This week you will search the literature in the school databases for article within 5 years of today’s date, that are appropriate for your PICOT question below.
1. Among adult patients in the acute care setting would the implementation of patient-centered interventions be more effective compared to the usual fall prevention interventions in reducing incidence of falls two months after implementation?
The article is a QUALITATIVE research study.
- Read the first few sentences of methods section of your articles to assess what type of article you have
- Critique each article using the appropriate Appraisal Forms. The form takes you through a reflection on WHY was research done-HOW was research done and WHAT was found.
- Review rubric carefully to ensure all questions have been answered. Points are deducted for articles not loaded or if incorrect type of article submitted.
- All answers to questions are brief and only 1- 2 sentences. Example: What group produced the guideline? Answer: US Preventive Services Task Force develops recommendations about preventive services based on a review of high-quality scientific evidence and publishes its recommendations on its website and or in a peer reviewed journal
- Avoid any copying and pasting 7 or more words of content from the article or another source. Use your own words to create your answers. APA is not required for content of answers on template
- APA is only required for your citation on the template.
APPENDIX E
Appraisal Guide:
Findings of a Qualitative Study
Citation:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Synopsis
What experience, situation, or subculture does the researcher seek to understand?
Does the researcher want to produce a description of an experience, a social process, or an event, or is the goal to generate a theory?
How was data collected?
How did the researcher control his or her biases and preconceptions?
Are specific pieces of data (e.g., direct quotes) and more generalized statements (themes, theories) included in the report?
What are the main findings of the study?
Credibility
Is the study published in a source
that required peer review? Yes No Not clear
Were the methods used appropriate
to the study purpose? Yes No Not clear
Was the sampling of observations or
interviews appropriate and varied
enough to serve the purpose of the study? Yes No Not clear
*Were data collection methods
effective in obtaining in-depth data? Yes No Not clear
Did the data collection methods
avoid the possibility of oversight,
underrepresentation, or
overrepresentation from certain
types of sources? Yes No Not clear
Were data collection and analysis
intermingled in a dynamic way? Yes No Not clear
*Is the data presented in ways that
provide a vivid portrayal of what was
experienced or happened and its
context? Yes No Not clear
*Does the data provided justify
generalized statements, themes,
or theory? Yes No Not clear
Are the findings credible? Yes All Yes Some No
Clinical Significance
*Are the findings rich and informative? Yes No Not clear
*Is the perspective provided
potentially useful in providing
insight, support, or guidance
for assessing patient status
or progress? Yes Some No Not clear
Are the findings
clinically significant? Yes All Yes Some No
* = Important criteria
Comments
___________________________________________________________________________
___________________________________________________________________________
APP E-2 Brown
Brown APP E-1
RESEARCH Open Access
Qualitative research to inform economic
modelling: a case study in older people’s
views on implementing the NICE falls
prevention guideline
Joseph Kwon1* , Yujin Lee2 , Tracey Young1 , Hazel Squires1 and Janet Harris1
: High prevalence of falls among older persons makes falls prevention a public health priority. Yet
community-based falls prevention face complexity in implementation and any commissioning strategy should be
subject to economic evaluation to ensure cost-effective use of healthcare resources. The study aims to capture the
views of older people on implementing the National Institute for Health and Care Excellence (NICE) guideline on
community-based falls prevention and explore how the qualitative data can be used to inform commissioning
strategies and conceptual modelling of falls prevention economic evaluation in the local area of Sheffield.
: Focus group and interview participants (n = 27) were recruited from Sheffield, England, and comprised
falls prevention service users and eligible non-users of varying falls risks. Topics concerned key components of the
NICE-recommended falls prevention pathway, including falls risk screening, multifactorial risk assessment and
treatment uptake and adherence. Views on other topics concerning falls prevention were also invited. Framework
analysis was applied for data analysis, involving data familiarisation, identifying themes, indexing, charting and
mapping and interpretation. The qualitative data were mapped to three frameworks: (1) facilitators and barriers to
implementing the NICE-recommended pathway and contextual factors; (2) intervention-related causal mechanisms
for formulating commissioning strategies spanning context, priority setting, need, supply and demand; and (3)
methodological and evaluative challenges for public health economic modelling.
: Two cross-component factors were identified: health motives of older persons; and professional
competence. Participants highlighted the need for intersectoral approaches and prioritising the vulnerable groups.
The local commissioning strategy should consider the socioeconomic, linguistic, geographical, legal and cultural
contexts, priority setting challenges, supply-side mechanisms spanning provider, organisation, funding and policy
(including intersectoral) and health and non-health demand motives. Methodological and evaluative challenges
identified included: incorporating non-health outcomes and societal intervention costs; considering dynamic
complexity; considering social determinants of health; and conducting equity analyses.
© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article’s Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
* Correspondence: jkwon6@sheffield.ac.uk
1School of Health and Related Research, University of Sheffield, Regent Court
(ScHARR), 30 Regent Street, Sheffield, England S1 4DA
Full list of author information is available at the end of the article
Kwon et al. BMC Health Services Research (2021) 21:1020
https://doi.org/10.1186/s12913-021-07056-1
http://crossmark.crossref.org/dialog/?doi=10.1186/s12913-021-07056-1&domain=pdf
https://orcid.org/0000-0002-2860-7280
https://orcid.org/0000-0003-0450-9667
https://orcid.org/0000-0001-8467-0471
https://orcid.org/0000-0002-2776-4014
https://orcid.org/0000-0002-0754-7223
http://creativecommons.org/licenses/by/4.0/
http://creativecommons.org/publicdomain/zero/1.0/
mailto:jkwon6@sheffield.ac.uk
s: Holistic qualitative research can inform how commissioned falls prevention pathways can be feasible
and effective. Qualitative data can inform commissioning strategies and conceptual modelling for economic
evaluations of falls prevention and other geriatric interventions. This would improve the structural validity of
quantitative models used to inform geriatric public health policies.
Keywords: Falls, Falls risk, Falls prevention, National Institute for health and care excellence guideline,
Implementation, Qualitative research, Facilitators and barriers, Economic model, Public health
Background
Falls among older people impose significant morbidity
and mortality burdens [1]. Around 30% of community-
dwelling persons aged 65+ fall each year [2]. Falls can re-
sult in fatal or debilitating injuries such as hip fractures
[3], provoke fear of further falls [4], and induce func-
tional decline [5]. They also impose substantial burdens
on care systems through hospitalisations and long-term
care admissions [6] and on informal caregivers [7]. Falls
prevention is hence a public health priority [8].
The rationale for intervention is further supported by
randomised controlled trial (RCT) findings that diverse
community-based falls prevention interventions signifi-
cantly reduce the number of falls and fallers [9, 10]. In
England and Wales, the National Institute for Health
and Care Excellence (NICE) clinical guideline 161
(CG161) is the normative reference point for local clin-
ical practice [2]. This recommends that persons aged
65+ receive falls risk screening at routine visits to health
and social care professionals; those screened to be at
high risk would then be referred to multidisciplinary falls
risk assessment and tailored treatments, including exer-
cise, home assessment and modification (HAM), medica-
tion modification and vision improvements [2]. These
treatments may also be delivered individually as single-
component interventions [11–13], either as substitutes
for the multifactorial intervention or as non-mutually
exclusive complements [14, 15]. These interactions be-
tween screening and treatment components, the multi-
factorial risk profile of falls as a geriatric syndrome [16],
and the wider environmental risk factors [17, 18] intro-
duce substantial complexity to falls prevention [19, 20].
Due to this complexity, community-based falls preven-
tion strategies face significant implementation challenges
[21–24]. For example, a recent survey of English GPs
found that only 31% routinely screened their older pa-
tients for falls history; the median annual number of re-
ferrals to falls prevention services per GP was just 10
[25]. Implementation quality can be suboptimal even in
RCT settings. For example, the uptake rate for a UK trial
of falls prevention exercise was 6% [26]; adherence to
different components of multifactorial interventions is as
low as 28% [27]; and 16% of participants withdraw from
falls prevention exercise at trial conclusion [28]. Low im-
plementation reduces the effectiveness and population
reach/impact of falls prevention [20]. Accordingly, NICE
CG161 incorporated a systematic synthesis of older peo-
ple’s views on the facilitators and barriers to falls preven-
tion (covering the period 1990–2003), but found no
study that explored their views on multifactorial pack-
ages (p. 101) [2]. More recent qualitative works have
likewise focused on specific components of the falls pre-
vention pathway, including receptiveness to falls preven-
tion advice [29], falls risk assessment [30], and exercise
uptake [31, 32] and adherence [33]. This is an important
evidence gap given that complexity results from the
interaction of facilitators and barriers across different
pathway components. A more holistic approach to quali-
tative research with current or potential falls prevention
service users is warranted.
Health economic evaluation is a comparative analysis
of alternative healthcare strategies in terms of costs and
consequences with the purpose of informing the efficient
use of scarce resources under a constrained healthcare
budget [34]; it can also incorporate further decisional
criteria beyond cost-effectiveness, such as reduction in
social inequities of health, according to stakeholder pref-
erence [35–37]. One vehicle for economic evaluation is
decision modelling that represents the key causal mecha-
nisms of a decision problem in mathematical and statis-
tical/probabilistic relationships [34]. Decision models are
particularly well-suited for considering all relevant costs
and effects of interventions over long time horizons, and
for evaluating ‘what-if’ scenarios for the full target popu-
lation of the decision-making jurisdiction [38]. One such
scenario is the commissioning of implementation re-
sources to change current local practice into a form ap-
proaching the NICE-recommended pathway.
A de novo economic model is likely required if the
existing economic models or evidence are insufficient
for informing local decision-making: e.g., due to unreal-
istic representation of local practice and/or shortcom-
ings in characterising the key causal mechanisms.
Currently, the decision model developed to inform
CG161 [39] evaluates a multifactorial intervention for
the national population and may not be locally generalis-
able; while the locally applicable Public Health England
Return on Investment tool [11] only evaluates single-
component interventions. This presents a rationale for
developing a de novo model evaluating the cost-
Kwon et al. BMC Health Services Research (2021) 21:1020 Page 2 of 19
effectiveness relative to current practice (and wider deci-
sional outcomes) of a strategy that locally implements
the NICE-recommended pathway.
Qualitative research with current and potential con-
sumers of health services can contribute to economic
modelling in two important ways [40, 41]: (a) eliciting
appropriate commissioning strategies; and (b) under-
standing the key methodological and evaluative chal-
lenges to public health economic modelling.
Concerning (a), the model-evaluated commissioning
strategy should fully reflect the complex network of
intervention-related casual mechanisms influencing im-
plementation. Several frameworks exist to capture such
complexity [40], including the Context and Implementa-
tion of Complex Interventions (CICI) framework [20]
which was developed as part of the INTEGRATE-HTA
project to consider a comprehensive set of factors influ-
encing the assessment of complex health technologies
[19]. CICI distinguishes between contextual factors (e.g.,
socio-cultural, legal) and implementation mechanisms
(e.g., professionals, organisations) that shape implemen-
tation quality. Priority-setting challenges – e.g., reducing
social inequities of health [35] – also arise from the im-
plementation context [40]. Given the CICI framework’s
lack of focus on demand-side mechanisms (e.g., motiva-
tions of the older persons to engage in healthy behaviour
[42]), it could be supplemented by the health needs as-
sessment (HNA) framework that incorporates demand,
supply and need/eligibility as distinct yet overlapping do-
mains [43]. Inductive qualitative data analysis could
commence with themes sourced from this combined
framework, and thereafter interact with new themes
emerging from the data to arrive at the final thematic
framework informing the commissioning strategies [44,
45].
Concerning (b), the nature of falls being a public
health problem faced by a broad spectrum of older pop-
ulations – rather than a clinical problem faced by a well-
defined, narrow patient group – presents further com-
plexity to model development [41]. According to a sys-
tematic methodological review, the key methodological
challenges to public health economic modelling include:
(i) capturing non-health outcomes and societal interven-
tion costs; (ii) considering dynamic complexity in health
determinants and intervention need; (iii) considering
theories and models of human behaviour based on
psychology and sociology; and (iv) considering social de-
terminants of health and issues of equity [46]. Address-
ing such challenges is part of the INTEGRATE-HTA
recommendations (see chapter 3) [19], and is necessary
for improving the structural validity of the decision
model [41]. The same inductive analysis can identify
how these challenges relate to the local decision problem
and hence to the decision model structure [41].
In all, a de novo qualitative study of older people is
warranted, first to holistically explore the facilitators and
barriers for implementing the NICE-recommended falls
prevention pathway, and second to proactively use the
resulting qualitative data to inform economic modelling.
The latter would improve upon the siloed approach that
is widely prevalent in the literature, whereby qualitative
research is conducted and interpreted separately from
economic evaluation, even when both designs are in-
cluded in the same project [39, 47, 48].
The study aims to capture the subjective views of older
people on implementing the NICE CG161 guideline on
community-based falls prevention and use the qualita-
tive data to inform the development of a conceptual falls
prevention economic model. The latter would guide
commissioning decisions in a local health economy seek-
ing to implement CG161, Sheffield being one such set-
ting. The research objectives are to:
1. Identify the facilitators and barriers for implementing
key components of the CG161 community-based falls
prevention pathway – including falls risk screening
and assessment, falls risk awareness, and uptake and
adherence of treatments within multifactorial inter-
vention – and contextual factors influencing the
pathway implementation in Sheffield.
2. Inform potential local commissioning strategies on
falls prevention by understanding the causal
mechanisms in context, supply, need and demand
that influence implementation.
3. Identify the methodological and evaluative
challenges associated with developing a public
health economic model of falls prevention in the
local context.
Given the aim of informing a model applicable to a
local health economy, the identified qualitative themes
would likely be locally specific. Hence, the main target
audience (outside of Sheffield) are economic modellers
and qualitative researchers (and commissioners sponsor-
ing them) interested in applying the methodology used
in this case study to other local health economies and
public health areas. That said, the facilitators and bar-
riers identified under the first objective would be gener-
alisable to other urban community settings in England
and Wales and hence be of interest to professionals and
patient groups seeking to improve the implementation
of local falls prevention.
Methods
The qualitative research involved focus groups and inter-
views with older persons living in the community. The
Kwon et al. BMC Health Services Research (2021) 21:1020 Page 3 of 19
ethics approval was obtained from the Research Ethics
Committee at the School of Health and Related Re-
search, University of Sheffield (ref. 025248). Written
consent was obtained from willing participants.
Target population and sampling
The target population comprised persons aged 65+ in
Sheffield, England, and persons aged 50–64 who are at
high falls risk. The latter group was included to explore
the rationale for earlier prevention as is currently recom-
mended for inpatient settings by CG161 [2]. Purposive
sampling covered multiple categories of participant char-
acteristics in terms of falls risk and service use as illus-
trated in Fig. 1.
According to CG161, those with a history of fall(s) re-
quiring medical attention or recurrent falls in the past
year and/or mobility and balance problems were defined
as high-risk [2]. Low-risk individuals were sampled be-
cause they are still eligible for falls risk screening and/or
interested in early prevention.
Recruitment continued until all participant categories
were covered and themes saturated. Specifically, two
focus groups (FG1, FG2) were formed from two separate
cohorts enrolled in Dance to Health, a falls prevention
programme that combines evidence-based Otago and
Falls Management Exercise components in dance rou-
tines [49, 50]; these groups contained high and low risk
service users. Two further groups (FG3, FG4) were
formed from a Patient and Public Involvement group
meeting regularly at the Northern General Hospital and
a social group meeting at Zest Community, a local social
enterprise offering leisure, health and work support ser-
vices to diverse age groups; these contained high and
low risk service non-users. Two interview participants
were recruited from Dance to Health and Zest
Community.
Focus groups were held directly before/after the regu-
lar meetings. Community organisation staff confirmed
before research commencement whether their members
could give informed consent. One participant declared
memory problems while another a recent diagnosis of
Alzheimer’s disease; but both were regular attendees of
community groups and expressed confidence in partici-
pating. After obtaining written consents, questionnaires
were administered to collect data on demographics, falls
history and fear of falling, current physical activity, and
contact with falls prevention services.
Focus group participants were previously acquainted
from attending the same activity and were comfortable
sharing their experiences in the group. The main inter-
viewer (JK) introduced himself and his PhD project aim
and presented himself as someone wanting to learn from
the participants. Participants were motivated to help the
interviewer understand their perspective on falls and
falls prevention. For interviews, around 15 min were
spent for the participants and the interviewer to become
acquainted in conversing (at interviewees’ homes) before
the research commenced.
topics
The main discussion topics were structured around the
sequential steps of the proactive prevention pathway rec-
ommended by CG161 [2], namely: (i) falls risk screening/
assessment by professionals; (ii) participant suggestions on
raising falls risk awareness in the community; (iii) initial
uptake of different treatments; and (iv) long-term
Fig. 1 Categories for study participant characteristics
Kwon et al. BMC Health Services Research (2021) 21:1020 Page 4 of 19
adherence to treatments. The pathway is proactive in that
it is initiated by professional referral of high-risk individ-
uals after falls risk screening. If mentioned by participants,
two further pathways were discussed: the reactive pathway
– where older persons are referred to falls prevention by
professionals after medical attention for a fall, which is
also recommended by CG161 (see recommendations
1.1.2.1, 1.1.3.2 and 1.1.6.1) [2]; and the self-referred path-
way – where older persons enrol in falls prevention with-
out professional referral.
A simplified graphical summary of the proactive
pathway, as shown in Fig. 2, was used to explain the
main topics to participants. Four treatment types –
exercise, HAM, medication change and vision im-
provement – were explained while emphasising that
other types exist, such as chiropody. It was also
highlighted that a reactive pathway after a serious fall
is commonly used, and that a self-referred pathway is
recommended by experts [51]. Further contextual fac-
tors influencing falls risk and prevention (e.g., safety
of pedestrian walks in Winter) were actively explored
as they emerged during discussion.
Data collection
Recorded audio data were transcribed and anonymised.
The questionnaire data were similarly transferred to an
Excel spreadsheet and anonymised. Both data were
stored securely in the University designated folder.
Data analysis
A framework analysis was employed for the analysis of
obtained data [44, 45]. The approach involved five
stages: (a) familiarisation – which involves repeated lis-
tening to audio and reading of transcripts for immersion
in the data; (b) identifying a thematic framework –
which is based on an a priori set of issues related to the
research objectives and themes emerging from the data;
(c) indexing – which systematically applies the thematic
framework to the transcripts; (d) charting – which ‘lifts’
the data from the transcripts and rearranges them (e.g.,
in a tabular format) according to the thematic frame-
work; and (e) mapping and interpretation – which seeks
associations and develops policy-related strategies from
the charted data based on a priori issues and emerging
themes. Stages (a) to (c) were conducted independently
by two authors (JK and YL). All authors contributed to
stages (d) and (e).
From stage (b) onwards, three frameworks related to
the research objectives were constructed using a priori
concepts and themes emerging from the data:
(I) Framework to understand the facilitators and
barriers to components of the NICE CG161 falls
prevention pathway and cross-component and con-
textual factors.
(II) Framework to inform potential commissioning
strategies by accounting for causal mechanisms in
context, priority setting, need/eligibility, supply and
demand.
(III)Framework to understand the key methodological
challenges to public health economic model
development.
Framework (I): facilitators and barriers and cross-
component and contextual factors
This framework closely followed the structure of the dis-
cussion topics and charted the main themes identified
from the data. Facilitators and barriers for the pathway
implementation that emerged from the data were ar-
ranged by a priori thematic categories corresponding to
the NICE CG161 pathway components – i.e., (i) falls risk
screening/assessment by professionals; (ii) raising falls
risk awareness; (iii) initial uptake of treatments; and (iv)
long-term adherence to treatments. Cross-component
factors – i.e., facilitators and barriers influencing mul-
tiple pathway components – were highlighted.
Fig. 2 Graphical summary of the recommended falls prevention guideline used to introduce the discussion topics to focus group and
interview participants
Kwon et al. BMC Health Services Research (2021) 21:1020 Page 5 of 19
Additional contextual factors influencing the pathway
implementation were noted as they emerged from the
data.
Framework (II): potential commissioning strategies
This framework rearranged the main themes under Frame-
work (I) into a format that guides commissioning strategies
(actual or model-evaluated). An a priori CICI-HNA frame-
work was constructed that combined the thematic categor-
ies within the CICI [20] and the HNA frameworks [43].
This is illustrated in Fig. A in Supplementary Material with
accompanying descriptions. In brief, the CICI framework
distinguished between implementation context (e.g., socio-
economic, legal) and mechanisms (e.g., provider, funding)
[20]. The HNA framework distinguished between supply,
demand and need/eligibility [43]: supply corresponded to
the CICI implementation mechanisms; demand encom-
passed personal and external factors influencing uptake/ad-
herence decisions (e.g., health-related motives for healthy
behaviour [42], community marketing, self-efficacy promo-
tions [52, 53]); need/eligibility was determined by normative
clinical and public health guidelines and intervention stud-
ies that demonstrated a group’s ability to benefit from an
intervention [43]. Further thematic categories that emerged
from the data were noted (e.g., priority setting challenges
that contextualised commissioning [35]). The mapped
themes informed commissioning strategies by highlighting
which CICI-HNA factors were modifiable – i.e., lie within
the decision space which is defined by the stakeholders in-
volved, decision time horizon and budget/capacity con-
straints – and to what extent.
Framework (III): challenges for public health economic
modelling
The thematic categories of key methodological chal-
lenges for public health economic modelling were taken
from a systematic methodological review [46]: (i) captur-
ing non-health outcomes and societal intervention costs;
(ii) considering dynamic complexity in health determi-
nants and intervention need; (iii) considering theories
and models of human behaviour based on psychology
and sociology; and (iv) considering social determinants
of health and issues of equity. Additional challenges as-
sociated with economic modelling and evaluation were
also identified from the emerging data.
Results
Participant characteristics
Twenty-seven persons participated in research across
four focus groups (FG1–4) and two interviews (INT1–2)
between October 2019 and January 2020. Table 1 sum-
marises their characteristics.
Regarding current access to falls prevention, 11 re-
ported having spoken to a professional about falls risk.
Nevertheless, 21 reported recent use of services with
some falls prevention properties [9], suggesting that the
main falls prevention pathway under current practice is
self-referral by older persons. Of the 21 users, 13 re-
ported accessing multiple interventions. The most widely
accessed services were physiotherapy and falls education.
Framework (I): facilitators and barriers and cross-
component and contextual factors
Table 2 summarises the identified facilitators and bar-
riers to implementation by pathway component. The
themes are numbered to facilitate re-mapping to later
frameworks. Table A in Supplementary Material shows
the direct transcript quotes for each theme. Figure B in
Supplementary Material graphically illustrates how
themes were mapped from qualitative data to Frame-
work (I) and subsequently re-mapped to Frameworks
(II) and (III).
Falls risk screening and assessment by professionals
Factors influencing falls risk screening and assessment
by professionals could be divided into three groups: (A)
professional competence; (B) system-wide approaches
and resources; and (C) motivation and awareness of
older persons. Participants were aware of the importance
of professional competence in conducting the falls risk
screening, particularly incompetence as barriers. For ex-
ample, one participant had noticed the narrow scope of
professional risk assessment:
(FG1) “I’d think it was important if somebody went
to a health professional, the health professional would
check on a whole lot of background information
apart from immediate health thing – you know, what
is your living, housing situation.” (Theme [1–6])
Nevertheless, participants were also aware of the impact
of system-level approaches and resources beyond indi-
vidual professional competence and made suggestions
on improvement. One such suggestion was to adopt a
proactive, data-based approach to risk screening akin to
mass vaccination:
(FG1) “And with regards to hooking people in,
when flu jab time comes up, we all get a text or a
message or we get told that we need a flu jab. So,
follow that lead, really. I’m sure there’s a record
showing age groups and then tell them ‘Look, this
service is available. Come on in!’” (Theme [1, 2])
Moreover, a few comments suggested that older person’s
motivation to maintain health would facilitate profes-
sional efforts to discuss falls risk and prevention:
Kwon et al. BMC Health Services Research (2021) 21:1020 Page 6 of 19
Table 1 Summary of participant characteristics
Field Variable N (%)
Demographics Sex Female 20 (74)
Male 7 (26)
Age < 60 5 (19)
60–64 1 (4)
65–69 5 (19)
70–74 5 (19)
75–79 7 (26)
80–84 2 (7)
85–89 1 (4)
> = 90 1 (4)
Fall history and fear of falling Experienced fall in previous year Yes 14 (52)
No 13 (48)
Number of falls in previous year 0 13 (48)
1 6 (22)
2 4 (15)
3+ 4 (15)
Whether fall(s) required medical attentiona (% among fallers) Yes 8 (57)
No 6 (43)
Fall resulted in fracture (% among fallers) Yes 3 (21)
How worried are you about falling while walking or balancing? 1 Never 4 (15)
2 Hardly 5 (19)
3 Sometimes 11 (41)
4 Often 4 (15)
5 All the time 3 (11)
Current physical activity level Currently engaged in some exercise group/activityb Yes 19 (70)
No 8 (30)
History of falls risk screening Whether spoken to a GP or other professionals about risk of falling in previous year Yes 11 (41)
No 16 (59)
If yes, where was it? (% among Yes for previous question) GP 5 (45)
Social care 0 (0)
Falls clinic 3 (27)
A&E 0 (0)
Hospital 2 (18)
Other 1 (9)
Falls prevention service use in past year Type of falls prevention service usec Physiotherapy 12
Occupational therapy 1
HAM 4
Medication change 0
Vision surgery 5
Vit D supplement 6
Assistive device 7
Footwear change 6
Falls education 12
Acronym: HAM home assessment and modification
a At least GP visit
b Suggested options were Chairobics, Pilates, dancing, swimming and group walks with additional space for participants to state other exercise/physical
activity types
c The list of services was taken from Cochrane systematic review of falls prevention trials [9]. However, the questionnaire did not explicitly label these services as
falls prevention interventions in order to invite responses from participants who may have received a multi-purpose service (e.g., physiotherapy or vitamin D
supplementation) without awareness of its falls prevention property. Overall, 21 participants (78%) indicated use of one or more service
Kwon et al. BMC Health Services Research (2021) 21:1020 Page 7 of 19
(FG4) “If I was at risk, I would be happy to talk to
[the professionals]. Because I would be happy to
take any advice on anything that keeps me good as
possible for as long as possible, if that makes sense.”
(Theme [1–4])
Raising awareness of falls risk
Participants generally recognised that falls risk awareness
is a matter of understanding the ageing process, not only
from a certain senior age but from earlier adult life
stages. For example, one participant expressed the
Table 2 Summary of identified facilitators and barriers to the falls prevention pathway components
Pathway component [Thematic category #] Facilitator [Thematic category #] Barrier [Thematic category #]
Falls risk screening and assessment
by professionals [1]
(A) Professional competence
• General approachability of professionals [1] • Lack of proactive professional approach [1–5]
• Lack of professional attention to environmental
risk factors [1–6]
(B) System-level approaches and resources
• Proactive, data-based approach to falls risk
screening [1, 2]
• Specialist expertise and equipment [1–3]
• Time constraint in routine practice [1–7]
(C) Motivation and awareness of older persons
• Older person’s motivation to maintain health [1–4] • Older person’s lack of falls risk awareness [1–8]
Raising awareness of falls risk [2] • Awareness from earlier life-course stage [2-1]
• Awareness of falls risk by informal caregivers [2]
• Lack of awareness of the physical ageing
process [2, 3]
Initial uptake of falls prevention
treatments [3]
(A) Motivation and awareness of older persons
• Older person’s experience of falling [3-1]
• Older person’s experience of the physical ageing
process [3-2]
• Older person’s motivation to maintain health [3]
• Older person’s lack of falls risk awareness [3–15]
• Low motivation of older persons [3–16]
(B) Facilitators and barriers in the community
• Community marketing [3, 4]
• Peer recommendations [3–5]
• Marketing health benefits of interventions [3–6]
• Lack of information in community [3–17]
• Barriers related to socioeconomic class [3–18]
• Linguistic barriers to information uptake [3–19]
(C) Intervention characteristics
• Intervention is free/cheap [3–7]
• Intervention is enjoyable [3–8]
• Intervention is of suitable difficulty [3–9]
• Intervention is safe [3–10]
• Intervention is conveniently located [3–11]
• High intervention cost [3–20]
• Inconvenient timing of intervention [3–21]
• Lack of safe venues for intervention [3–22]
• Transport access and cost issues [3–23]
(D) Professional competence and funding
• Professional recommendations are more important than
peer recommendations [3–12]
• Professional awareness of community initiatives [3–13]
• Person-centred professional referrals [3–14]
• Lack of professional awareness of community
initiatives [3–24]
• Commandeering attitude of professionals [3–25]
• Reactive professional approach [3–26]
• Mismatch between area-based demand and
supply [3–27]
Adherence and long-term participation
in falls prevention treatments [4]
(A) Motivation and health of older persons
• Older person’s motivation to maintain health [4-1] • Older person’s illness and comorbidities [4–10]
(B) Positive and negative experiences of intervention
characteristics
• Experience of intervention reducing falls risk [4-2]
• Experience of wider health benefits of interventions
[4-3]
• Intervention is enjoyable [4]
• Intervention enables high social participation [4, 5]
• Intervention is individually tailored [4–6]
• High intervention cost [4–11]
• Intervention is of unsuitable difficulty [4–12]
• Intervention is not individually tailored [4–13]
• Inconvenient timing of intervention [4–14]
• Transport access issues [4–15]
(C) Professional availability and competence and funding
• Availability of staff [4–7]
• Proactive professional approach to sustain adherence
[4–8]
• Good professional-participant relationship [4–9]
• Lack of professional and volunteer staff [4–16]
• Insufficient public sector funding [4–17]
Kwon et al. BMC Health Services Research (2021) 21:1020 Page 8 of 19
difficulty of staying aware of falls risks at home during
the gradual ageing process:
(FG1) “Well, it happens so gradually, doesn’t it …
when it is part of ageing and degenerative thing, it’s
not like they go over night from being perfect to be-
ing in a wheelchair. It’s such a gradual thing. And
you get used to stuff. You get used to the fact that
the rug was curled up at the end.” (Theme [2, 3])
The role of informal caregivers in maintaining awareness
of falls risk, particularly in the living environment shared
with older persons, was also highlighted.
Initial uptake of falls prevention treatments
Factors influencing the initial uptake of treatments could
be divided into four main groups: (A) motivation and
awareness of older persons; (B) facilitators and barriers
in the community; (C) intervention characteristics; and
(D) professional competence and funding.
For (A), experiences of falls and increasing physical
constraints associated with ageing were important cata-
lysts for treatment uptake. That said, one participant de-
clined to enrol in falls prevention despite an experience
of falling and professional referral; the fall experience
was thought to be the result of a specific situation (post-
prandial syncope) rather than a symptom of general
vulnerability:
(FG4) “The only time I had fallen over is if I’m stand-
ing up suddenly. I go dizzy and I had a blackout and
fall over. The nurse at the medical centres offered for
me to go on a course to avoid falling. But I thought it
wasn’t really necessary because I only fall in that situ-
ation. So I didn’t go on the course. I just have to be
careful when I stand up.” (Theme [3–15])
For (B), the level of information on the treatment in the
community – spread via marketing and peer recommen-
dations – was an important determinant of uptake, while
participants perceived socioeconomic and linguistic bar-
riers in how the information is received and acted upon:
(FG3) “I think it’s the actual area, and I do actually
think it’s class related in terms of whether people
would actually get up and go to something even if it’s
advertised, unless there’s somebody actually suggest-
ing having it up in GP surgeries.” (Theme [3–18])
Important intervention characteristics included cost, en-
joyability, suitable difficulty, safety, location, timing, sup-
port facilities (e.g., lack of handrail at venue entrance),
and transport issues (availability and cost). Individuals
considered whether the specific combination of these
characteristics suited their preference and ability to pay.
For example, one participant perceived modest private
cost as an acceptable trade-off to enjoyability, while an-
other perceived transport costs as a key main barrier:
(FG3) “I do think people would find the three odd
pounds if they found [the intervention] absorbed
them and really interested them.” (Theme [3–8])
(FG1) “And also, money and transport, not a lot of us
can afford to go, because it’s usually, what, a fiver to
get you where you want to go and back and return.
Not a lot of people can afford to. When you are on
universal credit or job seeker’s allowance and benefit,
I think when you’ve got a disability like I have long
enough. I think it should be like the over 60s [person
was under 60], they have a bus pass.” (Theme [3–23])
Participants acknowledged the influential role of profes-
sionals in determining their treatment uptake, more in-
fluential than their peers according to theme [3–12].
The key steps were professional awareness of falls pre-
vention initiatives in the community, followed by pro-
active recommendations or referrals made in a
respectful and person-centred manner:
(FG1) “One person when we had a meeting found
out that so many doctors were handing out too
many drugs instead of an alternative. There was an
alternative. [My doctor at surgery] said, ‘I’d want
you to go and do an aquarobics’ and that helped
me, that helped me so much that I didn’t need the
drugs.” (Theme [3–14])
Adherence and long-term participation in falls prevention
treatments
Factors influencing long-term treatment adherence
could be divided into three main groups: (A) motiv-
ation and health of older persons; (B) positive and
negative experiences of intervention characteristics;
and (C) professional availability and competence and
funding.
Significant illness or comorbidity impeded older per-
sons’ adherence to interventions (theme [4–10]); but
preventing an adverse health/functional status also
served as a motivation for adherence:
(FG3) “Wanting to maintain what you’ve got. Not
wanting to lose your independence. And hang on
[to] independence as long as possible because I live
alone as well.” (Theme [4-1])
Positive intervention experiences or characteristics that sus-
tained adherence included falls risk reduction, wider health
Kwon et al. BMC Health Services Research (2021) 21:1020 Page 9 of 19
benefits, enjoyability, high social participation, and tailoring
to individual ability. Negative ones included high cost, un-
suitable difficulty, lack of tailoring, inconvenient timing and
transport problems. Active involvement of healthcare pro-
fessionals was not a guarantee that the intervention experi-
ence would be positive:
(FG3) “[The GP] set up [a programme] for people
to stop falls. And I was in a group of about 8 people.
And it was like a small version of going to the gym.
And I went to that once and then I postponed it be-
cause it’s too hard for my hands.” (Theme [4–12])
Discontinuities in staff availability and funding unsur-
prisingly impeded long-term adherence. Otherwise, good
bonding between the professional leader and participants
was an important facilitator:
(INT1) “She [the Dance to Health instructor] goes
out of her way to have friendly relationship with
everyone that goes. And I think it works. You al-
ways get a cuddle when you arrive. And she always
shows interest in you, what you are doing and what
difficulties you have, and so on.” (Theme [4–9])
Cross-component factors
Two common themes across components were older
persons’ health motives (themes [1–8, 4-1, and, 3-16])
and professional competence ([1–1, 1–5, 1–6, 3–12 to
3–14, 3–24 to 3–26, 4–8 and 4–9). First, older persons’
health-related goals such as maintaining independence
facilitated risk screening by professionals ([1–4]), risk
awareness ([2-1]) and intervention uptake ([3]) and ad-
herence ([4-1]). Secondly, participants perceived that it
is professionals’ responsibility to identify all relevant falls
risk factors and prescribe relevant treatments (e.g., [1-6
and 3-14]); incompetence resulted in iatrogenic harm
despite patient’s awareness:
(FG2) “I’ve got loads of medication variation prob-
lems. For me, I don’t really expect GPs to improve
things, but they never told me ‘Oh we could change
this into that’. He [the GP] just expects me to just
keep pre-ordering the medications. So I leave it that
way.” (Theme [3–26])
There was a close overlap in factors determining treat-
ment uptake and adherence and long-term participation,
both components sharing the themes concerning motiv-
ation of older persons, intervention characteristics and
professional competence. As for factor differences, ex-
perience of falling was mentioned as a facilitator for up-
take ([3-1]) but not adherence. Socioeconomic and
linguistic barriers were mentioned only for uptake ([3-18
and 3-19]), likely because they are sufficient to discour-
age both uptake and adherence for the marginalised sub-
groups.
constraints impeded both uptake and
adherence, though in different ways: adherence was pre-
dictably curtailed by the funding cut at the end of the
pilot period ([4–17]); while uptake was impeded by de-
liberate policy to concentrate funding in deprived areas
despite higher demand in well-off areas:
(FG3) “Now, to be honest, this [well-off] area
doesn’t usually have anything. You know, I mean,
all the money and the grant has been put into only
deprived areas.” (Theme [3–27])
Contextual factors influencing the falls prevention pathway
Table 3 summarises the contextual factors that influ-
enced the pathway implementation. They could be di-
vided into two groups: (i) intersectoral factors; and (ii)
prioritising the vulnerable groups. Table B in Supple-
mentary Material shows the direct transcript quotes.
Intersectoral factors Intersectoral factors concerned
matters typically addressed outside the healthcare system,
including the safety and health-promoting features of local
public spaces, the relationship between home ownership
and ability to implement home modifications, and poten-
tial communitarian approaches that mobilise the commu-
nity to meet common goals. Older participants mentioned
how in the past the local community would handle the
challenges that lie outside the local/central government’s
responsibility; the decline in communal responsibility was
perceived to explain the increase in local health hazards:
(FG1) “I don’t think neighbours are neighbours any-
more, either. When we were younger, I remember
when snow came here, all the men of each family
would come and make a path. And they don’t do
that now.” (Theme [5-4])
Prioritising the vulnerable groups Another set of
themes concerned the need to prioritise the most vul-
nerable individuals at risk of a serious fall or loss of in-
dependence. Three groups were identified: persons with
complex comorbidities; persons experiencing cognitive
decline; and socially isolated persons. The reported ex-
perience of the diabetic participant who was below age
65 (hence below the eligibility age for the proactive path-
way) illustrated how vulnerable individuals concurrently
face multiple risk factors for serious falls:
(FG1) “If I had a bad day with my high sugar levels.
I’ve had my bad day with blurriness. And I come
down a lot of stairs and I fell X times coming down
Kwon et al. BMC Health Services Research (2021) 21:1020 Page 10 of 19
from attic and obviously coming out of my building
which is a high old building. And then you’ve got to
come down some more which is always full of
leaves.” (Theme [6-1])
Despite this, public support for home assessment and
modification was denied due to her ability to walk 100 m
without problem, and support from other care profes-
sionals was similarly lacking.
Framework (II): potential commissioning strategies
Table 4 re-maps the identified themes according to the
CICI-HNA framework (see also Figure B in Supplemen-
tary Material).
Context, priority setting and need/eligibility
The first column of Table 4 groups together the themes
on context, priority setting and need/eligibility. Not all
contextual domains in the CICI framework were identi-
fied; the five identified were socioeconomic, linguistic/
ethnic, setting/geographical, legal/regulatory and cul-
tural. The commissioner and stakeholders should discuss
to what extent the contextual factors are modifiable via
intersectoral policies (i.e., lie within the decision space).
For example, the difficulty of making safety modifica-
tions to rented properties was mentioned several times:
(FG4) “And I couldn’t [modify my house] because I
live in a rented property. It’s not mine. I’m not
allowed to do anything.” (Theme [5-3])
This could potentially be addressed by new housing reg-
ulations that incentivise relevant action by landlords.
The culture of communal responsibility could be en-
hanced to some extent by supporting community orga-
nisations and civic initiatives.
Several priority setting challenges emerged from the
data. The commissioner should consider prioritising
intervention access for several marginalised sub-
groups: socially deprived; ethnic minority; with com-
plex comorbidities; cognitively impaired; and socially
isolated. Ideally, the prioritisation should not come at
the expense of reduced services for non-marginalised
subgroups.
The commissioner may also decide to change the eligi-
bility criteria for falls prevention according to local pri-
orities. Currently, CG161 recommends community-
based falls risk screening for those aged 65 and over,
followed by referral to multifactorial intervention for
those at high falls risk defined by falls history and abnor-
mal gait/balance. The screening protocol can be ex-
panded to include those with complex comorbidities
who are aged less than 65; the risk factors examined for
referral can similarly be expanded to cover frailty and
non-health factors such as social isolation. A separate
pathway may be designed for cognitively impaired per-
sons who require tailored support from dedicated
organisations:
(INT2) “But with these walks which are organised
by the Alzheimer’s Society is that there are qualified
people leading the walks.” (Theme [4–7])
Supply
Older participants identified a broad range of supply-
side issues and solutions at provider/organisation, fund-
ing/policy and intersectoral levels as shown in the sec-
ond column of Table 4. The commissioner should
determine which solutions lie within the decision space:
e.g., certain professional attributes such as commandeer-
ing attitude may not be modifiable in the short run. Sig-
nificant investments – e.g., a new Falls Clinics, changes
to GP reimbursement schedule for risk screening –
would similarly take time and be constrained by the
budget.
Demand
The last column of Table 4 arranges the demand-side
themes by three types: health and fall-related motives of
older persons; non-health and social motives; and external
influences on demand. Importantly, the external influ-
ences are modifiable by using auxiliary implementation
strategies (e.g., community marketing). Older persons are
also receptive of professional recommendations; hence,
this influence can be maximised by improving professional
attributes such as awareness of community initiatives:
(FG3) “When I was having as many as things I’ve
had, I had to see Professor [name] at Hallamshire
[Teaching Hospital]. So actually, I sent him details
of [Dance to Health] and he wrote me to send me a
very brief letter back saying ‘Thank you for this. I
think I can put this to my other patients who have
got a similar thing.’” (Theme [3–13])
Table 3 Summary of contextual factors influencing the falls prevention pathway
Intersectoral factors [Thematic category 5] Prioritising the vulnerable groups [Thematic category 6]
• Health hazards in local public spaces [5-1]
• Health-promoting local public spaces [5-2]
• Home ownership and modification [5-3]
• Communitarian approaches [5-4]
• Persons with complex comorbidities [6-1]
• Persons experiencing cognitive decline [6-2]
• Socially isolated persons [6-3]
Kwon et al. BMC Health Services Research (2021) 21:1020 Page 11 of 19
T
a
b
le
4
Th
em
es
ar
ra
n
g
ed
b
y
th
e
C
IC
I-H
N
A
fr
am
ew
o
rk
to
in
fo
rm
co
m
m
is
si
o
n
in
g
d
ec
is
io
n
s
C
o
n
te
xt
,
p
ri
o
ri
ty
se
tt
in
g
a
n
d
n
ee
d
/e
lig
ib
ili
ty
[T
h
em
e
#
]a
Su
p
p
ly
[T
h
em
e
#
]
D
em
a
n
d
[T
h
em
e
#
]
Im
p
le
m
en
ta
tio
n
co
n
te
xt
•
•
So
ci
o
ec
o
n
o
m
ic
d
iv
id
e
[3
–
18
]
•
Li
n
g
u
is
ti
c
d
iv
id
e/
b
ar
rie
r
[3
–
19
]
•
H
ea
lt
h
h
az
ar
d
s
an
d
o
p
p
o
rt
u
n
it
ie
s
in
lo
ca
l
g
eo
g
ra
p
h
y
[5
-1
,5
-2
]
•
Le
g
al
/r
eg
u
la
to
ry
b
ar
rie
rs
fo
r
te
n
an
ts
to
m
o
d
ify
th
ei
r
h
o
m
es
[5
-3
]
•
C
u
lt
u
re
o
f
co
m
m
u
n
al
re
sp
o
n
si
b
ili
ty
th
at
ad
d
re
ss
ed
ke
y
fa
lls
ris
k
fa
ct
o
rs
is
n
o
lo
n
g
er
st
ro
n
g
[5
-4
]
Pr
o
vi
d
er
an
d
o
rg
an
is
at
io
n
•
Po
si
ti
ve
p
ro
fe
ss
io
n
al
at
tr
ib
u
te
s:
ap
p
ro
ac
h
ab
le
[1
,2
];
aw
ar
e
o
f
co
m
m
u
n
it
y
in
it
ia
ti
ve
s
[3
–
24
];
p
ro
ac
ti
ve
an
d
p
er
so
n
-c
en
tr
ed
ca
re
[3
–
14
];
g
o
o
d
re
la
ti
o
n
sh
ip
w
it
h
in
te
rv
en
ti
o
n
p
ar
ti
ci
p
an
ts
[4
–
9]
•
N
eg
at
iv
e
p
ro
fe
ss
io
n
al
at
tr
ib
u
te
s:
re
ac
ti
ve
ap
p
ro
ac
h
[1
–
26
];
p
ar
ti
al
at
te
n
ti
o
n
to
ris
k
fa
ct
o
rs
[1
–
6]
;c
o
m
m
an
d
ee
rin
g
at
ti
tu
d
e
[3
–
25
]
•
Fa
ci
lit
y/
eq
u
ip
m
en
t:
sp
ec
ia
lis
t
Fa
lls
C
lin
ic
s
[1
–
3]
;s
af
e
an
d
w
el
l-l
o
ca
te
d
ve
n
u
es
[3
–
23
]
•
Po
si
ti
ve
in
te
rv
en
ti
o
n
ch
ar
ac
te
ris
ti
cs
:l
o
w
co
st
[3
–
20
];
w
el
l-s
ta
ff
ed
[4
–
16
];
en
jo
ya
b
le
[3
–
8]
;h
ig
h
so
ci
al
p
ar
ti
ci
p
at
io
n
[4
,5
];
su
it
ab
le
an
d
ta
ilo
re
d
d
iff
ic
u
lt
y
[3
–
13
];
sa
fe
[3
–
10
];
g
o
o
d
ti
m
in
g
[3
–
21
]
H
ea
lt
h
an
d
fa
ll-
re
la
te
d
m
o
ti
ve
s
•
M
o
ti
va
ti
o
n
to
m
ai
n
ta
in
h
ea
lt
h
fa
ci
lit
at
es
ris
k
sc
re
en
in
g
an
d
u
p
ta
ke
[1
–
6]
•
Pr
ev
io
u
s
ex
p
er
ie
n
ce
o
f
fa
ll
m
o
ti
va
te
s
u
p
ta
ke
[3
-1
]
•
Ex
p
er
ie
n
ce
o
f
th
e
p
h
ys
ic
al
ag
ei
n
g
p
ro
ce
ss
m
o
ti
va
te
s
u
p
ta
ke
[3
-2
]
•
Ex
p
er
ie
n
ce
o
f
in
te
rv
en
ti
o
n
re
d
u
ci
n
g
fa
lls
ris
k
an
d
im
p
ro
vi
n
g
w
id
er
h
ea
lt
h
m
o
ti
va
te
s
ad
h
er
en
ce
[4
-2
,4
-3
]
•
La
ck
o
f
fa
lls
ris
k
an
d
ag
ei
n
g
aw
ar
en
es
s
im
p
ed
es
ris
k
sc
re
en
in
g
an
d
u
p
ta
ke
[1
–
15
]
Pr
io
rit
y
se
tt
in
g
ch
a
lle
n
g
es
•
Pr
io
rit
is
in
g
ac
ce
ss
fo
r
so
ci
al
ly
d
ep
riv
ed
an
d
et
h
n
ic
m
in
o
rit
y
su
b
g
ro
u
p
s
[3
–
19
]
•
Pr
io
rit
is
in
g
ac
ce
ss
fo
r
vu
ln
er
ab
le
g
ro
u
p
s:
co
m
p
le
x
co
m
o
rb
id
it
ie
s;
co
g
n
it
iv
el
y
im
p
ai
re
d
;s
o
ci
al
ly
is
o
la
te
d
[6
-1
,6
-2
,6
-3
]
•
W
h
er
e
p
o
ss
ib
le
,n
ee
d
s
o
f
m
ar
g
in
al
is
ed
g
ro
u
p
s
sh
o
u
ld
b
e
m
et
w
it
h
o
u
t
d
en
yi
n
g
se
rv
ic
es
to
n
o
n
-m
ar
g
in
al
is
ed
g
ro
u
p
s
[3
–
27
]
Fu
n
d
in
g
an
d
p
o
lic
y
•
H
ea
lt
h
p
ro
m
o
ti
o
n
in
ea
rli
er
lif
e
co
u
rs
e
st
ag
es
[2
-1
]
•
U
se
o
f
ro
u
ti
n
e
d
at
a
to
fa
ci
lit
at
e
ris
k
id
en
ti
fic
at
io
n
[1
]
•
A
lle
vi
at
in
g
ti
m
e
co
n
st
ra
in
ts
in
ca
re
ro
u
ti
n
e
p
ra
ct
ic
e
[1
–
7]
•
Fu
n
d
in
g
to
re
m
o
ve
p
riv
at
e
in
te
rv
en
ti
o
n
co
st
s
[3
–
20
],
su
st
ai
n
ed
o
ve
r
th
e
lo
n
g
te
rm
[4
–
17
]
•
A
u
xi
lia
ry
im
p
le
m
en
ta
ti
o
n
st
ra
te
g
ie
s:
in
fo
rm
at
io
n
to
in
fo
rm
al
ca
re
g
iv
er
s
[2
];
co
m
m
u
n
it
y
m
ar
ke
ti
n
g
[3
–
6]
;p
ee
r
h
ea
lt
h
ch
am
p
io
n
s
[3
–
5]
Ps
yc
h
o
so
ci
al
m
o
ti
ve
s
•
Ps
yc
h
o
so
ci
al
b
en
ef
it
s
o
f
in
te
rv
en
ti
o
n
s
m
o
ti
va
ti
n
g
u
p
ta
ke
an
d
ad
h
er
en
ce
:e
n
jo
ya
b
ili
ty
[3
–
8]
;s
o
ci
al
p
ar
ti
ci
p
at
io
n
[4
,5
]
•
G
o
o
d
p
ro
fe
ss
io
n
al
-p
ar
ti
ci
p
an
t
re
la
ti
o
n
sh
ip
fa
ci
lit
at
es
ad
h
er
en
ce
[4
–
9]
N
ee
d
/e
lig
ib
ili
ty
•
C
o
n
si
d
er
n
ee
d
s
o
f
ch
ro
n
ic
al
ly
ill
,f
ra
il
an
d
w
it
h
co
m
o
rb
id
it
ie
s
(w
h
o
m
ay
b
e
ag
ed
< 65 ) [4 – 10 ]
•
Id
en
ti
fy
ap
p
ro
p
ria
te
in
te
rv
en
ti
o
n
s
fo
r
co
g
n
it
iv
el
y
im
p
ai
re
d
[6
-2
]
•
C
o
n
si
d
er
ta
rg
et
in
g
th
o
se
liv
in
g
in
vu
ln
er
ab
le
ci
rc
u
m
s
t
an
ce
s
su
ch
as
so
ci
al
ly
is
o
la
ti
o
n
[6
-3
]
In
te
rs
ec
to
ra
l
p
o
lic
y
•
Im
p
ro
ve
p
u
b
lic
sp
ac
es
:s
af
er
an
d
m
o
re
h
ea
lt
h
-p
ro
m
o
ti
n
g
[5
-1
,5
-2
]
•
C
h
an
g
e
in
ce
n
ti
ve
s
fo
r
la
n
d
lo
rd
s
to
m
o
d
ify
h
o
m
es
[5
-3
]
•
M
ak
e
tr
an
sp
o
rt
ch
ea
p
er
an
d
m
o
re
ac
ce
ss
ib
le
[3
–
23
]
•
Su
p
p
o
rt
co
m
m
u
n
it
y
o
rg
an
is
at
io
n
s
an
d
in
iti
at
iv
es
[5
-4
]
Ex
te
rn
al
in
flu
en
ce
s
o
n
d
em
an
d
•
O
ld
er
p
er
so
n
s
ar
e
re
ce
p
ti
ve
to
au
xi
lia
ry
im
p
le
m
en
ta
ti
o
n
st
ra
te
g
ie
s,
in
cl
u
d
in
g
co
m
m
u
n
it
y
m
ar
ke
ti
n
g
an
d
p
ee
r
re
co
m
m
en
d
at
io
n
s
[3
–
6]
•
O
ld
er
p
er
so
n
s
ar
e
p
ar
ti
cu
la
rly
re
ce
p
ti
ve
to
p
ro
fe
ss
io
n
al
re
co
m
m
en
d
at
io
n
s
[3
–
14
]
A
cr
o
n
ym
:
C
IC
I:
C
o
n
te
xt
an
d
Im
p
le
m
en
ta
ti
o
n
o
f
C
o
m
p
le
x
In
te
rv
en
ti
o
n
s
(C
IC
I)
fr
am
ew
o
rk
[2
0
];
H
N
A
:
H
ea
lt
h
N
ee
d
s
A
ss
es
sm
en
t
fr
am
ew
o
rk
[4
3
].
a
Se
e
Ta
b
le
s
2
an
d
3
fo
r
th
em
es
b
y
fa
lls
p
re
ve
n
ti
o
n
p
at
h
w
ay
co
m
p
o
n
en
t
an
d
Ta
b
le
s
A
an
d
B
in
Su
p
p
le
m
en
ta
ry
M
at
er
ia
l
fo
r
tr
an
sc
ri
p
t
q
u
o
te
s
Kwon et al. BMC Health Services Research (2021) 21:1020 Page 12 of 19
Framework (III): challenges for public health economic
modelling
Table 5 summarises the methodological and evaluative
challenges for falls prevention economic model identi-
fied from the qualitative data (see also Figure B in Sup-
plementary Material).
Methodological challenges
The data identified several non-health outcomes
(e.g., social benefits of group exercise) and societal
intervention costs (e.g., private intervention and
transport costs, costs of venues donated by local
church) which were important facilitators and bar-
riers. No older person mentioned time opportunity
cost imposed on him/herself or his/her caregiver
from attending interventions; but such costs may be
incurred if interventions are conducted in incon-
venient times and venues and should thus be incor-
porated in the model.
The dynamic processes of ageing and falls risk pro-
gression, starting before the age of 65, were men-
tioned by some participants as motivating factors for
intervention uptake/adherence; yet others perceived
the emerging illnesses as major barriers:
Table 5 Methodological and evaluative challenges for falls prevention economic modelling
Methodological challenges [Theme #]a Evaluative challenges [Theme #]
Capturing non-health outcomes and societal intervention costs
• Model should capture social benefits of falls prevention interventions
[3–8].
• Model should capture private intervention and transport costs [3–23].
• Model should capture any time opportunity cost to participants and
informal caregivers: e.g., due to inconvenient timing or location [3–21].
Perspective, type of analysis and time horizon
• Under CUA, the generic health utility measure such as EQ-5D may not
fully capture social benefits of interventions [3–8]; the model should
consider broader wellbeing measure (e.g., ICECAP-O [54, 55])
• Societal perspective is likely necessary to capture societal intervention
costs [3–23].
• Long time horizons required to capture dynamic trajectories and
evaluate system changes incurring large sunk costs (e.g., [1–3]).
Considering dynamic complexity
• Model should incorporate dynamic trajectories of ageing and falls risk
influencing older person’s demand and appropriate professional
response [1–5].
• Model should capture the dynamic trajectories of variables that
delineate vulnerable subgroups (e.g., cognitive status, frailty) [6-1, 6-2, 6-
3].
• Model should capture wider health benefits of interventions beyond
falls prevention [4-3].
• Model should incorporate seasonal changes in falls risk due to
environmental risk factors [5-1].
Types of intervention scenarios evaluated
• Main intervention scenario should incorporate: local eligibility criteria
tailored to changing falls risk profile; multiple non-mutually exclusive
intervention pathways; external evidence on interventions which have
similar characteristics as those preferred by local older persons.b
• Intervention costing should incorporate: cost of risk identification; cost
of auxiliary implementation strategies; fixed/sunk costs for major system
changes; cost of additional resources to achieve full set of positive
intervention characteristics; cost of professional training to obtain
positive attributes; and funding to sustain intervention over sufficiently
long period.c
• Additional scenarios conducting value of implementation analyses to
evaluate auxiliary implementation strategies [2–6].
• Additional scenarios evaluating intersectoral policies (e.g., environmental
interventions [5-1, 5-2]) and earlier life-course preventive interventions
[2-1].
Considering theories/models of human behaviour based on psychology
and sociology
• Model should incorporate the health/social motives of older persons
that influence demand [1–4]
• Model should incorporate sociological and contextual factors that
influence falls prevention: cultural factors promoting/weakening
communal responsibilities for health promotion and safety [5-1, 5-2, 5-
4]; regulatory barriers [5-3].
Considering social determinants of health
• Model should incorporate socioeconomic and ethnic/linguistic variables
and social isolation as social determinants of health [3–19].
Analysis of equity and other priority setting criteria
• Model should examine equity-efficiency trade-offs in adopting strategies
that reduce social inequities of health [3–27] or prioritise other vulner-
able groups [4–10].
Acronym: CCA: cost-consequence analysis; CUA: cost-utility analysis: ICECAP-O: ICEpop CAPability measure for Older people; NICE CG161: National Institute for
Health and Care Excellence Clinical Guideline 161 [2]
a See Tables 2 and 3 for themes by falls prevention pathway component and Tables A and B in Supplementary Material for transcript quotes
b Local decision-maker could set the eligibility criteria for falls prevention referral, e.g., to cover those aged less than 65 who have complex comorbidities [6-1].
The intervention strategy should accommodate the changing falls risk profile that necessitates different treatments over time [1–5]. Non-mutually exclusive
prevention pathways include: (i) proactive – involving referrals of high-risk older persons by professionals after risk screening as recommended by NICE CG161 [2];
(ii) self-referred – where older persons enrol in falls prevention without professional referral; and (iii) reactive – where older persons are referred to falls prevention
by professionals after medical attention for a fall. Key intervention characteristics beyond cost are: staffing level [4–16]; enjoyability [3–8]; social participation [4, 5];
suitable and tailored difficulty [3–13]; safety [3–10]; and good timing [3–21]. External evidence (e.g., efficacy from randomised controlled trial) should be sourced
from interventions with desirable characteristics
c Cost of risk identification includes the cost of conducting risk screening in GP routine practice [1–7]. Auxiliary implementation strategies include information
provision to informal caregivers [2], community marketing [3–6] and promotion of peer recommendations [3–5]. Major system changes include improvements to
data systems [1] and new Falls Clinics [1–3]. Additional resources may be required to achieve the full set of positive intervention characteristics: e.g., hiring venues
that are safe [3–22] and easy to reach [3–23]. Investment in training may increase the level of positive professional attributes including approachability [1, 2];
awareness of community initiatives [3–24]; person-centred care [3–14]; and relationship-building with intervention participants [4–9]. Funding should be sustained
until the intervention has had enough time to generate substantial results [4–17]
Kwon et al. BMC Health Services Research (2021) 21:1020 Page 13 of 19
(FG4) “Well, I used to go swimming a lot every
week. But then, since a long period of illness, I
stopped going.” (Theme [4–10])
Either way, the model should seek to capture the dy-
namic trajectories of physical and cognitive capacities,
functional status and health perception that determine
the intervention demand and the composition of vulner-
able subgroups. Moreover, the dynamic progression
means that persons at different stages of the falls risk
progression have different intervention needs; the model
can quantify the added benefits of an intervention strat-
egy that tailors treatments to progression stages relative
to a strategy that does not. An example of the latter was
perceived by older participants:
(INT2) “I think [the professionals] ought to check
things like stairs and back steps. And not expect the
elderly people to report it, because they are prob-
ably so used to these things when they’ve lived in
the house all the time and are not necessarily aware
of how less well coordinated they are from before.”
(Theme [1–5])
Participants also highlighted wider health benefits of ex-
ercise beyond falls prevention, including improved mo-
bility and mental health:
(FG2) “Lots of my family have noticed the difference
in my posture, in my walk; things like, I used to
struggle bending down, picking things up from the
floor. It gets you down. It affects your mental
health. So yeah, my family have noticed a huge dif-
ference.” (Theme [4-3])
Hence, the model should incorporate multiple simultan-
eous health effects of falls prevention exercise; if this
proves too complex, then at least the fall’s impact on
wider health and functional outcomes (e.g., on a multi-
variate frailty index [56]) should be incorporated to cap-
ture the full health benefits of falls prevention.
Finally, the model should incorporate key psycho-
logical and sociological factors identified from the quali-
tative data (e.g., health motives influencing demand)
using relevant external quantitative data. Social determi-
nants of health identified from the data included socio-
economic and ethnic/linguistic barriers to intervention
access and social isolation as a marker of vulnerable
subgroup.
Evaluative challenges
Given the range of non-health outcomes and societal
intervention costs, the model evaluation should consider
using a broader wellbeing measure and taking the
societal perspective [54, 55]. The model time horizon
should be sufficiently long to capture the dynamic tra-
jectories of key variables and the full health impact of in-
terventions; large sunk costs incurred by intervention
may also be evaluated over a longer horizon.
Several intervention scenarios emerged from the data
that should be evaluated under base case analysis and al-
ternative scenario analyses. All three prevention path-
ways – proactive, self-referred and reactive – were
mentioned in the data (see theme [1–5] for participant
discussion of a reactive HAM receipt), and hence should
be considered in the base case analysis. The main inter-
vention scenario (compared to usual care under base
case analysis) should incorporate interventions that have
some or all of the positive characteristics (see Table 4)
such as allowing individually tailored difficulty. Where
external studies are used as data sources (e.g., RCT for
efficacy), they should evaluate interventions with similar
characteristics as the model scenario.
Intervention costing should incorporate not only the
cost of intervention delivery but also the cost of auxiliary
implementation strategies used to generate the given up-
take and adherence; for the proactive pathway, the cost
of professional risk screening and referral should be in-
cluded. Major system-level changes (e.g., integrated data
system for risk screening) would incur fixed/sunk costs
which may be incorporated as annuitized overheads.
Costs would be incurred if additional professional train-
ing (resources) is required to obtain positive professional
attributes (intervention characteristics).
An alternative, heuristic method to directly incorporat-
ing psychological and sociological variables in the model
is to conduct value of implementation analyses as alter-
native intervention scenarios [57]. Additional monetary
value of hypothetical improvements in intervention up-
take/adherence can be estimated without knowing what
psychological or sociological factors contributed to the
improvements. The additional value is the maximum
amount that can be invested in auxiliary implementation
strategies that produce the given improvements.
The lower intervention access for the socioeconomi-
cally deprived and ethnic minority subgroups would
mean that the intervention is less cost-effective. A
strategy that prioritises access for these groups to re-
duce social inequities of health (e.g., concentrating
funding in deprived areas [theme 3–27]) would intro-
duce an equity-efficiency trade-off. The model should
parameterise the causal mechanisms to quantify the
trade-off; the strategy would be accepted if stake-
holders find the trade-off to be reasonable [36]. A
similar process of equity-efficiency evaluation can be
applied to other vulnerable subgroups identified, i.e.,
those with complex comorbidities and cognitive
impairment.
Kwon et al. BMC Health Services Research (2021) 21:1020 Page 14 of 19
Discussion
This study explored older people’s views on facilitators
and barriers for implementing the community-based
falls prevention pathway recommended by NICE as well
as broader themes on raising falls risk awareness, inter-
sectoral initiatives and prioritisation of vulnerable
groups. Participants included service users and non-
users and those at high and low risks of falling. The
study also explored how the identified themes can be
mapped on to frameworks that can inform commission-
ing decisions via a de novo falls prevention economic
model. It was thereby shown that the framework analysis
approach [44] can flexibly accommodate diverse frame-
works according to research aims.
The methods and results of this study contribute to
the growing field of research exploring how qualitative
evidence can be effectively used to inform health tech-
nology assessment (HTA) [40]. The recent NICE Deci-
sion Support Unit (DSU) report, for example, critiques
the limited consideration of qualitative evidence in the
current NICE HTA guideline (process and methods
guideline 9; PMG9) and sees the use of established,
purpose-specific frameworks – including the CICI
framework – as a tool for accelerated and standardised
incorporation of qualitative evidence in the HTA
decision-making process [40]. This study showed that
the CICI framework, despite its focus on supply-side
conditions, can be applied to service users and eligible
non-users. Previous qualitative studies have indeed
shown that older people are sensitive to supply-side is-
sues including cultural-linguistic context of intervention,
professional attributes and intervention characteristics
[45, 58–60], making their views highly relevant to
commissioning decisions that must consider how the
supply-side conditions are perceived and accepted by
service users. This study facilitated attention on users’
perception and demand by supplementing the CICI
framework with the HNA framework that conceptualises
intervention access as an outcome of interactions be-
tween demand, supply and normative need. Such flexible
adaptation of the CICI framework is encouraged by the
framework developers [20]. Moreover, both the CICI
framework developers and the DSU report focus on the
application of CICI to qualitative and mixed-methods
systematic reviews and not to primary qualitative re-
search [20, 40]. By applying the framework to primary
research, this study demonstrates the wider potential
reach of the framework.
This study also showed that the primary qualitative re-
search on service users can identify the key methodo-
logical and evaluative challenges to public health
economic evaluation and thus function as a vital step
within the conceptual modelling process [41]. Having
identified the key causal mechanisms, the qualitative
data can also identify the necessary group of stake-
holders to modify them, and those not already involved
in the project can subsequently be recruited. These are
ex-ante, or prospective, applications of the qualitative
evidence to inform the de novo model development. Yet
ex-post application may be equally valuable: in England
and Wales, clinical commissioning groups (CCGs) and
local authorities are required to implement an interven-
tion approved by NICE HTA within 3 months of the ap-
proval unless major local barriers to implementation can
be identified (recommendation 1.5.1) [61]. The local
qualitative evidence can identify such barriers and/or an-
ticipate any major differences in the local cost-
effectiveness and population-level outcomes relative to
those predicted by the HTA. Moreover, the decision
model underlying the HTA approval can be critiqued
based on the methodological and evaluative challenges
identified by the local qualitative evidence. If the model
performs poorly in addressing the challenges, then a de
novo model can be commissioned; the qualitative data
would then be applied ex-ante. As mentioned, the ex-
ante approach is more relevant for community-based
falls prevention since no HTA has been conducted, and
existing models [11, 39] do not adequately address the
methodological challenges. The 2019 surveillance for the
update to NICE CG161 (not yet published at the time of
writing, August 2021) also mentions no plan for eco-
nomic evaluation nor indeed for primary/secondary
qualitative research with older persons [62].
The holistic approach to exploring the falls prevention
facilitators/barriers identified two cross-component fac-
tors: health motives of older persons; and professional
competence. The role of health motives in influencing
older persons’ health behaviour has been debated in the
literature. One study in Scotland found that older people
are unlikely to participate in exercise for health reasons
but rather for the social rewards; while another found that
health motives (e.g., maintaining functional independence)
help translate intentions into actual change in health be-
haviour [42]. This study found that health motives operate
alongside the social rewards of interventions which cor-
roborates the findings of a previous qualitative systematic
review of older persons’ views [58]. CG161 similarly rec-
ognises both factors and recommends that care profes-
sionals provide information on the physical benefits of
modifying falls risk to older persons and caregivers (rec-
ommendation 1.1.10.2), while also promoting the social
values of interventions (1.1.9.2) [2]. The absolute and rela-
tive strengths of health and non-health motives impact
the final combination of intervention characteristics and
auxiliary implementation strategies: for example, strength-
ening the health motives would require well-framed health
messaging [52], while addressing the social motives is a
matter of better intervention design. Commissioners
Kwon et al. BMC Health Services Research (2021) 21:1020 Page 15 of 19
should nevertheless note the wide diversity of motives/
preferences in the older population: one survey of 134
older persons, for example, found that 46% preferred to
exercise alone versus 44% in a group [63]. Importantly,
the group environment may be less preferred by margina-
lised social groups (theme [3–18]); alternative intervention
types, such as home-based digital falls prevention exercise
taken up at home [64], may be considered.
The importance of the second cross-component factor,
professional competence, is affirmed by CG161 which
recommends that all healthcare professionals regularly
dealing with older persons “develop and maintain basic
professional competence in falls assessment and preven-
tion” (1.1.10.1) [2]. Yet older participants perceived external
constraints placed even on competent professionals, includ-
ing time constraints. This corroborates the findings from a
previous survey of English GPs which specified insufficient
consultation time and lack of allied health professionals in
the community as the most prominent barriers to imple-
menting CG161 [25]. Therefore, commissioning should
comprehensively account for care system bottlenecks and
carefully cost the solutions for their removal. One eco-
nomic model, for example, incorporated the cost of a city-
wide falls risk screening that was assumed to operate like a
cancer screening programme [65]. Costs that are fixed/sunk
would interact with uptake rate to produce worse cost-
effectiveness if uptake is inadequate [66] and economies of
scale if uptake is increased [65]. Hence, models should ac-
curately portray the cost structure (fixed vs. variable) to
characterise the impact of implementation quality on cost-
effectiveness. Aggregate population-level health and/or eco-
nomic impact is another outcome largely determined by
implementation; the NICE PMG9, for example, stresses the
need to account for such impact in HTA decisions (see rec-
ommendations 5.12.3 to 5.12.7). Yet cost-per-unit ratios
(e.g., incremental cost-effectiveness ratio) are often inter-
preted in isolation when using economic evidence for
decision-making [67–69]. The final model informed by the
qualitative evidence should present both ratio and aggre-
gate outcomes so that the full impact of implementation
quality could be quantified [70].
Less emphasised in CG161 but visible in the qualita-
tive data (e.g., theme [4–16]) is the role of nonclinical
professionals and volunteers who can substantially influ-
ence both supply and demand given their proximity to
older persons in the community [71]: a pilot falls pre-
vention scheme in Sheffield, for example, found that falls
risk screening conducted at local community groups and
lunch clubs significantly increased uptake [72]. It is
hence critical to value the nonclinical and volunteer con-
tributions; and value of implementation analysis offers a
heuristic method to that end [57]. For example, one falls
prevention model set in a Massachusetts community of
population size 44,000 estimated that increasing falls
prevention uptake from 50 to 75% would yield an add-
itional $2.79 million which is the maximum amount that
can be invested in community organisations to generate
such uptake increase [73]. Such monetary value can be
combined with qualitative data on demand-side influ-
ences to devise a cost-effective implementation strategy.
The methods used in this study are applicable to other
geriatric health areas. One care strategy attracting policy
attention is integrated care, designed to create “connect-
ivity, alignment and collaboration within and between
the cure and care sectors at the funding, administrative
and/or provider levels” [74]. Since 2014 in England, the
Better Care Fund obliges CCGs and local authorities to
create a shared budget for health and social care and
other public services, and also invests its own capital
(£6.4 billion in 2019–20) to facilitate integration [75].
Such a strategy brings problems of implementation as
diverse service components and teams are combined
[76]; the empirical results for integrated care schemes
are accordingly mixed [77, 78]. The holistic, cross-
component qualitative investigation of the facilitators
and barriers is likely critical for the schemes’ implemen-
tation. The contextual factors are similarly critical as the
age-related physical decline increases the influence of
the wider environment in determining intervention need
and demand [79–82]. The key methodological and
evaluative challenges must likewise be addressed by any
economic model of geriatric public health interventions:
for example, the social disparity in health status is a
prominent feature of geriatric population and raises
equity issues [83, 84].
Strengths and limitations
The simultaneous coverage of three frameworks – cross-
component factors, intervention-related causal mecha-
nisms and public health modelling challenges – is a key
strength of this study. As mentioned, qualitative research
and economic evaluation are typically siloed with no
interdisciplinary learning [39, 47, 48]. By contrast, this
study explores how qualitative data can directly inform
model-based economic evaluation.
The study nevertheless has limitations. The purposive
sampling could have accounted for social categories such
as area-level deprivation, particularly given the import-
ance of social determinants of falls prevention access.
The sampling was concentrated around older persons
living near the Sheffield city centre, meaning that per-
sons living in rural suburbs were under-represented.
Falls prevention service users were recruited mainly
from Dance to Health group exercise programme, mean-
ing that other service types were under-represented.
Only six participants (22%) reported no current/previous
use of services with falls prevention properties, meaning
that views of service non-users were under-represented.
Kwon et al. BMC Health Services Research (2021) 21:1020 Page 16 of 19
Moreover, the sampling did not distinguish between ser-
vice non-users and those who had rejected falls preven-
tion who would have had significantly different views.
Informal caregivers’ views could have been elicited given
their central role in facilitating falls prevention [85]. A
final caveat is that conceptual modelling is incomplete
without eliciting the views of commissioners and falls
prevention professionals [41]. Accordingly, this study is
part of a broader research project that engaged commis-
sioners and professionals in the conceptual modelling.
Conclusion
Better understanding of older persons’ health motives
and higher professional competence can improve the
implementation of the NICE-recommended falls preven-
tion pathway. Older persons are sensitive to implemen-
tation causal mechanisms, meaning that their views can
inform contextual and supply-side changes to promote
falls prevention and wider health promotion. They are
also important stakeholders who can inform the devel-
opment of a complex public health economic model.
The conceptual model informed by qualitative data can
direct the gathering of quantitative evidence and ensure
the structural validity of the final model used for local
decision-making. Future commissioning projects should
similarly employ qualitative research with service users
as the first step towards operationalising a quantitative
economic model of the decision problem.
CCG: Clinical commissioning groups; CG: Clinical guideline; CICI: Context and
Implementation of Complex Interventions; FG: Focus group; HAM: Home
assessment and modification; HNA: Health Needs Assessment; HTA: Health
Technology Assessment; INT: Interview; NICE: National Institute for Health
and Care Excellence; PMG: Process and methods guideline; RCT: Randomised
controlled trial
The online version contains supplementary material available at https://doi.
org/10.1186/s12913-021-07056-1.
Additional file 1.
Authors would like to thank all focus group and interview participants and
the community organizations in Sheffield, the United Kingdom, that
facilitated the research: Dance to Health, Sheffield; Northern General Sheffield
Teaching Hospital; and Zest Community, Sheffield.
All authors were involved in the design of the qualitative research. Mr.
Joseph Kwon and Dr. Janet Harris recruited participant groups. Mr. Kwon and
Ms. Yujin Lee conducted the focus groups and interviews for data collection,
transcribed the audio recordings and conducted thematic analysis. All
authors were involved in the manuscript writing process. The authors read
and approved the final manuscript.
Funding
Mr. Joseph Kwon was supported by the Wellcome Trust [108903/B/15/Z].
Anonymised transcripts of the recorded focus groups and interviews used
for data analysis are available from the corresponding author on reasonable
request.
The research ethics approval was obtained from the Research Ethics
Committee at the School of Health and Related Research, University of
Sheffield (ref. 025248). All parts of the qualitative research were conducted in
accordance with guidelines provided by the Research Ethics Committee.
Written consent to participate was obtained from all participants after they
were informed of the research content.
No personal data were included in this manuscript. Recorded audio data
were transcribed and anonymised. The questionnaire data were similarly
transferred to an Excel spreadsheet and anonymised.
The authors declare none.
1School of Health and Related Research, University of Sheffield, Regent Court
(ScHARR), 30 Regent Street, Sheffield, England S1 4DA. 2Warwick Medical
School, University of Warwick, Gibbet Hill Road, Coventry, England CV4 7AL.
Received: 5 June 2021 Accepted: 13 September 2021
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- Abstract
Background
Methods
Results
Conclusions
Background
Aim and objectives
Methods
Target population and sampling
Discussion topics
Data collection
Data analysis
Framework (I): facilitators and barriers and cross-component and contextual factors
Framework (II): potential commissioning strategies
Framework (III): challenges for public health economic modelling
Results
Participant characteristics
Framework (I): facilitators and barriers and cross-component and contextual factors
Falls risk screening and assessment by professionals
Raising awareness of falls risk
Initial uptake of falls prevention treatments
Adherence and long-term participation in falls prevention treatments
Cross-component factors
Contextual factors influencing the falls prevention pathway
Framework (II): potential commissioning strategies
Context, priority setting and need/eligibility
Supply
Demand
Framework (III): challenges for public health economic modelling
Methodological challenges
Evaluative challenges
Discussion
Strengths and limitations
Conclusion
Abbreviations
Supplementary Information
Acknowledgements
Authors’ contributions
Funding
Availability of data and materials
Declarations
Ethics approval and consent to participate
Consent for publication
Competing interests
Author details
References
Publisher’s Note
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Formatting
Title Page
Citation
Outline
