HEALTH PROMOTION INTERNATIONAL Vol. 19. No. 3 © Oxford University Press 2004. All rights reserved.
Program sustainability of a community-based intervention to prevent falls among older Australians
1Health Promotion Unit, Northern Rivers Area Health Service, Lismore, NSW, Australia, 2School of Public Health, Queensland University of Technology, Brisbane, Queensland, Australia and 3University Department of Rural Health, University of Sydney, Lismore, NSW, Australia
Address for correspondence: Lisa Barnett, Health Promotion Unit, Northern Rivers Area Health Service, PO Box 498, Lismore, NSW 2480, Australia, E-mail: lisab{at}nrahs.nsw.gov.au
SUMMARY
Multi-strategy interventions have been demonstrated to prevent falls among older people, but studies have not explored their sustainability. This paper investigates program sustainability of Stay on Your Feet (SOYF), an Australian multi-strategy falls prevention program (1992–1996) that achieved a significant reduction in falls-related hospital admissions. A series of surveys assessed recall, involvement and current falls prevention activities, 5 years post-SOYF, in multiple original SOYF stakeholder groups within the study area [general practitioners (GPs), pharmacists, community health (CH) staff, shire councils (SCs) and access committees (ACs)]. Focus groups explored possible behavioural changes in the target group. Surveys were mailed, except to CH staff and ACs, who participated in guided group sessions and were contacted via the telephone, respectively. Response rates were: GPs, 67% (139/209); pharmacists, 79% (53/67); CH staff, 63% (129/204); SCs, 90% (9/10); ACs, 80% (8/10). There were 73 older people in eight focus groups. Of 117 GPs who were practising during SOYF, 80% recalled SOYF and 74% of these reported an influence on their practice. Of 46 pharmacists operating a business during SOYF, 45% had heard of SOYF and 79% of these reported being ‘somewhat’ influenced. Of 76 community health staff (59%) in the area at that time, 99% had heard of SOYF and 82% reported involvement. Four SCs retained a SOYF resource, but none thought current activities were related. Seven ACs reported involvement, but no activities were sustained. Thirty-five focus group participants (48%) remembered SOYF and reported a variety of SOYF-initiated behaviour changes. Program sustainability was clearly demonstrated among health practitioners. Further research is required to assess long-term effect sustainability.
Key words: Australia; older people; falls prevention; Stay on Your Feet; sustainability
INTRODUCTION
With ageing of the population, falls-related injuries are an increasingly important public health issue (Gillespie et al., 1997
; Mitchell and Moller, 2002). Falls among older people can be prevented by interventions targeting multiple risk factors (Tinetti et al., 1994; Gillespie et al., 1997; Feder et al., 2000; Mitchell and Moller, 2002). The impact of such community-based interventions can be viewed as a direct result of their reach, effectiveness, adoption, implementation and sustainability (Hawe et al., 1997; Glasgow et al., 1999).
Crisp and Swerissen describe sustainability as incorporating program sustainability, agency sustainability and sustainability of program effects (Crisp and Swerissen, 2002). Others have identified long-term institutionalization/incorporation of a program within an organization and capacity building in the recipient community as important components (Steckler and Goodman, 1989; Lefebvre, 1990; Goodman et al., 1993; Bracht et al., 1994; Hawe et al., 1997; Bush and Mutch, 1999; Glasgow et al., 1999). The systematic study of sustainability is in its infancy and new indicators are currently being developed (Goodman et al., 1993; Scheirer, 1993; Hawe et al., 1997; Bush and Mutch, 1999). Determinants are still unclear due to lack of an empirical knowledge base (Shediac-Rizkallah and Bone, 1998). To our knowledge there are no published studies addressing any aspect of sustainability of a multifactorial, community-based falls-prevention intervention.
Our study assessed program sustainability of the 1992–1996 Stay on Your Feet (SOYF) program across multiple community stakeholder groups, 5 years post-intervention. These groups were general practitioners (GPs), pharmacists, community health (CH) staff, shire councils (SCs), access committees (ACs) and the original target group.
The Stay on Your Feet (1992–1996) intervention
SOYF was a multi-strategic, community-wide intervention to decrease the number and severity of falls among the 80 000 non-institutionalized older people (
60 years of age) living in North Coast, New South Wales (NSW), Australia. It was evidence-based and had a comprehensive evaluation design (van Beurden et al., 1998). SOYF addressed footwear/foot-care, vision, physical activity, balance and gait, medication use, and home and public environmental hazards (Garner et al., 1996; Hahn et al., 1996). Multiple strategies including awareness raising, community education, policy development, engaging health professionals, and interventions directly targeting individuals were implemented. The health impact of SOYF immediately following the intervention (1996) was a 22% lower incidence of self-reported falls (p = 0.17) and a 20% lower age-standardized rate of falls-related hospital admissions (p < 0.01) in the intervention area compared with the control area (Kempton et al., 2000).
METHODS
Setting and sample
The surveys took place between October 2001 and June 2002 throughout the Northern Rivers Area Health Service (NRAHS) in NSW, Australia (Table 1). Ethical approval was received from NRAHS (No. 171).
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Survey instruments
Most of the survey instruments were two pages in length and conducted by mail (GPs, pharmacists, SCs) or telephone (ACs). The CH instrument was more comprehensive (three pages and involved displays of SOYF resources as memory prompts at specific stages in the survey process) and was completed in the presence of a Health Promotion Officer trained to administer the instrument. Focus groups were conducted with older people who were part of the SOYF target group.
GP survey instrument
A full description of the GP survey instrument has been published elsewhere (Barnett et al., 2003). Briefly, GPs were asked if they had heard of SOYF and, if so, to what extent SOYF had influenced their practice. They were also asked whether they still had the resource folder and to what extent they used it. Current falls-prevention practice was assessed by four questions, each with a four-part Likert response scale.
Pharmacy survey instrument
A full description of the pharmacy survey instrument has been published elsewhere (van Beurden et al., 2003). Briefly, pharmacists were asked if they had heard of SOYF and, if so, to what extent SOYF had influenced their practice, and whether they had adopted any specific activities from SOYF. Current falls-prevention practice was assessed by six questions, each with a four-part Likert response scale.
Community health survey instrument
Community health centres in NRAHS deliver primary health care to the community in a multi-disciplinary format. The CH survey instrument was developed in conjunction with health promotion officers from CH centres in the locality, to survey those in community nursing, physiotherapy, occupational therapy and health promotion. The survey requested current position, recall and involvement in relation to SOYF, details of falls-prevention activities since 1990, and whether the activity was related to SOYF. It also assessed barriers and enablers to SOYF program sustainability, including asking what made the activity possible and, if the activity had ceased, the reason why.
Falls-prevention activities were categorized in terms of SOYF strategies. These were: promotional material (books, leaflets, calendars and magnets), ‘falls-safe’ products, press releases in the media, assessing client risk factors and providing referrals, gentle exercise, walking groups, group talks, medication checks/advice, disposal of medication, preventing falls in public places, home safety, and footwear/care. Staff could have contributed to the various strategies by: helping to develop or establish new activities; engaging in activities as part of their usual work role; promoting/displaying, attending, or conducting/facilitating relevant activities; training others; providing or receiving referrals; or liasing with/supporting other workers/agencies engaged with the activities. A measure of program sustainability was calculated as the proportion of staff who initially became engaged in a falls-prevention activity through SOYF during 1992–1996 and who reported continued involvement 5 years later.
Shire council survey instrument
SCs are key agents in local development and building, and health and social planning, taking responsibility for many safety issues surrounding the public environment, including roads, footpaths and shopping areas. The SC survey instrument was developed from the original SOYF SC baseline survey in conjunction with a SC Environmental Health Officer. The survey targeted whole SCs. This required input from a range of staff within each shire. It asked: (i) for a list of positions involved in falls prevention; (ii) whether the SC had the SOYF resource ‘Preventing Falls in Public Places’ and to what extent it was used; (iii) what was done to prevent falls and what components related to SOYF; and (iv) whether any activities adopted through SOYF had ceased.
Access committee survey instrument
Shire ACs can be established by, or in association with SCs to assess public places regarding physical accessibility, and instigate improvements. SOYF aimed to encourage ACs to address environmental falls-related hazards as well as falls-related hazards. The AC instrument covered key organizations represented, roles, involvement in SOYF, and whether this involvement had continued. Activities included SOYF strategies described above for the CH survey instrument.
Focus groups
Focus groups with community-dwelling residents aged 60 years were conducted as part of the formative evaluation for a new falls-prevention intervention. These included two questions relevant to the present study: (i) participants' recall of SOYF and (ii) behavioural changes they attributed to SOYF. Participants were recruited within the study area from older people's organizations and clubs. All gave permission for focus group discussions to be taped and recordings were subsequently transcribed.
Data and analysis
After coding and entering, data were cleaned and analysed using SAS (SAS Institute, 2001). Frequency analyses were performed on grouped data and then by subgroups. Qualitative data from focus group transcriptions were analysed by two researchers using NU*DIST software (Qualitative Solutions and Research Pty Ltd, 1991–1997). A combined report was distilled from the initial reports by a broader panel of four researchers. It was not possible to identify individuals accurately and where the commonness of a particular response is given, this reflects an estimate by the group coordinator based on transcripts.
RESULTS
1. General practitioners
The response rate among GPs was 67% (139/209). Of the 117 GPs who were practising in the study area at any time during SOYF, 80% had heard of the program, and of those, most (74%) thought that SOYF had influenced their practice. Half (51%) still had a SOYF resource folder, and for those who did it was used at least ‘occasionally’ by 59%. The most common activity was ‘checking potential for medications to contribute to falls risk’ in older adult patients, with 75% of GPs doing so ‘most’/‘almost all’ of the time. Additional details regarding GP responses are provided elsewhere (Barnett et al., 2003).
2. Pharmacists
The response rate for pharmacists was 79% (53/67). Of the 46 pharmacists who had operated a retail pharmacy at any time during 1992–1996, 45% had heard of SOYF, and 79% of these reported being ‘somewhat’ influenced by the program. Over half (53%) reported checking medications for ‘most’ or ‘almost all’ of their older clients (aged 60 years) to assess the potential to contribute to falls, and 72% reported that they urged ‘most’ or ‘almost all’ older clients to bring in out-of-date medications for disposal. Additional details regarding pharmacist responses are provided elsewhere (van Beurden et al., 2003).
3. Community health staff
Of 204 potential staff in community nursing, physiotherapy, occupational therapy and health promotion, 129 (63%) completed the survey: 57% were in nursing, 26% in physiotherapy, 12% in occupational therapy and 5% in health promotion. The 75 who did not complete the survey were unavailable either at the arranged group meetings or when subsequently reminded.
Of the 76 staff (59%) in the area at the time of SOYF, 99% had heard of SOYF. Most of these staff (82%) reported being involved. The three falls-prevention activities undertaken by staff since 1990 that were highly related to SOYF were promotional material [70/87 (81%)], medication disposal [23/33 (70%)] and falls-safe products [42/74 (57%)] (Table 2). Falls-prevention activities that least related to SOYF were public places [7/23 (30%)] and walking groups [16/47 (34%)].
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Preventing falls in public places, despite being the activity least related to SOYF, was sustained more than any other (71%) by the few staff that had taken it on through SOYF. This was followed by medication checks and advice, and gentle exercise classes (53% and 50%, respectively). Activities associated with falls-related press releases, walking groups, group talks and promotional material were poorly sustained (0%, 19%, 23% and 24%, respectively).
When asked what made involvement in SOYF-related activities possible, the most common of the 510 responses was that it was ‘part of normal work role’ (41%), followed by ‘availability of resources’ (19%), a ‘prioritised project’ (14%) and ‘compatible with other projects’ (8%). The most common reasons for why an activity had ended, among the 168 comments, were ‘resources and funding ceased’ (41%), followed by ‘work and staffing issues’ (14%) and ‘lowered priority’ (13%).
4. Shire councils
Nine of the 10 SCs (90%) responded to the survey. Each SC nominated a different combination of staff (12 different positions nominated) as playing a role in preventing falls. Four SCs (44%) said they had a copy of the manual of guidelines entitled Preventing Falls in Public Places, with three unsure and two indicating that they did not. Only one (11%) said that they used it and that was ‘occasionally for reference’.
Of the nine responding SCs, six (67%) reported doing regular checks of footpaths, four (44%) of roads, two (22%) of steps and one (11%) of shops. Six (67%) reported having policies and processes for maintenance requests in relation to falls prevention, six (67%) in relation to incident reporting, and five (56%) in relation to hazard reporting. One SC (11%) was in the process of developing hazard check policy and processes. None had a comprehensive falls-prevention policy.
Three SCs (33%) had strategies regarding access and safety that function via checks at design and construction stages based on standards from the Building Code of Australia. One SC (11%) suggested that ‘realistically, council could not adopt all the strategies in SOYF because of budget pressures’ and none thought their falls-related activities were related to SOYF.
5. Access committees
Eight of the 10 SCs (80%) had an AC. All ACs had representatives from SCs and agencies for people with disabilities. Four (50%) also had representatives from aged services. Three (38%) included health service representatives and one included a parent with young children.
Roles of the ACs included to advocate, advise and assist SCs on issues of safety and access for people with disabilities.
The ACs with broader membership included issues of safety and access for the wider community.
Four of the eight ACs were established since SOYF was initiated in 1992. Seven of the eight ACs were involved in falls-prevention activities and cited that they were assisted by the SOYF booklet, media campaigns, local falls advisers, workshops and sample products. Five years on, the ACs had not continued any of the initiated SOYF activities.
6. Older people
The community sample of older people consisted of 73 participants from eight focus groups (eight to 10 in each). Three quarters (74%) were female, 77% of the sample were aged 70 years and 86% had lived in the study area for at least 10 years.
Thirty-five participants (48%) remembered SOYF either on initial questioning or after being prompted with promotional materials. Females remembered SOYF more than males [33/54 (61%) compared with 2/19 (11%), respectively]. Most participants remembered as a result of seeing the book (93%), with four (11%) remembering because of a personal fall, and one (3%) recalling a talk by their GP.
More than half the participants outlined behavioural changes they had made due to SOYF. Although further precise numeric breakdown of qualitative responses was not possible (or intended), the most common behaviour change was taking up daily walking. Improving home safety was a common response (e.g. using bath and shower mats, using a chair in the bathroom, removing loose mats throughout the home, and using a small step-ladder instead of trying to reach up into high cupboards). Some said they had made footwear changes, now choosing to wear sneakers, or shoes with broader, lower heels. Other responses included taking more care (e.g. looking out for hazards on the footpath), being more self-aware (particularly while walking), using a walker to maintain balance, and ensuring glasses were a good fit.
DISCUSSION
This paper presents the first published assessment of sustainability of a multi-component falls-prevention intervention. It should be noted that the sample was largely rural, that there were no intervention-free comparison groups and no data on non-respondents. Some caution should therefore be exercised in interpreting the results. Despite these limitations, we have largely convergent data from multiple stakeholder groups, thus the study provides information that may be useful to those planning a similar intervention.
It is encouraging that the majority of GPs remembered SOYF and felt that their practice had been influenced. Results for pharmacists indicate that whilst their recall of SOYF was less than for GPs, more of those who did recall SOYF reported an influence on their practice.
SOYF was probably most well known and remembered by CH professionals. Much falls-prevention activity undertaken by this group was considered to be related to SOYF. That distribution of ‘promotional materials’ was the activity most highly related to SOYF is of no surprise considering that this activity was most likely a direct result of program promotions. Disposal of out-of-date medication has been encouraged since 1998 by a national initiative, Return Unwanted Medications (http://www.returnmed.com.au), but from 1990–1997 it is likely that the push for medication disposal in this area came largely from SOYF.
Efforts of CH staff to prevent falls in public places appear to be quite sustainable. This may reflect the way staff are engaging in such an activity (perhaps becoming committee members on relevant SC committees) or might simply reflect strong commitment by those involved. Both medication checks and gentle exercise classes were sustained at >50%, which is encouraging (a 60% program survival rate has been suggested as a reasonable achievement) (Bracht et al., 1994) and could indicate incorporation into staff roles.
Interesting insights were obtained from CH staff on barriers and enablers to sustainability. That CH staff reported involvement in SOYF activities as ‘part of normal work role’ indicates an incorporation of SOYF into regular duties and provides direct evidence of program institutionalization (Hawe et al., 1997). ‘Prioritization’ as an enabler, and ‘no longer a priority’ as a barrier confirm that priority setting of a health issue is an important element in capacity building (Schwartz et al., 1993). That activities were considered ‘compatible with other projects’ indicates a good fit between the program and the goals/values of the delivering organization (in this case CH centres), which has been identified as being helpful in sustainability (Scheirer, 1981; Steckler and Goodman, 1989; Bracht et al., 1994; Rissel et al., 1995; Herbert and White, 1996). The main reason CH staff ended SOYF activities, ‘resources and funding ceased’, is consistent with the literature (Schwartz et al., 1993; O'Loughlin et al., 1998) and may explain why activities associated with promotional materials were poorly sustained. Our finding of ‘work and staffing issues’ as a barrier to sustainability is consistent with a previous study (O'Loughlin et al., 1998), which found that ‘few staff changes’ was an enabler of perceived sustainability.
The impact of SOYF on local government presents a different picture. That none of the SCs thought their falls-prevention activities were related to SOYF suggests that the project may have had little impact, at least in terms of current recall. It is likely that reported activities (regular checks of footpaths and having policies and processes for maintenance requests and incident reporting) are most likely directly related to fear of litigation. Certainly, a self insurance program in NSW recommends to SCs that periodic identification and monitoring plus process systems for footpath maintainance and repair are now required to reduce the possibility of claims (Statewide Mutual, 2002).
Perhaps the recommendations and guidelines were simply not practical from a SC perspective, due to the many SC roles and departments involved in falls prevention, as well as numerous competing priorities and budgetary constraints. On reflection, in order to achieve sustainable change in local government and associated committees, it may be preferable to concentrate on key policy changes as opposed to a manual of guidelines that may or may not be adhered to.
It is heartening that the behavioural changes reported by focus group participants were consistent with the messages disseminated by SOYF. Furthermore, the intervention strategies in which they were embedded were designed to be self-sustaining (Garner et al., 1996). Effectiveness of these interventions was also reflected previously in the high level of reach of intervention components within the target group, measured both at mid-term and at the end of intervention (Kempton et al., 2000).
Clearly stakeholder groups have incorporated SOYF strategies to different degrees, ranging from a high level (CH staff) to what may be considered non-existent (SCs and ACs). Enablers and barriers identified in the CH setting are consistent with much of the literature in this area and provide an insight into program sustainability within this setting. In other stakeholder groups, sustainability is likely to relate to prioritization and reach of implementation, internal factors within organizations, personal interest, and influence from other sectors. What is certain is that a multi-strategy falls-prevention intervention, which reported measurable immediate outcomes, has also demonstrated program sustainability amongst health practitioners and some behavioural change in the original target group. As effect sustainability is the ultimate goal of health promotion programs, it has been questioned whether program sustainability is necessarily always a desirable aim (Crisp and Swerissen, 2002). What remains to be investigated is whether the program sustainability translates into effect sustainability in terms of self-reported falls rates and falls-related hospital admissions.
ACKNOWLEDGEMENTS
We wish to thank Gina Davis, Janice Backhouse, Elizabeth Patterson, Maxine Molyneux, Di Anson, Julia Gill and Jan Mills for their contribution to design and/or implemention, and Denise Hughes for technical support. Our research was funded in part by Injury Prevention and Control (Australian Research Collaboration).
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