Reducing Falls Among Community-Dwelling Older Adults From Clinicians’ Perspectives: A Systems Modeling Approach

Abstract

Background and Objectives Falls among older adults are a significant health problem globally. Studies of multicomponent fall prevention programmes in randomised controlled trials demonstrate effectiveness in reducing falls, however, the translation of research into the community remains challenging. While there is an increasing interest to understand the factors contributing to implementation barriers, the dynamic relationships between factors are less well examined. Furthermore, evidence on implementation barriers from Asia is lacking as most of these studies originate from the West. As such, this study aims to engage stakeholders in uncovering the factors that facilitate or inhibit implementing community-based fall prevention programmes in Singapore, with a focus on the inter-relationship between those factors. Research Design and Methods Healthcare professionals familiar with fall prevention programmes were invited to discuss the enablers and challenges to the implementation. This effort was facilitated using a systems modelling methodology of Group Model Building (GMB), to share ideas and to create a common conceptual model of the challenges. The GMB employs various engagement techniques to draw on the experiences and perceptions of all stakeholders involved. Results This process led to the development of a Causal Loop Diagram (CLD), a qualitative conceptual model of the dynamic relationships between the barriers and facilitators of implementing fall prevention programmes. Results from the CLD show that implementation is influenced by two main drivers: healthcare provider factors that influenced referrals, and patient factors that influenced referral acceptance and long-term adherence. Key leverage points for potential interventions were identified as well. Discussion and Implications The overall recommendation emphasised closer coordination and collaboration across providers to ensure sustainable and effective community-based fall prevention programmes. This has to be supported by a national effort, involving a multidisciplinary stakeholder advisory group. These findings generated would be promising to guide future approaches to fall prevention.

Factors Influencing the Implementation of a Fall Prevention Exercise Program for Community-Dwelling Older Adults: A Qualitative Study Guided by the PRECEDE-PROCEED Model

“… 8 , 9 Physical activity programs, especially those which integrated balance and strength exercises, have demonstrated efficacy in reducing falls among older adults, with an approximately/average 17% reduction in fall rates reported in a systematic review by Sherrington et al 10 , 11 However, despite the evidence, such tailored fall prevention programs are not widely available in the community setting in Singapore. 12 In view of these considerations, a multidisciplinary team from Changi General Hospital (CGH), including geriatricians, physiotherapists, exercise physiologists, and community care colleagues, partnered with community-based stakeholders like Sport Singapore, ActiveSG, and NTUC Health, to develop the “Steady Feet” (SF) fall prevention exercise program for community-dwelling older adults. A comprehensive description of SF has been previously described by Ong et al 13 …”

“…This is particularly so for community-based fall prevention exercise program like SF that is still in its infancy. 12 While promising initial results were observed with SF, it is acknowledged that its implementation remains a challenge. Anecdotally the adoption of SF within the community was sub-optimal as it is yet to be integrated as part of routine clinical and/or community practices.…”

“…Falls prevention is generally perceived to be less important compared to other pathologically defined health needs, and therefore not prioritized. 12 Most clinicians do not prioritise fall prevention in the clinic due to competing demands and time constraints and is poorly referred by clinicians. 12 This situation was exacerbated with COVID-19 pandemic where safe-distancing measure was imposed, restricting group exercises including SF.…”

“… 12 Most clinicians do not prioritise fall prevention in the clinic due to competing demands and time constraints and is poorly referred by clinicians. 12 This situation was exacerbated with COVID-19 pandemic where safe-distancing measure was imposed, restricting group exercises including SF. 16 Even after COVID-19 related restrictions were lifted, recruitment of participants into SF continued to be difficult.…”

“…Cost, accessibility, time constraints, and alignment with social and cultural context were identified as aspects that could influence the implementation of fall prevention. 19 While closer coordination and collaboration between providers has been recommended, 12 engagement of older adults has also been advocated for. 20 , 21 Understanding their beliefs, attitudes, and priorities about falls and their management was highlighted as key for successful fall prevention intervention and has been highly recommended in the assessment of determinants.…”