A co-designed conceptual model for implementing falls prevention programmes for community-dwelling older adults in Singapore: a systems thinking approach

Abstract

Introduction: Implementing falls prevention programmes in the community presents numerous challenges. We sought to understand the dynamics between the determinants influencing implementation to develop a common conceptual model describing the complexities of implementing falls prevention programmes in Singapore.

Methods: A full-day group model building workshop with a series of structured activities was organised with 31 multidisciplinary stakeholders. Stakeholders who attended include healthcare professionals of different specialities (i.e. geriatrics, rehabilitation medicine, physiotherapy, nursing), community-based voluntary welfare organisations, researchers and policymakers.

Results: A causal loop diagram was developed to illustrate the determinants influencing implementation of community-based fall prevention programmes. It revealed factors driving key implementation and service outcomes in supply and demand of such programmes. Determinants of these outcomes were synthesised into four themes: (i) structural factors affecting the management and resource allocation for community-based falls prevention programmes, (ii) participation in programmes affected by older adults' willingness and ability to participate, (iii) perceived value as a composite of costs and benefits, and (iv) social support and exercise self-efficacy motivating long-term adherence. Furthermore, in our analysis of feedback relationships, two organisational behaviours were identified: unsustainable growth due to resource constraints (Limits to Growth) and tensions between executing symptomatic or fundamental solutions (Eroding Goals). Stakeholders also explored strategies for effective implementation.

Conclusions: A conceptual model describing the dynamics of implementing community-based fall prevention programmes was developed. This informed the formulation of a National Falls Prevention Framework, a priority action step for the effective implementation of these programmes in Singapore.

Keywords: falls; falls prevention; group model building; older people; participatory research; qualitative research; systems thinking.

Figure 1

Procedure figure illustrating the relationship between objectives for the workshop, specific activities to achieve objectives and results obtained.

Figure 2

Full CLD illustrating the factors influencing the implementation of falls prevention programmes, from the perspective of a multidisciplinary group of stakeholders.

Figure 3

Prioritised leverage points for interventions and their specific implementation strategies to improve effectiveness of implementation as developed by a multidisciplinary stakeholder group. The prioritised leverage points are: number of risk assessments conducted by hospital HCPs, lack of structured referral pathways, number of risk assessments conducted by community HCPs, performance of falls prevention programmes, effectiveness of programmes, quality of programmes, indirect costs, older adults’ exercise self-efficacy and older adults’ willingness to participate. Along with that, stakeholders have formulated the following implementation strategies to target specific leverage points (as illustrated in the hexagons): a National Falls Prevention Framework, standardising outcome measures, behavioural change interventions and caregiver relief.