Vicky Scott

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

PROBLEM As the evidence-based movement has advanced in public health, changes in public health practices have lagged far behind creating a science to service gap. For example, science has produced effective falls prevention interventions for older adults. It now is clearer WHAT needs to be done to reduce injury and death related to falls. However, issues have arisen regarding HOW to assure the full and effective uses of evidence-based programs in practice. SUMMARY Lessons learned from the science and practice of implementation provide guidance for how to change practices by developing new competencies, how to change organizations to support evidence-based practices, and how to change public health systems to align system functions with desired practices. The combination of practice, organization, and system change likely will produce the public health benefits that are the promise of evidence-based falls prevention interventions. IMPACT ON PUBLIC HEALTH: For the past several decades, the emphasis has been solely on evidence-based interventions. Public health will benefit from giving equal emphasis to evidence-based implementation. IMPACT ON INDUSTRY We now have over two decades of research on the effectiveness of fall prevention interventions. The quality of this research is judged by a number of credible international organizations, including the Cochrane Collaboration (http://www.cochrane.org/), the American and British Geriatrics Societies, and the Campbell Collaboration (http://www.campbellcollaboration.org/). These international bodies were formed to ponder and answer questions related to the quality and relevance of research. These developments are a good first step. However, while knowing WHAT to do (an evidence-based intervention) is critical, we also need to know HOW to effectively implement the evidence. Implementation, organization change, and system change methods produce the conditions that allow and support the full and effective use of evidence-based interventions. It is time to focus on utilization of implementation knowledge in public health. Without this focus the vast amount on new evidence being generated on the prevention of falls and related injuries among older adults will have little impact on their health and safety.

Recommendations for a core outcome set for measuring standing balance in adult populations: a consensus-based approach.

Background Standing balance is imperative for mobility and avoiding falls. Use of an excessive number of standing balance measures has limited the synthesis of balance intervention data and hampered consistent clinical practice. Objective To develop recommendations for a core outcome set (COS) of standing balance measures for research and practice among adults. Methodology A combination of scoping reviews, literature appraisal, anonymous voting and face-to-face meetings with fourteen invited experts from a range of disciplines with international recognition in balance measurement and falls prevention. Consensus was sought over three rounds using pre-established criteria. Data sources The scoping review identified 56 existing standing balance measures validated in adult populations with evidence of use in the past five years, and these were considered for inclusion in the COS. Results Fifteen measures were excluded after the first round of scoring and a further 36 after round two. Five measures were considered in round three. Two measures reached consensus for recommendation, and the expert panel recommended that at a minimum, either the Berg Balance Scale or Mini Balance Evaluation Systems Test be used when measuring standing balance in adult populations. Limitations Inclusion of two measures in the COS may increase the feasibility of potential uptake, but poses challenges for data synthesis. Adoption of the standing balance COS does not constitute a comprehensive balance assessment for any population, and users should include additional validated measures as appropriate. Conclusions The absence of a gold standard for measuring standing balance has contributed to the proliferation of outcome measures. These recommendations represent an important first step towards greater standardization in the assessment and measurement of this critical skill and will inform clinical research and practice internationally.

What does it mean to transform knowledge into action in falls prevention research? Perspectives from the Canadian Institutes of Health Research.

INTRODUCTION The concept of knowledge translation as defined by the Canadian Institutes for Health Research and the Knowledge to Action Cycle, described by Graham et al (Graham et al., 2006), are used to make a case for the importance of using a conceptual model to describe moving knowledge into action in the area of falls prevention. METHOD There is a large body of research in the area of falls prevention. It would seem that in many areas it is clear what is needed to prevent falls and further syntheses can determine where the evidence is sufficiently robust to warrant its implementation as well as where the gaps are that require further basic research. CONCLUSION The phases of the action cycle highlight seven areas that should be paid attention to in order to maximize chances of successful implementation.

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.

Falls and fall prevention programmes in developing countries: Environmental scan for the adaptation of the Canadian Falls prevention curriculum for developing countries

PROBLEM Falls in older persons in developing countries are poorly understood, and falls prevention and health promotion programmes for this population are largely lacking. METHODS A systematic review was carried out of relevant literature on falls and prevention programmes, and falls prevention education, and a scan undertaken of health promotion programmes for older persons in a representative country - South Africa. RESULTS Studies on the risk and prevalence of falls are largely retrospective and hospital-based, with varied methodology, including study period, sampling method and sample size. Falls prevalence is based largely on self-reports in studies on general trauma in all age groups. Falls incidence varies from 10.1% to 54%. No reports could be traced on sustained falls prevention or health promotion programmes. CONCLUSION Scant research has been conducted and little preventive education offered on falls in older persons. Adaptation of the Canadian Falls Prevention Curriculum for developing countries will help to fill gaps in knowledge and practice. IMPACT ON INDUSTRY With rapid increase in the populations of older persons in developing countries, research on age related disorders such as falls is required to guide policy and management of falls.

Evaluation of an evidence-based education program for health professionals: The Canadian Falls Prevention Curriculum© (CFPC)

INTRODUCTION A staged, mixed methods approach was applied to the development and evaluation of an evidence-based education program for health care professionals and community leaders on how to design, implement and evaluate a fall prevention program. Stages included pre-development, development, pilot testing and impact on practice. The goal of the evaluation was to determine if the Canadian Falls Prevention Curriculum met the needs of the target audience and had an impact on learning and practice. METHODS Methods included a needs assessment, systematic reviews, pre-post tests of learning, follow-up surveys and interviews, and descriptive reports of stakeholder involvement. The needs assessment and systematic review of existing programs indicated that there was a demand for a comprehensive, evidence-based curriculum on fall prevention and that no similar curricula existed. Pre-post test findings showed significant increases in learning and follow-up surveys showed a positive impact on practice. IMPACT ON INDUSTRY Evidence shows that the most effective fall prevention efforts are those that address the multifactorial nature of fall risk, with proven interventions provided by trained clinicians. The Canadian Falls Prevention Curriculum provides evidence-based training for clinicians and community leaders using a public health approach to fall prevention that includes instruction on how to define the problem, assess the risk, examine best practices, implement the program, and conduct evaluation of the programs effectiveness.

An educational video to promote multi-factorial approaches for fall and injury prevention in long-term care facilities

BackgroundOlder adults living in long term care (LTC) settings are vulnerable to fall-related injuries. There is a need to develop and implement evidence-based approaches to address fall injury prevention in LTC. Knowledge translation (KT) interventions to support the uptake of evidence-based approaches to fall injury prevention in LTC need to be responsive to the learning needs of LTC staff and use mediums, such as videos, that are accessible and easy-to-use. This article describes the development of two unique educational videos to promote fall injury prevention in long-term care (LTC) settings. These videos are unique from other fall prevention videos in that they include video footage of real life falls captured in the LTC setting.MethodsTwo educational videos were developed (2012–2013) to support the uptake of findings from a study exploring the causes of falls based on video footage captured in LTC facilities. The videos were developed by: (1) conducting learning needs assessment in LTC settings via six focus groups (2) liaising with LTC settings to identify learning priorities through unstructured conversations; and (3) aligning the content with principles of adult learning theory.ResultsThe videos included footage of falls, interviews with older adults and fall injury prevention experts. The videos present evidence-based fall injury prevention recommendations aligned to the needs of LTC staff and: (1) highlight recommendations deemed by LTC staff as most urgent (learner-centered learning); (2) highlight negative impacts of falls on older adults (encourage meaning-making); and, (3) prompt LTC staff to reflect on fall injury prevention practices (encourage critical reflection).ConclusionsEducational videos are an important tool available to researchers seeking to translate evidence-based recommendations into LTC settings. Additional research is needed to determine their impact on practice.

Barriers and facilitators to hip protector compliance: a systematic review

Background Hip protectors (HP) represent an attractive strategy for reducing hip fractures in high-risk elderly individuals. However, clinical studies have yielded conflicting results regarding their clinical effectiveness. This is mainly due to poor compliance (acceptance and adherence) among users. As a result, there is an urgent need to identify potential barriers and facilitators to initial acceptance and continued adherence with HP use. Aims/Objectives/Purpose The objective of this Systematic Review is to (1) synthesize available research evidence to identify factors that influence HP compliance among older adults in long-term care facilities; (2) interpret the findings to identify the best strategies to overcome perceived barriers and improve acceptance and adherence with HP use; and (3) package and disseminate the findings in a form that is relevant, practical and easily interpreted by the knowledge users and decision makers. Methods A key word search was conducted for studies published in English between 2000 and 2011 that employed quantitative, qualitative, or mixed-methods research designs. Each study was independently reviewed by two reviewers against the inclusion criteria with discrepancies determined by a third. Results/Outcomes 24 articles met the criteria and 63 barrier and facilitator factors were separated into 4 levels: organizational, staff, resident, and product. Significance/Contribution to the field 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 will be able to use the information to design better clinical trials that will yield high acceptance and adherence.

Preventing falls and related injuries among seniors in assisted living residences

Introduction The purpose of this study was to addresses a gap in the fall prevention literature with a focus on Assisted Living Residences (ALRs) – a new community housing option for a rapidly growing number of older persons that are at high risk falls. The result of the 1-year collaborative study was the development of Best Practice Guidelines for integration into routine care. Methods A 6-month prospective, action research intervention was conducted at two ALR sites, with 161 residents. Measures included focus groups, pre/post staff and resident surveys, pre/post measures of balance and gait, and 6-month fall/injury surveillance. Interventions included staff and resident training on fall tracking, fall prevention education for staff and residents, and physical activity interventions. Results Over 6 months, 155 falls were recorded, with 38% (N=73) of residents identified as having at least one fall and 43% (N=72) of falls resulting in injury. There was a statistically significant reduction in the rate of falls per 1000 resident days between the first and second three-month periods (X2=11.98; p=0.001). Fall risk reduction was demonstrated by a significant difference (t=3.16, p=.002) in pre/post Timed-Up-and-Go scores. Focus group findings included the need to tailor prevention to joiners and non-joiners of group intervention activities. Conclusion The study demonstrated that fall prevention guidelines can be implemented within routine service delivery in ALRs with a positive effect on fall risk reduction.