Implementing the evidence for preventing falls among community dwelling older people a systematic review

Journal of Safety Research 42 (2011) 443–451

Contents lists available at SciVerse ScienceDirect

Journal of Safety Research
journal homepage: www.elsevier.com/locate/jsr

Literature Review

Implementing the evidence for preventing falls among community-dwelling older
people: A systematic review
Victoria Goodwin a,⁎, Tracey Jones-Hughes b, Jo Thompson-Coon a, Kate Boddy a, Ken Stein a, b
a
b

PenCLAHRC, Peninsula College of Medicine and Dentistry, University of Exeter, Veysey Building, Salmon Pool Lane, Exeter, UK, EX2 4SG
PenTAG, Peninsula College of Medicine and Dentistry, University of Exeter, Veysey Building, Salmon Pool Lane, Exeter, UK, EX2 4SG

a r t i c l e

i n f o

Article history:
Received 30 September 2010
Received in revised form 13 July 2011
Accepted 28 July 2011
Available online 10 November 2011
Keywords:
Falls prevention
Implementation
Older adults

Evidence-based practice
Systematic review

a b s t r a c t
Problem and objective: The translation of the evidence-base for preventing falls among community-dwelling
older people into practice has been limited. This study systematically reviewed and synthesised the effectiveness of methods to implement falls prevention programmes with this population. Methods: Articles published
between 1980 and May 2010 that evaluated the effects of an implementation strategy. No design restrictions
were imposed. A narrative synthesis was undertaken. Results: 15 studies were identified. Interventions that
involved the active training of healthcare professionals improved implementation. The evidence around
changing the way people who fall are managed within primary care practices, and, layperson, peer or community delivered models was mixed. Impact on industry: Translating the evidence-base into practice involves
changing the attitudes and behaviours of older people, healthcare professionals and organisations. However,
there is a need for further evaluation on how this can be best achieved.
© 2011 National Safety Council and Elsevier Ltd. All rights reserved.

1. Introduction
Falls are an increasing public health concern, affecting a third of people aged 65 and over. It has been estimated that even if age-adjusted incidence rates remain stable, the number of hip fractures worldwide will
climb from 1.66 million in 1990 to 6.26 million in 2050 (Sambrook &
Cooper, 2006). This rising trend exists despite many high quality reviews and clinical guidelines providing evidence for the prevention of
falls among community-dwelling older people (American Geriatrics
Society and the British Geriatrics Society, 2010; Gillespie et al., 2009;
National Institute for Health Clinical Excellence, 2004). However, on
closer examination it is apparent that this evidence base has not necessarily been transferred into clinical practice (Royal College of Physicians,
2007; Tinetti, Gordon, Sogolow, Lapin, & Bradley, 2006). As such, falls
and fall-related injuries continue to escalate (Department of Health,
2009) with a less than optimal provision of evidence-based healthcare
(Goodwin et al., 2010).
One aspect of this problem originates from the lack of understanding
on how to effectively implement the evidence-base, particularly where
routine practice may be in contrast to the experimental conditions observed in the original research (Roen, Arai, Roberts, & Popay, 2006).
For example, clinicians and patients may be required to change behavior

and adopt new practices; and organizations may be required to develop
⁎ Corresponding author. Tel.: + 44 1392 262745; fax: + 44 1392 421009.
E-mail address: (V. Goodwin).

alternative systems of working across professional and organizational
boundaries (Rose, Alkema, Choi, Nishita, & Pynoos, 2007; Tinetti et al.,
2006). Known barriers to implementation of falls prevention strategies
include (Tinetti et al., 2006):
•
•
•
•

Time;
Lack of knowledge and skills;
Complex health and social issues;
Service organization issues, such as fragmentation or a lack of coordination; and
• Financial issues.
Facilitators of successful implementation are (Ganz, Alkema, &
Wu, 2008; Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004):
• Effective leadership and collaboration;
• Strategies adopting simpler interventions;
• Benefits of the intervention to be observable by those intending to
adopt the intervention; and
• An approach which can be adapted to meet the needs of organizations and practitioners.
We therefore performed a systematic review of studies in which
the implementation of a falls prevention strategy has been evaluated.
We identify and explore the existing evidence base, and attempt to
identify key factors for successful implementation of falls prevention
strategies.

0022-4375/$ – see front matter © 2011 National Safety Council and Elsevier Ltd. All rights reserved.
doi:10.1016/j.jsr.2011.07.008


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V. Goodwin et al. / Journal of Safety Research 42 (2011) 443–451

2. Methods
The systematic review was conducted according to a predefined
protocol that was developed following consultation with experts in
the field and is available from the authors on request.
2.1. Literature search and eligibility criteria
By analysis of key studies, we devised a search strategy to identify
relevant papers capturing the process of implementation in the management of accidental falls among older people (Fig. 1). No methods filter
was applied. The master search strategy was adapted and run in the following electronic databases from 1980 to May 2010: AMED and CINAHL
(Using the EBSCO interface); Cochrane Database of Systematic Reviews;
CENTRAL; Medline; Embase and Psychinfo (Using the OVID interface);
and the Social Sciences Citation Index. We scrutinized the bibliographies
of included studies and of other identified relevant review papers in the
search for additional articles.
Studies were included if they reported the evaluation of an implementation strategy for the prevention of falls among communitydwelling older adults. Outcomes could include, for example, behavior
change, attitudes, and uptake of recommendations. Studies were excluded if they only reported health outcomes, such as fractures or
healthcare utilization. There were no restrictions on study design. Editorials, opinion papers, and studies reported only as conference abstracts were excluded. Only papers published in the English
language were included in the review.
Two reviewers independently screened all titles and abstracts. Full
text manuscripts of any relevant titles/abstracts were obtained and
the relevance of each study was assessed according to the inclusion
and exclusion criteria. Studies that did not fulfill the criteria were excluded and their bibliographic details listed with the reason for exclusion. Any discrepancies were resolved by consensus and, where

necessary, a third reviewer was consulted.

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

Accidental Falls/
(fall or falls or faller$1 or fallen).ti,ab.
1 or 2
exp Aged/
(senior$1 or elder* or older or old or oldest).ti,ab.

4 or 5
3 and 6
(prevent* or reduce* or manage*).ti,ab.
7 and 8
Program Evaluation/
Information Dissemination/
Barrier*.ti,ab.
evaluat*.ti,ab.
translat*.ti,ab.
feasibility.ti,ab.
integrat*.ti,ab.
implement*.ti,ab.
disseminat*.ti,ab.
adopt*.ti,ab.
10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19
9 and 20
limit 21 to yr="1980 -Current"

Fig. 1. Master search strategy written for Medline (OVID) and adapted for different
databases.

2.3. Data synthesis
To determine whether effective methods of implementation were
consistent across studies, data were summarized using evidence tables and synthesized using a narrative approach. Where data allowed,
relationships and differences between studies were identified based
on factors such as healthcare system, professions involved, or the nature of the implementation method.

2.2. Data extraction and quality assessment

3. Results

Data were extracted from included papers independently by two
reviewers using a standardized, piloted data extraction form. The following data were extracted: study location and setting, study design,
implementation method, fall prevention intervention, study population, outcomes and follow up, analysis and results.
The quality of individual studies were assessed independently by
two reviewers using the Cochrane risk of bias tool (Higgins & Green,
2009). The tool includes six key criteria against which potential risk
of bias is judged. These being:

3.1. Search results and study characteristics

• Was the allocation sequence adequately generated and described to
enable the assessment of whether it would produce comparable
groups following randomization?
• Was the allocation adequately concealed and described in enough detail
to determine whether allocation of research participants could have
been predicted before or during recruitment by research personnel?
• Were participants, personnel or outcome assessors adequately
blinded to allocation during the study, what methods were used
and were they successful?
• Were incomplete outcome data, such as exclusions, attrition, or missing
data reported, with reasons and how these were dealt with in analyses?
• Was the study free of suggestion of selective outcome reporting (e.g., by
pre-specifying outcomes and analyses of interest and reporting these)?
• Was the study apparently free from other problems that could put it
at risk of bias, such as study design, extreme baseline imbalances?

A total of 3,638 unique titles and abstracts were identified from the
search following removal of duplicates (Fig. 2); 3,530 studies were excluded following a review of titles and abstracts as not meeting the inclusion criteria. A full-text assessment of 108 articles resulted in the
exclusion of 93 studies (7 did not target community-dwelling older people; 76 did not evaluate implementation; 6 were opinion papers, 3 were

only available as abstracts, and 1 paper was not available in English).
The remaining 15 studies met the selection criteria and were included
in the review.
Six studies were undertaken in the United States (Baraff, Lee, Kader, &
Penna, 1999; Brown, Gottschalk, Van Ness, Fortinsky, & Tinetti, 2005;
Fortinsky et al., 2008; Healy, Haynes, McMahon, Botler, & Gross, 2005;
Shah, Maly, Frank, Hirsch, & Reuben, 1997; Wenger et al., 2009), four in
Australia (Barnett et al., 2004; Deery, Day, & Fildes, 2000; McClure et al.,
2010; Stackpool, 2006), and one each in Canada (Scott, Votova, &
Gallagher, 2006), New Zealand (Gardner, Robertson, McGee, &
Campbell, 2002), Sweden (Larsson, Hägvide, Svanborg, & Borell, 2010),
Belgium (Milisen, Geeraerts, & Dejaeger, 2009), and Hong Kong (Sze,
Lam, Chan, & Leung, 2005). A variety of study designs were utilized including a non-randomized controlled trial (n=1), cross-sectional studies
(n =3), cohort studies (n =4), surveys (n =5), process evaluation
(n =1), and a case series (n =1).
3.2. Assessment of study quality

The results were tabulated by individual reviewers for each study
and compared. Disagreements were resolved through consensus involving a third reviewer where necessary.

When examining the quality of each study (Table 1), all were
found to be at a high risk of bias. In terms of blinding, six studies


V. Goodwin et al. / Journal of Safety Research 42 (2011) 443–451

(Deery et al., 2000; McClure et al., 2010; Scott et al., 2006; Shah et
al., 1997; Sze et al., 2005; Wenger et al., 2009) did not provide a
clear indication as to whether participants or outcome assessors
were blinded. As all but one study (Wenger et al.) did not include

a comparator group, participants were aware of the intervention
and, where outcomes were self-reported, this may result in potential reporting bias. In most cases, we were unable to ascertain
whether all collected outcome data were reported. Only one study
(McClure et al.) was considered to be free from other sources of
bias such as baseline imbalance between groups.
3.3. Implementation methods and their effects
Table 2 describes each individual study with the corresponding results presented in Table 3. Implementation methods included training
of healthcare professionals (n = 6), changes to primary care/general
practice management (n = 3), peer or lay volunteer-delivered programs (n = 3), and community awareness programs (n = 3). The
level of description of the implementation strategies was mixed,
with some studies providing only brief details.
3.3.1. Training of health care professionals
Six studies (Baraff et al., 1999; Brown et al., 2005; Fortinsky et al.,
2008; Larsson et al., 2010; Milisen et al., 2009; Scott et al., 2006) utilized training and dissemination of evidence to healthcare professionals. For those that reported the duration of training, it varied
from 30 minutes to one day, targeting a range of staff including

doctors, nurses, physical and occupational therapists, and healthcare
support workers.
Two of the studies (Brown et al., 2005; Fortinsky et al., 2008)
reported on a comprehensive approach to implementation as part of
the Connecticut Collaboration for Falls Prevention (CCFP). This program incorporated training and dissemination of evidence-based
falls prevention interventions using behavior change strategies, opinion leaders, media awareness campaigns, outreach visits to older people, and patient and provider materials. This collaborative approach
resulted in improvements in fall-prevention assessment and management among physical therapists, community-based rehabilitation
therapists, and nurses. Thirty-eight percent of physical therapists
reported almost always using falls prevention strategies six weeks
following training, compared with 14% before training; 68% increased
their use of falls prevention strategies in practice with 7% decreasing
use in practice. A year after training, more than 70% of community
based practitioners reported undertaking assessments of balance,
mobility and postural hypotension, with around half assessing home

hazards and poly-pharmacy. Around half of home health agencies
(HHA) had 100% of their clinical staff following the recommended
falls assessment and management strategies for mobility, postural
hypotension, polypharmacy, home hazards, and balance
management.
Three (Baraff et al., 1999; Milisen et al., 2009; Scott et al., 2006) of
the remaining four studies using training explicitly evaluated their
implementation methods in terms of changing clinical practice behaviors. Baraff et al. (1999) trained medical and nursing staff in

Number of records identified
through database searching
n=3701

Number of records screened after
duplicates removed
n=3638

Number of records excluded
n=3530

Number of full-text articles
searched for eligibility
n=108

445

Number of full-text articles
excluded n=93
Reason for exclusion:
-Full-text not available in English

(n=1)
-Abstract only (n=3)
-Opinion paper (n=6)
-Did not address falls prevention in
community-dwelling older people
(n=7)
-Did not evaluate implementation
(n=76)

Number of papers selected for
inclusion
n=15
Fig. 2. Flow diagram for study selection.


446

V. Goodwin et al. / Journal of Safety Research 42 (2011) 443–451

Table 1
Quality Assessment of Included Studies using the Cochrane Risk of Bias Tool.
Study

Sequence
generation

Allocation
generation

Blinding

Incomplete
outcome data

Selective
outcome reporting

Other sources
of bias

Baraff et al. (1999)
Barnett et al. (2004)
Brown et al. (2005)
Deery et al. (2000)
Fortinsky et al. (2008)
Gardner et al. (2002)
Healy et al. (2005)
Larsson et al. (2010)
McClure et al. (2010)
Milisen et al. (2009)
Scott et al. (2006)
Shah et al. (1997)
Stackpool (2006)
Sze et al. (2005)
Wenger et al. (2009)

No
No
No
No

No
No
No
No
No
No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

No
No

No
Unclear
Yes
Yes
No
Yes
Unclear
No
Unclear
Unclear
Yes
Unclear
Unclear

Yes
No
Unclear
No
No
Unclear
No
Unclear
Yes
No
Unclear
No
Yes
Unclear
Unclear

Yes
Unclear
Yes
No
Yes
Unclear
Unclear
No
Unclear
Unclear
Unclear
Unclear
Yes
Unclear
Unclear

No
Unclear
No
No
Unclear
Unclear
No
No
Yes
No
Unclear
No
Unclear
No

No

Yes = adequately addressed
No = inadequately addressed

emergency departments (ED) in a locally developed guideline and
reported improvements in documentation for some aspects of history
taking, assessment, and actions. When examining issues around the
implementation of a falls prevention guideline with communitybased healthcare staff, Milisen et al. (2009) reported that 88% of practitioners considered falls prevention important. However, there was
some disagreement between professions regarding responsibility for
the assessment and management of fall risk factors and how best to
implement the guideline in practice. Only half of nurses thought it
would be feasible to implement guidelines into practice compared
with between 71% and 89% of GPs, physiotherapists, and occupational
therapists. Barriers to implementation were identified as time investment without financial compensation, poor patient and family motivation, and a lack of communication/collaboration between professionals.
Scott et al. (2006) reported a 25% increase in the fall-related knowledge
among healthcare support workers following training delivered by
nurses and therapists, although it is unclear as to the nature of this
knowledge. Using the Falls Prevention Checklist and Action Plan© the
uptake of recommendations by clients was low to moderate, for example, only 30% who had difficulties balancing whilst in the shower took
action to reduce the risk.

3.3.2. Changes to primary care management
A total of three studies (Gardner et al., 2002; Shah et al., 1997;
Wenger et al., 2009) evaluated changes to the management of falls
within primary care organizations as a result of the implementation
of a falls prevention strategy. Two of these studies (Shah et al.,
1997; Wenger et al., 2009) did so as part of a transformation of the
way in which common problems experienced by older people were
assessed and managed. The conditions included urinary incontinence,

depression, cognitive impairment, and functional limitations. Wenger
et al. (2009) reported improvements in achieving quality indicators
for falls, including history-taking, physical assessments, and interventions. Adherence to specialist recommendations by primary care physicians and patients was examined in one study by Shah et al. (1997),
although only 11% (15/139) of individuals required recommendations for falls. This study reported that recommendations were implemented by general practitioners in six out of nine cases. Among the
seven patients receiving self-care recommendations, three adhered.
The study by Gardner et al. (2002) evaluated the implementation of
primary care practice nurse training to deliver exercise interventions,
in terms of identifying older people for the exercise program and uptake. A perception of an inability to take part in an exercise program
was indicated by both general practitioners and older people. Reasons

for participation included perceived potential benefits in terms of
health and well being.
3.3.3. Peer or lay-volunteer training to implement programs
Three studies (Deery et al., 2000; Healy et al., 2005; Sze et al.,
2005) delivered training to peers (n = 1) or lay-volunteers (n = 2)
in order to deliver health promotion messages, relating to falls prevention, to older people. Deery et al. (2000) used peers to deliver educational sessions to groups of older people, although it is unclear as to
the duration or content of their training. The training of lay-volunteers
to advise and promote fall-related behavior change among older people
was undertaken in two studies (Healy et al., 2005; Sze et al., 2005) with
training lasting from 90 minutes to two days. These three studies examined changes in fall-related knowledge, attitudes, and behaviors and, in
the main, these outcomes improved in the short and longer term, with
the exception of Deery et al. (2000) where control group participants
had greater falls prevention knowledge at three months, although at
12 months the reverse was observed.
3.3.4. Community awareness programs
Three studies undertaken in Australia used community programs
to raise awareness about falls and promote falls prevention activities
among the population, although each of these were evaluated differently (Barnett et al., 2004; McClure et al., 2010; Stackpool, 2006).
Barnett et al. (2004) assessed recall and current falls prevention practices of healthcare staff and councils following the four year ‘Stay on
your Feet’ program. Five years after the commencement of the program, the 321 healthcare staff (GPs, pharmacists, community nurses,

occupational therapists, physiotherapists and health promotion staff)
took part in a survey. From this, 50% (70/139) of GPs and 30% (16/53)
of pharmacists thought the program influenced their practice. Among
the 129 community staff completing the survey, 48% had been involved
in the program, although many activities had been discontinued (such
as medication checks and exercise classes). Reasons included time
limited resources and a lower priority. Sustainability of activities was
reported to have been helped by the adoption of activities as part of normal work, resources, and compatibility with other projects. A follow on
from this study, by McClure et al. (2010), was undertaken to examine
whether less resource intensive methods would be effective. Although
they reported an increased awareness of falls and associated behavior
change among the older population, no improvements were found in
terms of fall-related injuries and hospitalization.
The health promotion program utilized by Stackpool (2006) using
community collaboration to promote physical activity among older


V. Goodwin et al. / Journal of Safety Research 42 (2011) 443–451

people found a 19% increase in the number of available physical activity
classes for older people and a 16% increase in attendance by older people over three years.

4. Discussion
There is some evidence to show that the implementation of falls
prevention programs into practice can be successful. Although we
identified a total of 15 studies, heterogeneity in terms of study design,
implementation methods and outcomes has limited the extent to
which the identified data could be synthesized. The level of description of the implementation strategies included in this review was
often limited. For example, the papers that report an aspect of the
CCFP program had clearly described implementation methods, but

the study by Deery and colleagues failed to describe how the peerdelivered model was developed, and omitted details such as how
peers were identified and trained, and the content of the training.
This is in agreement with a review of complex interventions in workplace settings performed by Egan, Bambra, Petticrew, and Whitehead
(2009), who found that implementation was frequently referred to
but was poorly described. A clear description of an intervention, albeit
a treatment or implementation method, is essential for study replication, whether to inform further research or to utilize the findings in
clinical practice. Context is also an important factor to describe as different healthcare systems and cultural considerations may impact on
whether translating evidence is applicable or feasible.
Successful programs generally included some aspect of training of
healthcare professionals in order to change clinical practice behaviors
that have been reported to be a key aspect of implementation (Bero et
al., 1998; Tinetti et al., 2006). Peer or lay delivered programs specifically aimed at changing knowledge, attitudes, and fall-related behaviors of
older people demonstrated some improvements, often related to avoiding or removing environmental hazards and extrinsic fall-risk factors.
However, none of the non-professionally delivered programs included
training in exercise provision, a key element of effective falls prevention
strategies (Gillespie et al., 2009; Sherrington et al., 2008). There is currently a trial underway in the UK comparing the effectiveness of usual
care with a peer-delivered home exercise program, and with a group
exercise intervention delivered by a qualified exercise instructor (Iliffe
et al., 2010).
Evidence on changing clinical practice within primary care was
mixed. This may be due to competing priorities with other conditions.
Community awareness programs appeared diverse in terms of outcomes and provided no clear picture in terms of the effectiveness of
this method of implementation. Furthermore, one of the studies
(Shah et al., 1997) evaluating impact in this area was published
prior to 2000 when the evidence for falls prevention interventions
was less well established. Falls therefore carried a relatively low priority
within healthcare.
There is no general consensus with regards to which outcomes
should be used to examine the impact of implementation, possibly
due to differing interpretations as to what implementation is. Within

the RE-AIM framework, Glasgow, Vogt, and Boles (1999) suggest the
evaluation of implementation programs refers to the fidelity and adherence to a program, whereas, Rabin, Glasgow, Kerner, Klump, and
Brownson (2010) suggest that evaluation requires a variety of outcomes that should be examined, from those at an individual level
(e.g., behavior change of patients or professionals), to organizational
level data, (e.g., healthcare costs). Policymakers and service commissioners are interested in improved outcomes, such as fall-related injuries or hospital admissions, which require effective falls prevention
interventions and effective implementation (FPG Child Development
Institute, 2011). The CCFP program was based upon an effective
multi-factorial intervention (Tinetti et al., 1994) that has also been
shown to result in a 9% (95% confidence interval [CI] 6 to 12%)

447

reduction in serious fall-related injuries and an 11% (95% CI 8 to
14%) reduction in medical service use (Tinetti et al., 2008).
To our knowledge, this is the first systematic review that has evaluated implementation strategies in relation to falls prevention among
older people. We conducted an extensive literature search in a range
of electronic databases and included a range of study designs as we
recognize that traditional randomized controlled trials are less feasible
and may not be appropriate when evaluating implementation into clinical practice (Medical Research Council, 2000; Rabin et al., 2010).
There are a number of limitations of this review. Firstly, although
we were able to identify a reasonable number of relevant papers, potential risk of bias was generally high or unclear (Higgins & Green,
2009). This was linked to the fact that most study methods did not incorporate a control element and some studies used surveys. Although
evidence suggests that the failure to report key quality indicators may
indicate bias, the extent of the size and direction of the impact of this
bias is not always clear. The quality assessment of studies designed to
evaluate the implementation of evidence into practice has not been
well researched and there are no guidelines to assist in the reporting
of this type of evaluation. The Cochrane risk of bias tool may not be
the most appropriate tool for evaluating quality in studies of this
type and there may be additional issues such as social desirability

bias that have not been addressed either in the publications or in
the assessment of their quality. Appraising evaluations of implementation is a relatively new area and further work is required to develop
appropriate methods (Egan et al., 2009). Secondly, we included only
papers that were available in English, although based on information
provided in the abstracts it is unlikely that the non-English language
papers identified in the search would have met the other selection
criteria. Thirdly, we did not include grey literature, defined as literature not published in journals, such as conference abstracts and
unpublished theses (Higgins & Green, 2009), which may have
highlighted further studies and reports, and finally, we were unable
to undertake meta-analyses due to heterogeneity in all aspects of
the included studies.
A small number of studies in this review employed mixed
methods. Implementation research is particularly ripe for such an
approach in which evidence of qualitative change can be set alongside elucidation of the reasons for such change. The fact that the majority of papers in our review were restricted to quantitative enquiry
means that the influence on implementation efforts at individual
(clinician or patient) and organizational levels is constrained.
In summary, there is evidence to support active training and
support of healthcare professionals in order to implement falls prevention evidence into clinical practice. The evidence around changing the
way people who fall are managed within primary care practices is
mixed, as is the use of community awareness programs and peer or
lay-delivered falls prevention programs. Nevertheless, questions
remain about the methods used to report, evaluate, and appraise implementation research, such as developing effective search strategies
and quality appraisal methods. The relative importance of this field
needs to be promoted alongside evidence for effective healthcare interventions in terms of funding if evidence is to be translated into policy
and clinical practice.
5. Impact on industry
The implementation of falls prevention research into practice involves changing the attitudes and behaviors of older people, healthcare
professionals, and organizations. However, there is a need for further
evaluation on how this can be best achieved.
Acknowledgement

This work was funded by the National Institute for Health Research (NIHR). This report/article presents independent research


448

Table 2
Description of Study Characteristics, Stratified by Type of Implementation Method.
Study

Country

Setting

Brown et al.
(2005)

USA

Physical
therapy
practices

Study purpose

Implementation strategy

Falls prevention
intervention

Sample

Population

Outcomes
evaluating
implementation

Follow up

Repeated
measures,
cohort study

To assess impact of
practice guideline on
process of care

Training of physicians (2 hours)
and nurses (30 minutes)

Not reported

3843 older people
(> 65 years) attending
ED

Documentary
evidence of history
taking, physical
examination and

action taken

1 year

Survey

To describe physical
therapists knowledge,
attitudes and behaviours
relating to fall prevention
To describe extent of
implementation of EBP by
nurses and therapists

CCFP programme comprising
training of physical therapists
(1 hour)

Medication
management,
vaccinations
and
ophthalmology
referral
Multi-factorial

CCFP programme comprising
training (90 minutes) of home
health care staff

Multi-factorial

184 nurses and rehabilitation
therapists from 19 home
health agencies (HHA)

-

94 physical therapy providers from 119 organisations

Self-reported use of 6 weeks
falls prevention
strategies and
change in practice.
1 year
Self-reported falls
prevention
assessment and
management
practice
1 year
Awareness of
campaign; use of a
hazard reporting
telephone line

Fortinsky et USA
al. (2008)

Community Survey

Larsson et al.
(2010)

Sweden

To evaluate the impact of
the programme on injury
rates

Training of community
practitioners (half day);
Media campaign 2006/7

Unclear

32 community practitioners;
82 members of public

21,898 people aged
> 55 years

Milisen et al.
(2009)

Belgium

Community Repeated
measures,
crosssectional

study
Community Survey

To test feasibility of
implementing a falls
prevention guideline

Staff training (2 hours)

Multi-factorial

23 GPs, 34 nurses, 25 PTs,
17 OTs

-

Scott et al.
(2006)

Canada

Community Repeated
measures,
cohort study

To evaluate the impact of
training on knowledge,
practice, falls and related
injuries

Training of community
healthcare support workers
(1 day)

Multi-factorial

57 community healthcare
support workers

87 people requiring
home help support

Strength and
balance training

61 general practitioners in
36 practices;
3 nurses

330 exercise
participants aged
> 80 years

Recruitment issues; 1 year
fidelity and
adherence

Multi-factorial
(individually
tailored)

Not reported

150 people >65 years
with urinary
incontinence, falls,
depression or
functional impairment

Physician
implementation
and patient
adherence rates

Changes to primary care practices
Gardner et al. New
Primary
(2002)
Zealand care

Shah et al.
(1997)

USA

Primary
care
practices

Process and

impact
evaluation of
a nonrandomised
trial
Case series

Nurse training (1 week)
Applicability and
feasibility of a primary care
nurse-delivered exercise
programme

To examine
implementation of CGA
recommendations

Communication between
geriatrician, primary care
physician and patient

Importance,
feasibility and
practicality of
guideline.
Change in
knowledge, uptake
of
recommendations

Unclear

Six
months

3 months

V. Goodwin et al. / Journal of Safety Research 42 (2011) 443–451

Training of healthcare professionals
Baraff et al.
USA
ED
(1999)

Study design


Table 2 (continued)
Study

Country

Setting

Study design

Study purpose

Implementation strategy

Falls prevention
intervention

Sample

Population

Outcomes
evaluating
implementation

Follow up

Wenger et al.
(2009)

USA

Primary
care
practices

Nonrandomised
trial

To examine effect of
ACOVE-2 intervention on
process of care

Changes to practice processes

and training of primary care
physicians (3 hours)

Unclear

2 practices;40 physicians

644 people aged
>70 years
experiencing falls,
urinary incontinence
or cognitive
impairment

% of quality
indicators satisfied

13 months

Peer or lay volunteer delivered programmes
Deery et al.
Australia Community Matched
(2000)
cohort with
repeated
measures

To assess impact of peer
education on fall-related
knowledge, attitudes and

behaviours

Peer-presented education sessions.
Training of peers unclear.

Education

Not reported

361 people
aged > 60 years
(education) and 174
age and sex matched
controls
349 older adults
(51–95 years)

Fall-related
attitudes,
knowledge and
behaviours

3 and
12 months

Fidelity to the
programme;
changes in fallrelated self-efficacy
and behaviours.
Knowledge and

awareness
regarding falls
prevention

6 weeks,
6 months,
1 year

Recall of SOYF,
involvement and
current falls
prevention
activities
Fall-related
behaviour change

5 years

USA

Community Repeated
measures,
cohort study

To examine whether a CBT Training of lay volunteers (2 days)
programme ‘a Matter of
Balance’ can be effectively
delivered by volunteers

Risk behaviour

change

Not reported

Sze et al.
(2005)

Hong
Kong

Community Survey

To evaluate impact of an
education and training
programme on awareness
and knowledge of fall
prevention

Training programme-community
centre staff and lay volunteers
(90 minutes); Educational seminar
for older people;

Education and
home hazard
modification

34 staff and 312
volunteers

5114 older people

321 healthcare
professionals); 9 shire
councils and 8 shire access
committees

80,000 people aged
>60 years

1,600 older people

(a) 43,821, (b) 58,722

Community awareness programmes
Barnett et al. Australia Community Surveys
(2004)

McClure et al. Australia Community Repeated
(2010)
measures,
crosssectional
study
Stackpool
Australia Community Repeated
(2006)
measures,
crosssectional
study

Multi-factorial
To assess sustainability of a Awareness raising, community
education, policy development,
community SOYF falls
engaging health professionals (1992
prevention programme
to 1996)
To evaluate whether a
population based
programme reduces falls
and injuries
To establish viability of
collaborative model to
promote physical activity
among older people

Multi-factorial
(a) Peer health promotion of falls
prevention activities, or (b) health
promotion officers delivering and
supporting physical activity. 2002 to
2006.
Collaborative management model
Physical activity
(2000 to 2003)

6 area Health Promotion units Not reported

Availability and
uptake of physical

activity
programmes

Unclear

4 years

3 years

V. Goodwin et al. / Journal of Safety Research 42 (2011) 443–451

Healy et al.
(2005)

ED Emergency Department; CFFP Connecticut Collaborative Falls Prevention; CGA Comprehensive Geriatric Assessment; ACOVE-2 Assessing Care of Vulnerable Elders; CBT Cognitive behavioural therapy; SOYF Stay of your Feet

449


450

V. Goodwin et al. / Journal of Safety Research 42 (2011) 443–451

Table 3
Individual Study Results, Stratified by Implementation Method.
Study

Results

Training of healthcare professionals

Baraff et al.
Improvement in 6 out 10 items on history taking; 2 out of 4 items on physical examination; 2 out of 6 items on actions taken
(1999)
Brown et al.
Most physical therapists reported an increased use of falls prevention strategies in practice.
(2005)
Fortinsky et al. Most community healthcare staff used recommended guidance for assessment and management of falls in practice
(2008)
Larsson et al.
Low awareness of campaign in the community (20%); 72% of fall prevention agents aware. 29 reports of community hazards in 6 months
(2010)
Milisen et al.
Disagreement between different professionals as to feasibility and roles in using falls prevention guideline.
(2009)
Scott et al.
Increased knowledge of staff, high use of checklist and action plan by staff, mixed uptake of recommendations by clients.
(2006)
Changes to primary care practices
Gardner et al.
Reasons for exclusion: being medically unwell; physical frailty; considered incapable of exercise. Reasons for participation: doctor recommendation, health/
(2002)
functional benefits, prevent falls. Reasons for declining: already active, too frail/unwell, commitment too long; not interested.
Shah et al.
6/9 physician recommendations implemented and all adhered to by patients. 3/7 self-care recommendations adhered to
(1997)
Wenger et al.
44% of intervention group and 23% controls met quality indicator for falls.
(2009)
Peer or lay volunteer programmes
Deery et al.

Greater changes in attitude reported for intervention group; Intervention group has lower knowledge at 3 months but greater at 12 months compared with
(2000)
controls; intervention group made more environmental changes and changed behaviour at 3 and 12 months.
Healy et al.
Significant improvements in self-efficacy and fall management.
(2005)
Sze et al.
Older people and volunteers reported gaining knowledge about falls prevention. Almost all community centre staff had set up falls prevention activities.
(2005)
Community awareness programmes
Barnett et al.
Culprit medication checked by more than half of GPs/Pharmacists most of time.Around half of community staff ran exercise classes. No councils had a
(2004)
comprehensive falls prevention policy. No access committees maintained falls prevention activities.
McClure et al.
Increased awareness of falls. Behaviour change of older people in relation to falls prevention.
(2010)
Stackpool
Increase in availability of exercise classes and enrolment.
(2006)

commissioned by the NIHR. The views expressed in this publication
are those of the author(s) and not necessarily those of the NHS, the
NIHR or the Department of Health.

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Victoria Goodwin, PhD, is a Senior Research Fellow for PenCLAHRC (Peninsula Collaboration for Leadership in Applied Health Research and Care) at the University of
Exeter, UK and a physiotherapist for Torbay Care Trust. She has recently completed a doctorate evaluating an exercise intervention to reduce falls among people with Parkinson's
disease. She is involved with the British Geriatrics Society specialist section for Falls and
Bone Health and is former national chair of AGILE (Chartered Physiotherapists working
with Older People). Her research interests are the rehabilitation of older people and those
with long term conditions.

Tracey Jones-Hughes, PhD, is an Associate Research Fellow for PenTAG (Peninsula Technology Assessment Group), currently working on Health Technology Assessment. She has
a diverse background, ranging from nursing to earning a PhD in environmental chemistry
at Plymouth University. However, more recently she became involved in project facilitation for PenCLAHRC, focusing on translation of research into clinical practice. Linking with
the varied nature of her career, Tracey's current research interests include systematic reviews of environment and human health related issues.

Jo Thompson-Coon, PhD, is a Research Fellow for PenCLAHRC as part of the evidence
synthesis team. Her background is in pharmacology and she has worked in the respiratory and complementary medicine fields. Her current role involves identifying and
prioritising potential local research projects and producing systematic reviews to inform evidence-based practice.

Kate Boddy, MSc, is an Information Specialist at PenCLAHRC where she has been working since 2009. She has been working in health services research since 2004 and received her MSc in Library and Information Management from the University of the
West of England in 2009. She has worked on numerous systematic reviews providing
information support and has a particular research interest in the ways in which different search interfaces can affect search results.
Ken Stein, MD, is Professor of Public Health with a background as a physician in general
practice. He directs a multi-disciplinary research group which undertakes evidence syntheses and economic evaluation on a wide range of health technologies and is deputy director of the PenCLAHRC which aims to improve the influence of research on NHS practice
in the UK.