to enhance neuromuscular function and also to neurorehabilitation approaches to enhance motor function (e.g., balance, motor planning, and coordination).

Older adults' views on barriers and facilitators to participate in a multifactorial falls prevention program: Results from Prevquedas Brasil

OBJECTIVES

To understand the reasons older people engage in a multifactorial fall prevention program and, to identify the barriers and facilitators for adherence.

METHODS

Cross-sectional study, with 218 older adults from the intervention group of a 12-week multifactorial fall prevention program (Prevquedas Brazil). We interviewed participants using a semi-structured questionnaire concerning reasons to engage in, barriers, and facilitators to participating in the program. We compared participants with low (0-5 sessions) and moderate/high (6-12 sessions) adherence regarding barriers and facilitators.

RESULTS

Physical and mental health problems (55 %), and competing demands (45.2 %) were the most frequent barriers reported. Pleasant environment (97.7 %), a sense of receiving proper care (96.7 %), and empathy with the team (96.7 %) were the main facilitators. Seven out of the twelve facilitators distinguished participants with high adherence from those with low adherence. Only the barriers related to the program characteristics and the lack of social support were able to identify participants with low adherence. Open-ended questions revealed that self-determination, commitment, and the desire of being physically active and fit promoted participation. Anticipated health benefits and functional gains, a need to take action due to fall consequences, and encouragement from others were among the reasons to engage in the program.

CONCLUSION

Although barriers should not be neglected, facilitators are critically important for adherence. Health professionals may develop skills to facilitate uptake and optimize older adults' participation. Implementing sustainable fall prevention programs in low and middle-income countries requires overcoming the fragmentation and inflexibility of healthcare services.

A Randomized Trial of a Multifactorial Strategy to Prevent Serious Fall Injuries

BACKGROUND

Injuries from falls are major contributors to complications and death in older adults. Despite evidence from efficacy trials that many falls can be prevented, rates of falls resulting in injury have not declined.

METHODS

We conducted a pragmatic, cluster-randomized trial to evaluate the effectiveness of a multifactorial intervention that included risk assessment and individualized plans, administered by specially trained nurses, to prevent fall injuries. A total of 86 primary care practices across 10 health care systems were randomly assigned to the intervention or to enhanced usual care (the control) (43 practices each). The participants were community-dwelling adults, 70 years of age or older, who were at increased risk for fall injuries. The primary outcome, assessed in a time-to-event analysis, was the first serious fall injury, adjudicated with the use of participant report, electronic health records, and claims data. We hypothesized that the event rate would be lower by 20% in the intervention group than in the control group.

RESULTS

The demographic and baseline characteristics of the participants were similar in the intervention group (2802 participants) and the control group (2649 participants); the mean age was 80 years, and 62.0% of the participants were women. The rate of a first adjudicated serious fall injury did not differ significantly between the groups, as assessed in a time-to-first-event analysis (events per 100 person-years of follow-up, 4.9 in the intervention group and 5.3 in the control group; hazard ratio, 0.92; 95% confidence interval [CI], 0.80 to 1.06; P = 0.25). The rate of a first participant-reported fall injury was 25.6 events per 100 person-years of follow-up in the intervention group and 28.6 events per 100 person-years of follow-up in the control group (hazard ratio, 0.90; 95% CI, 0.83 to 0.99; P = 0.004). The rates of hospitalization or death were similar in the two groups.

CONCLUSIONS

A multifactorial intervention, administered by nurses, did not result in a significantly lower rate of a first adjudicated serious fall injury than enhanced usual care. (Funded by the Patient-Centered Outcomes Research Institute and others; STRIDE ClinicalTrials.gov number, NCT02475850.).

Implementation of pharmaceutical care for older adults in the brazilian public health system: a case study and realistic evaluation

BACKGROUND

Pharmaceutical care services have been recognized as the most highly regarded professional pharmacy practice model that allows the identification, intervention, and resolution of drug related problems. This practice provides significant clinical outcomes and can reduce direct and indirect costs for health systems. However, its implementation can be complex and challenging, needing study experiences that aims at overcoming obstacles, especially in free and universal healthcare systems. The objective of this study is to evaluate the implementation of Ambulatory Care Pharmacy services for older adults at Paulista Institute of Geriatrics and Gerontology (IPGG), which is recognized in the city of São Paulo for offering pharmaceutical care services for over 10 years continuously. This initiative and process is independent of external academic interventions or educational institutions. It is hoped that the results may also contribute to advancing the implementation of pharmaceutical care service in similar health systems.

DESIGN

This is a case study using multiple sources of data. Qualitative and quantitative data were collected from institutional documents, by participant observation and interviews. Initial themes were identified by content analysis and analyzed under the context-mechanism-outcome configurations (CMO Configurations) in realistic evaluation.

SETTING

Geriatrics and Gerontology Institute of São Paulo (known as IPGG).

PARTICIPANTS

Eleven health professionals and three pharmaceutical care service users.

RESULTS

Three CMO configurations were identified and accepted: "Scenario Construction mediated by educational processes", "Contribution to complex needs resolution", and "Organizational Visibility". The CMO (Context-Mechanism-Outcomes) configuration "Logistic activities discourage clinical pharmaceutical services implantation" was denied due to the influence of accepted CMOs.

CONCLUSIONS

Educational processes which value transdisciplinary knowledge exchanges provide resources required to overcome important obstacles present during pharmaceutical care implementation. Thus, providing and seeking knowledge to build and offer context-consistent clinical health services as well as fulfilling organizational environment requirements can be the key to implement pharmaceutical care service.

Preventing falls in hospitalized elderly: design and validation of a team intervention

OBJECTIVE

The objective of the present study was the design and validation, by a panel of experts, of a team intervention to manage the risk of falls in the hospitalized elderly.

METHOD

The method used was a quanti-qualitative approach, using the Delphi method. The study was developed in two phases: in the first, five researchers designed the intervention; in the second, 13 professionals validated it.

RESULTS

The analysis of the content of the intervention designed by the participants in the first phase of the study allowed assignment of the indicators to the following previously defined categories: team formation; communication; leadership; monitoring; and mutual support. After two rounds, all the indicators obtained a consensus higher than 80%.

CONCLUSION

The present study allowed validation of a team intervention by a panel of experts, so that teams can manage the risk of falls in hospitalized elderly. The reliability test results ensure that the intervention can be used safely in clinics and for research.

Comprehensive geriatric assessment in Swedish acute geriatric settings

PURPOSE

Comprehensive geriatric assessment (CGA) is a widely used approach in geriatric care and involves multidisciplinary assessments focused on determining a frail elderly person's medical, psychological and functional capability to develop an integrated plan for treatment. The purpose of this paper is to describe and scrutinize the CGA implementation process at six acute geriatric departments in three county councils and to study the outcome by the documentation in the patient medical records, and the staff perceptions using CGA.

DESIGN/METHODOLOGY/APPROACH

The paper describes the implementation process stages. Outcome measures were based on patient medical records reviews at baseline and follow-ups at year 1 and year 2. Staff perceptions of using CGA were gathered by a questionnaire at the second follow-up.

FINDINGS

The implementation had not yet reached sustainability so the implementation process must continue. Results show that documentation on the different areas increased in year 1, as well as the use of standardized assessment tools. However, results from the reviews for year 2 showed some decrease. Staff considered CGA to have high value for the geriatric patient but pointed out the need for continuing education.

ORIGINALITY/VALUE

Successful strategies for this implementation were strong support from the managers, small seminars, CGA rounds, good introduction routines for new staff and the use of reminders such as pocket-sized focus cards. A high staff turnover occurred during the study, which probably had a significant negative impact on the results.

A public health approach to mobilizing community partners for injury prevention: A scoping review

OBJECTIVES

Reducing injuries in adults requires work with diverse stakeholders across many sectors and at multiple levels. At the local level, public health professionals need to effectively bring together, facilitate, and support community partners to initiate evidence-based efforts. However, there has been no formal review of the literature to inform how these professionals can best create action among community partners to address injuries in adults. Thus, this scoping review aims to identify theories, models or frameworks that are applicable to a community-based approach to injury prevention.

METHODS

Searches of scientific and less formal literature identified 13,756 relevant items published in the English language between 2000 and 2016 in North America, Europe and Australia. After screening and review, 10 publications were included that (1) identified a theory, framework or model related to mobilizing partners; and (2) referred to community-based adult injury prevention.

RESULTS

Findings show that use of theories, frameworks and models in community-based injury prevention programs is rare and often undocumented. One theory and various conceptual models and frameworks exist for mobilizing partners to jointly prevent injuries; however, there are few evaluations of the processes to create community action.

CONCLUSIONS

Successful community-based injury prevention must build on what is already understood about creating partnership action. Evaluating local public health professional injury prevention practice based on available theories, models and frameworks will identify successes and challenges to inform process improvements. We propose a logic model to more specifically guide and evaluate how public health can work locally with community partners.

Health Practitioners' Perceptions of Falls and Fall Prevention in Older People: A Metasynthesis

Fall prevention has received a great deal of consideration and funding, however fall rates have not reduced accordingly. Health practitioners are key stakeholders in the process of implementing fall prevention evidence into their clinical assessment and management of older people at risk of falling. Investigating health practitioners' clinical experiences and perceptions has been identified as a means to enhance the translation of knowledge. Four databases were searched for studies exploring health practitioners' perceptions of falls and fall prevention. A metasynthesis of eight qualitative studies was conducted. The findings suggest that health practitioners face substantial barriers in the implementation of fall prevention practices. These include personal, interpersonal, and clinical barriers in addition to limitations of the research evidence. This knowledge hopes to enhance targeted dissemination of knowledge, reducing the research-practice gap and improving clinical outcomes for older people at risk of falls.

Making fall prevention routine in primary care practice: perspectives of allied health professionals

Background

While there is strong evidence that fall prevention interventions can prevent falls in people aged 65 and over, translating evidence into routine practice is challenging. Research regarding how allied health professionals (AHPs) respond to this challenge is limited. As part of the Integrated Solutions for Sustainable Fall Prevention (iSOLVE) project, this study aimed to explore how AHPs were making fall prevention practice routine in primary care and the factors that influenced their fall prevention practice.

Methods

In-depth qualitative interviews were conducted with fifteen AHPs who had attended evidence-based workshops associated with the iSOLVE project. AHPs had backgrounds in physiotherapy, occupational therapy, exercise physiology and podiatry. Interviews explored how fall prevention was being incorporated into routine practice and the factors that influenced routinisation, including the project workshops. Thematic analysis was used to analyse the data.

Results

We found fall prevention was valued in practice and recognised as complex. AHPs worked through challenges relating to clients (multi-morbidity, complex living situations, client motivation), challenges working alongside other health professionals (understanding respective roles/overlapping roles, sense of competition, communication) and challenges associated with funding systems perceived as complicated and constantly changing. Despite these challenges, AHPs were adopting strategies for integrating fall prevention routinely. The iSOLVE workshops were perceived as important in supporting existing practice and in providing strategies to enhance practice.

Conclusions

Policy makers, program managers, educators and AHPs can adopt strategies identified in this research for routinising fall prevention such as being alert that falls are common, asking every client about falls, having processes for assessing clients for fall risk, and having structured and evidence-based programs to work with clients on fall prevention. Adapting and streamlining funding systems are also important for facilitating fall prevention work.

Knowledge, Practice, and Attitude of Nursing Home Staff Toward the Use of Physical Restraint: Have They Changed Over Time?

PURPOSE

Use of physical restraints is common in nursing homes, although empirical evidence has shown it to be a hazardous measure. This article aims to understand whether there were any changes in nursing home staff's knowledge, attitudes, and practices of using physical restraints in Hong Kong, after years of deliberation on this topic.

METHODS

A questionnaire about the knowledge, attitude, and practice of using physical restraint was sent to all 298 staff members in four nursing homes in Hong Kong run by a nongovernmental organization. The results were compared with previous findings from 1999 using the same questionnaire.

RESULTS

Overall, the staff had satisfactory knowledge of the daily application of physical restraints, such as the operational procedure and daily assessment. Concerning the conceptual knowledge of minimizing physical restraint use, their performance in the survey was less satisfactory. For example, only 6.6% of respondents were aware that residents had a right to reject the use of physical restraints, and 70% believed that there were no good alternatives to restraints. They showed appropriate attitudes in their practice of daily use of physical restraints. Compared with the previous study in 1999, a significant improvement was found in the attitudes (p = .0014) and practice (p = .0002) of using restraints, but there was no difference in their knowledge test results (p = .29).

CONCLUSIONS

The results of this study show a significant improvement among the nursing home staff in terms of their attitudes and practice of using restraints. In-service training for nursing staff should focus more on their knowledge of ethical considerations and the hands-on practice of using alternative devices (e.g., motion detectors or anti-slip pads).

CLINICAL RELEVANCE

The findings of this study suggest that in-service training for nursing staff should focus more on their knowledge of ethical considerations, the principles of using physical restraint, and the alternatives to restraint in order to fill the knowledge gaps of staff and improve the quality of care in nursing homes.

Health-Sector Responses to Intimate Partner Violence: Fitting the Response Into the Biomedical Health System or Adapting the System to Meet the Response?

This study aims to analyze how middle-level health systems' managers understand the integration of a health care response to intimate partner violence (IPV) within the Spanish health system. Data were obtained through 26 individual interviews with professionals in charge of coordinating the health care response to IPV within the 17 regional health systems in Spain. The transcripts were analyzed following grounded theory in accordance with the constructivist approach described by Charmaz. Three categories emerged, showing the efforts and challenges to integrate a health care response to IPV within the Spanish health system: "IPV is a complex issue that generates activism and/or resistance," "The mandate to integrate a health sector response to IPV: a priority not always prioritized," and "The Spanish health system: respectful with professionals' autonomy and firmly biomedical." The core category, "Developing diverse responses to IPV integration," crosscut the three categories and encompassed the range of different responses that emerge when a strong mandate to integrate a health care response to IPV is enacted. Such responses ranged from refraining to deal with the issue to offering a women-centered response. Attempting to integrate a response to nonbiomedical health problems as IPV into health systems that remain strongly biomedicalized is challenging and strongly dependent both on the motivation of professionals and on organizational factors. Implementing and sustaining changes in the structure and culture of the health care system are needed if a health care response to IPV that fulfills the World Health Organization guidelines is to be ensured.

What is required to facilitate implementation of Swedish physical activity on prescription? - interview study with primary healthcare staff and management

Background

The method, Swedish Physical Activity on Prescription (SPAP), has been launched in Swedish healthcare to promote physical activity for prevention and treatment of lifestyle related health disorders. Despite scientific support for the method, and education campaigns, it is used to a limited extent by health professionals. The aim of the study was to describe the views of health professionals on perceived facilitators, barriers and requirements for successful implementation of SPAP in primary healthcare.

Methods

Eighteen semi-structured interviews with stakeholders in SPAP, i.e. ten people working in local or central management and eight primary healthcare professionals in two regional healthcare organisations, were analysed using qualitative content analysis.

Results

We identified an overarching theme regarding requirements for successful implementation of SPAP: Need for knowledge and organisational support, comprising four main categories: Need for increased knowledge and affirmative attitude among health professionals; Need for clear and supportive management; Need for central supporting structures; Need for local supporting structures. Knowledge of the SPAP method content and core components was limited. Confidence in the method varied among health professionals. There was a discrepancy between the central organisation policy documents declaring that disease preventive methods were prioritised and a mandatory assignment, while the health professionals asked for increased interest, support and resources from management, primarily time and supporting structures. There were somewhat conflicting views between primary healthcare professionals and managers concerning perceived barriers and requirements. In contrast to some of the management’s beliefs, all primary healthcare professionals undisputedly acknowledged the importance of promoting physical activity, but they lacked time, written routines and in some cases competence for SPAP counselling.

Conclusion

The study provides knowledge regarding requirements to facilitate the implementation of SPAP in healthcare. There was limited knowledge among health professionals regarding core components of SPAP and how to practise the method, which speaks for in-depth training in the SPAP method. The findings highlight the importance of forming policies and guidelines and establishing organisational supporting structures, and ensuring that these are well known and approved in all parts of the healthcare organisation.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3021-1) contains supplementary material, which is available to authorized users.

Using a Mixed Methods Approach to Examine Practice Characteristics Associated With Implementation of an Adult Immunization Intervention Using the 4 Pillars Practice Transformation Program

Adult immunization rates are consistently suboptimal, exacting significant human and financial burden of preventable disease. Practice-level interventions to improve immunization rates have produced mixed results. The context of change critically affects implementation of evidence-based interventions. We conducted a randomized controlled cluster trial of the 4 Pillars Practice Transformation Program to increase adult vaccination rates in primary care practices and used qualitative methods to test intervention effects and understand practice characteristics associated with implementation success. We conducted qualitative interviews with staff from 14 practices to assess implementation experiences. Thematic analysis of data pointed to the importance of quality improvement history, communication and practice leadership, Immunization Champion leadership effectiveness, and organizational flexibility. Practices were scored on these characteristics and grouped into four types: Low Implementers, Medium Implementers, High Implementers, and Public/University Practices. Intervention uptake and immunization rate changes were compared, and a significant increase in influenza vaccination rates (3.9 percentage points [PPs]; p = .038) was observed for High Implementers only. Significant increases in Tdap vaccination rates were observed for High Implementers (9.3 PP; p = 0.006) and the Public/University groups (6.5 PP; p = 0.012), but not other groups. Practice characteristics may be critical factors in predicting intervention success.

Factors associated with an evidence-based measure of implementation for the Adolescent Community Reinforcement Approach

BACKGROUND

An evidence-based measure of implementation (EBMI) is an implementation outcome measure shown to have predictive validity with one or more future-measured constructs of importance. The current study sought to identify correlates and predictors of an EBMI called procedure exposure. Garner et al. (2016) found procedure exposure to be an EBMI for the Adolescent Community Reinforcement Approach (A-CRA).

METHODS

The dataset included 76 community-based substance use treatment organizations located across the United States. Organizational-level regression analyses, which were framed within the context of Chaudoir et al. (2013) framework for predicting implementation outcomes, were used to examine predictors of A-CRA procedure exposure RESULTS: The Washington Circle's treatment initiation performance measure (B=5.05 [SE=1.60], p=0.002), as well as session exposure (B=0.18 [SE=0.06], p=0.003), were significant predictors of A-CRA procedure exposure in the backward stepwise regression analysis (Adjusted R-square=0.55). The Washington Circle's treatment engagement performance measure (B=7.93 [SE=0.77], p<0.001), as well as time-to-proficiency (B=-0.04 [SE=0.02], p=0.02), each had significant bivariate relationships with A-CRA procedure exposure but were not retained in the final model.

CONCLUSIONS

Organizations implementing A-CRA are encouraged to make the following high priorities: (a) scheduling and completing a subsequent treatment session within 14days of their index session (treatment initiation) and (b) providing a targeted number of treatment sessions to each client (session exposure). To the extent organizations do this, they may be more likely to achieve higher levels of A-CRA procedure exposure.

Effectiveness of bedrails in preventing falls among hospitalized older adults: a systematic review

BACKGROUND

Falls are a major problem today affecting adults of any age, but the elderly are a population that is more susceptible to falls. Falls are the leading cause of injury or death among older adults. Hospitalized older people are particularly vulnerable to falls. Falls cause direct injuries (minor injuries, severe wounds of the soft tissues and bone fractures) to patients and increased length of stay. The prevention of falls is commonly considered an indicator of the quality of care. Therefore, health institutions and professionals treat the identification and implementation of strategies to prevent or minimize their effects as a high priority. Fall prevention interventions involving physical restraints are still common and considered a primary preventative measure, despite controversy in their use. One of the most frequently used restraint interventions is bedrails. The question of the effectiveness of bedrails in preventing falls cuts across all societies and cultures and has with significant implications for the clinical practice of nurses.

OBJECTIVES

The objective of this review was to identify the effectiveness of the use of bedrails in preventing falls among hospitalized older adults when compared with no use of bedrails or any type of physical restraints.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

The current review considered studies that included hospitalized adults (female and male), 65 years and over with any clinical condition in a non-intensive care unit (ICU).

TYPES OF INTERVENTION(S)

The current review considered studies that evaluated the use of bedrails as a restraint to prevent falls among older adults in non-ICUs compared to no use of bedrails or any type of physical restraints, for example, bedrails versus no bedrails, and bedrails versus no wrist or ankle ties.

TYPES OF STUDIES

The current review considered any randomized controlled trials (RCTs). In the absence of RCTs, other research designs such as non-RCTs, before and after studies, cohort studies, case-control studies, descriptive studies, case series/reports and expert-opinion were considered.

OUTCOMES

The current review considered studies that included primary outcomes (number of patients who fell or the number of falls per patient) and secondary outcomes (number of head trauma, bone fractures or soft tissue injuries).

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished articles. A three-step search strategy was utilized in 13 databases. Articles published in Portuguese, English and Spanish beginning from 1980 were considered for inclusion.

METHODOLOGICAL QUALITY

Assessment of methodological quality was not conducted as no articles were identified that met the inclusion criteria.

DATA EXTRACTION AND DATA SYNTHESIS

Data extraction and synthesis was not performed, because no articles were included in this systematic review.

RESULTS

The search identified a total of 875 potentially relevant articles. Sixteen articles were identified through the reference lists of all identified articles. One hundred and thirteen full-text papers were assessed by two independent reviewers to determine eligibility. However, 11 articles were not found (despite all the efforts), and 102 articles did not meet the inclusion criteria.

CONCLUSION

There is no scientific evidence comparing the use of bedrails in preventing falls among hospitalized older adults to no use of bedrails or any type of physical restraints.

PRÁTICAS DAS EQUIPAS NA PREVENÇÃO DE QUEDA NOS IDOSOS INSTITUCIONALIZADOS: CONSTRUÇÃO E VALIDAÇÃO DE ESCALA

RESUMO Objetivo: construir e determinar as características psicométricas da escala de práticas e comportamentos das equipes na gestão do risco de queda dos idosos institucionalizados. Método: a escala foi desenhada com base na revisão da literatura e na observação do trabalho das equipes numa instituição de longa permanência para idosos. Foi realizada a análise de conteúdo e a verificação do índice de concordância dos 14 itens iniciais por nove juízes. A escala foi aplicada a uma amostra de 152 cuidadores de seis instituições de longa permanência para idosos. A investigação respeitou os princípios éticos. Garantiu-se o anonimato e a confidencialidade dos dados. Resultados: após a determinação das caraterísticas psicométricas, verificámos que a escala, unidimensional, ficou constituída por seis itens, com um Alfa de Cronbach de 0,918, pontua entre 6 e 30 pontos. A análise dos resultados permite constatar que a informação sobre os fatores de risco e a discussão em equipe sobre as medidas preventivas nem sempre são mantidas, possibilitando que elementos diferentes da equipe possam valorizar medidas diferentes, o que não garante a continuidade de cuidados e a individualização das medidas face ao risco avaliado. Conclusão: a escala tem boas características psicométricas, podendo ser usada na investigação e na prática clínica para avaliar as práticas e os comportamentos das equipes na gestão do risco de queda em idosos institucionalizados.

Falls in long-term care institutions for elderly people: protocol validation

ABSTRACT Objectives: To validate the content of a fall management risk protocol in long-term institutions for elderly people. Methods: Methodological, quanti-qualitative study using the Delphi technique. The tool, based on the literature, was sent electronically to obtain consensus among the 14 experts that meet the defined inclusion criteria. Results: The 27 indicators of the protocol are organized in three dimensions: prepare for the institutionalization (IRA=.88); manage the risk of falls throughout the institutionalization (IRA=.9); and lead the communication and formation (IRA=1), with a CVI=.91. Two rounds were performed to get a consensus superior to 80% in every item. Conclusion: The values obtained in the reliability test (>0.8) show that the protocol can be used to meet the intended goal. The next step is the clinic validation of the protocol with residents of long-term care institutions for elderly people.

[The use of fall prevention strategies in home care: a survey in Flanders]

OBJECTIVES

Falls in community-dwelling older persons occur frequently. The consequences emphasize the need to screen systematically for an increased fall risk and a targeted multifactorial and multidisciplinary approach. This study describes the extent to which fall prevention strategies are applied by primary healthcare workers in Flanders. Insight in barriers is provided.

METHOD

An online survey was collected by the Centre of Expertise for Falls and fracture Prevention Flanders.

RESULTS

1483 respondents are included. 93% are confronted monthly with falls. 96% believe they can make a positive contribution to fall prevention. At least once a year, respondents inquire about falls (62%) and screen for gait/balance problems (84%). A multifactorial assessment is performed in case of a recent fall (95%) or an increased fall risk (76%). Most frequently respondents give advice on safe environment/behaviour (93%), walking aid (91%), personal alarm system (89%) and footwear (85%). Unmotivated older persons (75%) who ignore their fall risk (85%), insufficient time (60%), financial compensation (54%), staff (50%), communication (31%) and knowledge (23%) are important barriers.

CONCLUSIONS

Although respondents are aware of the importance of fall prevention, these results reveal a necessity of sufficient knowledge, structured multidisciplinary cooperation and a clear policy. Raising awareness of older persons remains crucial.

Functional Measures for Fall Risk in the Acute Care Setting: A Review

This review explores the evidence pertaining to the use of functional ability measures for fall risk in the acute care setting. We included studies from six bibliographic databases that investigated fall risk functional ability measures in hospitalized older adults (≥55 years). We utilized the following search terms: acute care, subacute care, critical care, inpatient, fall, and fall prevention. Nineteen articles met the inclusion criteria. Timed "Up and Go" (TUG) was identified as a feasible fall risk functional ability measure for clinicians; it demonstrated clinical performance of fair sensitivity (56%-68%) and good specificity (74%-80%). Clinical performance of other measures (Berg Balance Scale and Functional Reach test) was not as favorable as the TUG. Functional ability measures are underutilized in the acute care setting, potentially due to limited knowledge and training on administration. Combining functional measures with subjective screening tools may optimize performance and accuracy of identifying fall risk identification.

Clinical interventions, implementation interventions, and the potential greyness in between -a discussion paper

BACKGROUND

There is increasing awareness that regardless of the proven value of clinical interventions, the use of effective strategies to implement such interventions into clinical practice is necessary to ensure that patients receive the benefits. However, there is often confusion between what is the clinical intervention and what is the implementation intervention. This may be caused by a lack of conceptual clarity between 'intervention' and 'implementation', yet at other times by ambiguity in application. We suggest that both the scientific and the clinical communities would benefit from greater clarity; therefore, in this paper, we address the concepts of intervention and implementation, primarily as in clinical interventions and implementation interventions, and explore the grey area in between.

DISCUSSION

To begin, we consider the similarities, differences and potential greyness between clinical interventions and implementation interventions through an overview of concepts. This is illustrated with reference to two examples of clinical interventions and implementation intervention studies, including the potential ambiguity in between. We then discuss strategies to explore the hybridity of clinical-implementation intervention studies, including the role of theories, frameworks, models, and reporting guidelines that can be applied to help clarify the clinical and implementation intervention, respectively.

CONCLUSION

Semantics provide opportunities for improved precision in depicting what is 'intervention' and what is 'implementation' in health care research. Further, attention to study design, the use of theory, and adoption of reporting guidelines can assist in distinguishing between the clinical intervention and the implementation intervention. However, certain aspects may remain unclear in analyses of hybrid studies of clinical and implementation interventions. Recognizing this potential greyness can inform further discourse.

Clinical effectiveness of and attitudes and beliefs of health professionals towards the use of health technology in falls prevention among older adults

AIMS

To analyse the evidence on the effectiveness, usability and acceptability of health technology in falls detection and prevention among older adults.

METHODS

Five databases were searched from February 2004 to February 2014: PubMed, Medline, Embase, Cochrane and CINAHL, with reference lists reviewed and researchers contacted for additional articles. The interventions were health technology tools used for falls detection and prevention (e.g. computers, mobile phones, motion sensors). The outcomes were effectiveness of, and the attitudes of healthcare staff towards, health technology in preventing falls. Two review authors independently assessed full texts using modified versions of the Joanna Briggs Institute Critical Appraisal Checklists.

RESULTS

Full-texts of 51 out of 7927 articles were examined and 17 articles accepted following appraisal using Joanna Briggs Institute modified criteria. These were divided into subheadings of health information technology tool with visual cues (n = 2), sensors (n = 4), Webcam (n = 1) and electronic medical records (n = 3). Three of the seven systematic reviews evaluated sensor technology alone, whereas the remainder examined multicomponent interventions. There is a lack of research into the efficacy of and staff attitudes towards health technology in falls detection and prevention. One study found nurses accepted a health information technology toolkit with visual cues, with a single randomized controlled trial demonstrating a reduction in falls rates. Most studies regarding sensor technology were of low quality and did not find reduced falls rates or number of falls-related injuries. There was also mixed response from healthcare staff and users regarding the use of sensors, with concerns about privacy and false alarms. Video camera surveillance effectively reduced falls rates and was well accepted by nursing staff. However, patients had concerns for their privacy. Electronic medical records have not so far demonstrated a reduction in falls, with ongoing staff concerns about their usability.

CONCLUSION

Good-quality literature regarding the effectiveness and acceptability of health technology in falls detection and prevention is lacking. Further research into both these fields is vital prior to wider implementation of such tools in clinical practice.

Facilitators of and barriers to hip protector acceptance and adherence in long-term care facilities: a systematic review

BACKGROUND

Hip protectors represent an attractive strategy for reducing hip fractures among high-risk fallers in long-term care facilities. However, clinical studies yield conflicting results regarding their clinical value. This is mainly due to poor acceptance and adherence among users in wearing these devices. As a result, there is an urgent need to identify potential barriers and facilitators to initial acceptance and continued adherence with hip protector use.

PURPOSE

The objective of this systematic review is to synthesize available research evidence to identify factors that influence acceptance and adherence among older adults living in long-term care facilities.

METHODS

A key word search was conducted for studies published in English between 2000 and 2013 that employed quantitative, qualitative, or mixed-methods research designs. Two independent reviewers evaluated each article for inclusion, with a third reviewer when needed to resolve discrepancies.

RESULTS

Twenty-eight articles met our inclusion criteria, and facilitators and barriers were clustered into 4 socio-ecological levels: system (eg, facility commitment, staff shortages), caregiver (eg, belief in the efficacy of protectors, negative perceptions), resident (eg, clinical risk factors for falls and related fractures, acute illness), and product (eg, soft shell, discomfort).

DISCUSSION

The outcomes provide decision makers, health professionals, and caregivers with a greater awareness of strategies to improve compliance with the use of hip protectors. Furthermore, researchers can use this information to design clinical trials that yield high acceptance and adherence.

Older Adults' Opinions on Fall Prevention in Relation to Physical Activity Level

The purpose of this study was to explore and describe older adults' opinions regarding actions to prevent falls and to analyze differences in the opinions of highly versus less physically active older adults. An open-ended question was answered by 262 individuals aged 75 to 98 years living in the community. The answers were analyzed using qualitative content analysis, and differences in the categories were compared between highly and less physically active persons. Physical activity was measured according to a five-level scale. The content analysis resulted in eight categories: assistive devices, avoiding hazards, behavioral adaptive strategies, being physically active, healthy lifestyle, indoor modifications, outdoor modifications, and seeking assistance. Behavioral adaptive strategies were mentioned to a greater extent by highly active people, and indoor modifications were more often mentioned by less active older adults. Support for active self-directed behavioral strategies might be important for fall prevention among less physically active older adults.

Is it possible to detect an improvement in cancer pain management? A comparison of two Norwegian cross-sectional studies conducted 5 years apart

PURPOSE

Cancer pain (CP) management is challenging. In recent years, efforts were undertaken to achieve better CP management, e.g. clinical research, new treatment modalities, development of guidelines, education and focus on implementation. The aim of the present study was to compare the prevalence and characteristics of pain and breakthrough pain (BTP) between cross-sectional studies conducted in 2008 and 2014. It was hypothesized that an improvement in pain control would be observed the years in between.

METHODS

Two cross-sectional studies were conducted where adult cancer patients answered questions from Brief Pain Inventory and the Alberta Breakthrough Pain Assessment Tool for cancer patients. Physicians reported socio-demographic and medical data. Regression models were applied for analysis.

RESULTS

In total, 168 inpatients, 92 in 2008 and 76 in 2014, and 675 outpatients, 301 in 2008 and 374 in 2014, were included. The patient characteristics of the samples were comparable. Prevalence of CP among inpatients was 55 % in 2008 and 53 % in 2014, and among outpatients, 39 and 35 %, respectively. Inpatients reported average pain intensity (0-10 numerical rating scale, NRS) of 3.60 (standard deviation, SD 1.84) (2008) and 4.08 (SD 2.11) (2014); prevalence of BTP was 52 % (2008) and 41 % (2014). For outpatients, average pain intensity was 3.60 (SD 2.04) (2008) and 3.86 (SD 2.20) (2014); prevalence of BTP was 43 % (2008) and 37 % (2014). None of the differences were statistically significant.

CONCLUSION

Unexpectedly, no improvement in pain control was observed. Efforts are still needed to improve cancer pain management.

Applying the RE-AIM Framework to Inform the Development of a Multiple Sclerosis Falls-Prevention Intervention

Successfully addressing the problem of falls among people with multiple sclerosis (MS) will require the translation of research findings into practice change. This process is not easy but can be facilitated by using frameworks such as RE-AIM during the process of planning, implementing, and evaluating MS falls-prevention interventions. RE-AIM stands for Reach, Effectiveness, Adoption, Implementation, and Maintenance. Since its initial publication in 1999, the RE-AIM framework has become widely recognized across a range of disciplines as a valuable tool to guide thinking about the development and evaluation of interventions intended for widespread dissemination. For this reason, it was selected by the International MS Falls Prevention Research Network to structure initial discussions with clinicians, people with MS, and representatives of professional and MS societies about the factors we need to consider in the development of an MS falls-prevention intervention for multisite testing that we hope will someday be disseminated widely. Through a combination of small-group work and large-group discussion, participants discussed four of the five RE-AIM elements. A total of 17 recommendations were made to maximize the reach (n = 3), adoption (n = 5), implementation (n = 4), and maintenance (n = 5) of the intervention the Network is developing. These recommendations are likely to be useful for any MS rehabilitation researcher who is developing and testing interventions that he or she hopes will be widely disseminated.

A population-based intervention for the prevention of falls and fractures in home dwelling people 65 years and older in South Germany: protocol

Background

Falls and fall-related injuries pose a major threat to older peoples’ health, and are associated with increased morbidity and mortality. In the course of demographic changes, development and implementation of fall prevention strategies have been recognized as an urgent public health challenge. Various risk factors for falls and a number of effective interventions have been recognized. A substantial proportion of falls occur for people who are neither frail nor at high risk. Therefore, population-based approaches reaching the entire older population are needed.

Objective

The objective of the study presented is the development, implementation, and evaluation of a population-based intervention for the prevention of falls and fall-related injuries in a medium sized city in Germany.

Methods

The study is designed as a population-based approach. The intervention community is a mid sized city named Reutlingen in southern Germany with a population of 112,700 people. All community dwelling inhabitants 65 years and older are addressed. There are two main measures that are defined: (1) increase of overall physical activity, and (2) reduction of modifiable risk factors for falls such as deficits in strength and balance, home and environmental hazards, impaired vision, unsafe footwear, and improper use of assistive devices. The implementation strategies are developed in a participatory community planning process. These might include, for example, training of professionals and volunteers, improved availability of exercise classes, and education and raising awareness via newspaper, radio, or lectures.

Results

The study starts in September 2010 and ends in December 2013. It is evaluated primarily by process evaluation as well as by telephone survey.

Conclusions

Physical activity as a key message entails multiple positive effects with benefits on a range of geriatric symptoms. The strength of the design is the development of implementation strategies in a participatory community planning. The problems that we anticipate are the dependency on the stakeholders’ willingness to participate, and the difficulty of evaluating population-based programs by hard end points.

Trained Community Providers Conduct Fall Risk Screenings With Fidelity

Reliable and valid tools are available for health care providers to screen older adults for fall risk. Proficient administration of these tools by lay or community providers (individuals without formal medical training) may be a viable channel to expand the reach of fall risk screenings. However, the ability of community providers to administer screens is not known. This project examines community providers’ ability to proficiently administer a fall risk screening following a standardized training. Forty community providers were trained and then performed community screenings. Knowledge and confidence were assessed with pre- and postsurveys. A standardized skills checklist assessed proficiency in fall risk screening administration immediate posttraining and at onsite community screenings. Knowledge and confidence surveys demonstrated improvements pre- and posttraining ( p < .001). In all, 66% of participants demonstrated screening skill proficiency at their first onsite screening. With further coaching, 91% participants demonstrated proficiency by their third onsite screening. Participants achieving early proficiency were on average younger. Community providers can reliably administer a fall risk screening algorithm with training and coaching. This is a low-cost model and can extend the reach and dissemination of fall risk screenings, potentially providing early identification and interventions to those at risk of falling.

Brief Strategic Family Therapy: implementing evidence-based models in community settings

OBJECTIVE

To review a 40-year collaborative partnership between clinical researchers and clinicians, in developing, investigating and implementing Brief Strategic Family Therapy (BSFT).

METHOD

First, to review theory, practice and studies related to this evidenced-based therapy intervention targeting adolescent drug abuse and delinquency. Second, to present the BSFT Implementation Model created for the BSFT intervention-a model that parallels many of the recommendations from the implementation science literature.

RESULTS

Specific challenges encountered during the BSFT implementation process are reviewed, along with ways of conceptualizing and addressing these challenges from a systemic perspective.

CONCLUSION

The BSFT implementation uses the same systemic principles and intervention techniques as those that underlie the BSFT clinical model. Building on our on-the-ground experiences, recommendations are proposed for advancing the field of implementation science.

[Managing concerns about falls in older people: evaluation of the implementation of an evidence-based program]

INTRODUCTION

A cognitive behavioral program reduced concerns about falling and related avoidance behavior among older community-dwelling adults in a randomized controlled trial. In the current study we examined the effects and acceptability of the program after nation-wide implementation into home care organizations in The Netherlands.

METHODS

In a one-group pretest-posttest study with data collection before the start of the program and at 2 and 4 months, the effects and acceptability of the program were assessed in 125 community-dwelling older people. The outcomes of the effect evaluation included concerns about falls, related avoidance behavior, falls, fall-related medical attention, feelings of anxiety, symptoms of depression, and loneliness.

RESULTS

Pretest-posttest analyses with the Wilcoxon signed-rank test and the paired t-test showed significant improvements at 4 months for concerns about falls, activity avoidance, number of falls in the past 2 months, feelings of anxiety, and symptoms of depression. No significant differences were shown for the other outcomes.

DISCUSSION

After implementation in home care organizations, the outcomes indicate positive program effects on concerns about falls, avoidance behavior, and falls in community-dwelling older people. Given the similarity in results, i.e. between those of the previously performed randomized controlled trial and those of the current pretest-posttest study, we conclude that the program can be successfully implemented in practice. This article is an adjusted, Dutch version of Zijlstra GA, van Haastregt JC, Du Moulin MF, de Jonge MC, van der Poel A, Kempen GI. Effects of the implementation of an evidenc-based program to manage concerns about falls in older adults. The Gerontologist 2013;53(5):839-849; doi: 10.1093/geront/gns142.

Local health department assurance of services and the health of California's seniors

OBJECTIVE

To examine the extent to which local health department (LHD) assurance of select services known to promote and protect the health of older adults is associated with more favorable population health indicators among seniors.

DESIGN

Data from the California Health Interview Survey (CHIS: 2003, 2005, and 2007) were linked with the 2005 wave of the National Association of County and City Health Officials profile survey and the Area Resource File to assess the association of LHD assurance and senior health indicators. Assurance was measured by an index of 5 services, either directly provided or contracted by LHDs: cancer screening, injury prevention, comprehensive primary care, home health care, and chronic disease prevention. Multilevel regression models estimated the association of LHD assurance of services and each of 6 older adult health indicators, controlling for individual, LHD, and county characteristics that included key social determinants of health, such as poverty.

SETTING

Fifty-seven California counties.

PARTICIPANTS

33,154 older adults (age 65 and older).

MAIN OUTCOME MEASURES

Colorectal cancer screening, mammography, healthy eating, physical activity, and multiple falls among older adults.

RESULTS

Local health departments provided or contracted a median of 2 of the 5 services. In adjusted analyses, LHD assurance of services was generally unassociated with the seniors' health behaviors, screening, and falls. Greater LHD expenditures per capita were associated with significantly better mammography screening rates (adjusted odds ratio [AOR] = 1.22, P < 0.01) compared to jurisdictions in the bottom one-third of per capita LHD spending. Greater county-level poverty (a social determinant of health) was associated with greater junk food consumption (AOR = 1.14, P < 0.01) and worse fruit and vegetable consumption (AOR = 0.97, P < 0.01). Highly impoverished counties were consistently in the bottom quartile of performance across all indicators.

CONCLUSIONS

The LHD's assurance of select services known to promote and protect the health of older adults does not appear to translate into higher rates of colorectal cancer screening, mammography, healthy eating, physical activity, and fewer falls among seniors. County-level poverty is most strongly associated with older adult health, underscoring a key barrier to address in local senior health improvement efforts.

Physical Restraint Usage at a Teaching Hospital

This mixed method study examines the prevalence of restraint usage; perception of nurses and doctors about the practice and whether they were trained to apply physical restraints. The physical restraint prevalence tools were used to observe 172 adult patients and conduct 47 chart audits in the medical-surgical wards and a psychiatric unit in November 2011. Focus group discussions with nurses and doctors were conducted. Quantitative data were analyzed using the SPSS and focus group discussions thematically analyzed. The prevalence of physical restraints between the medical-surgical wards was 75%. Nurses and medical doctors were not formally trained to apply restraint, and had learnt from peer observation. They expressed sadness, guilt, and fear when restraints are used and identified that inadequate institutional support existed. Restraint usage was high, and nurses and doctors experienced moral dilemma when they perceived that lack of formal training and inadequate institutional support may contribute to patient injury.

Effects of the implementation of an evidence-based program to manage concerns about falls in older adults

PURPOSE OF THE STUDY

Concerns about falls and related activity avoidance are common in older people. A multicomponent program reduced these concerns and increased daily activity among older people in a randomized controlled trial. This study explored whether the effects and acceptability of the program maintain after its implementation into home care organizations.

DESIGN AND METHODS

In a pretest-post-test study, the effects and acceptability of the 8-week cognitive behavioral program was evaluated in 125 community-living older adults. Data on concerns about falls, related avoidance behavior, falls, fall-related medical attention, feelings of loneliness and anxiety, and symptoms of depression were collected prior to the start of the program and at 2 and 4 months.

RESULTS

Pretest-post-test analyses showed significant improvements at 4 months for concerns about falls, activity avoidance, number of falls in the past 2 months, feelings of anxiety, and symptoms of depression. No significant differences were shown for daily activity, feelings of loneliness, and fall-related medical attention.

IMPLICATIONS

After implementation in home care organizations, the program reduced concerns about falls, avoidance behavior, and falls in community-living older adults. These findings are highly consistent with the outcomes of a previously performed randomized controlled trial, indicating that the program can be successfully implemented in practice. Further dissemination of the program is recommended to reduce concerns about falls and related activity avoidance in community-living older people.