Sustainability of a Community-Based Falls Prevention Program: A Grounded Theory

Research has shown that a range of interventions are effective for preventing falls among older people living in the community. Yet the translation of these interventions into practice remains a challenge and it has been unclear how interventions and programs once implemented can be sustained over time. In this thesis, two studies are presented investigating the sustainability of community-based falls prevention programs. First, a systematic review of the literature was conducted to determine the extent and nature of research published on this topic. Fifteen disparate and methodologically diverse publications were included in the review. It was found that no theories have been empirically developed to explain or guide how sustainability can be achieved. A range of factors may influence whether programs continue or not, but it was unclear from the review which factors or combination of factors were the most important for program sustainability. While programs may be more likely to continue over time when supported by multi-strategic interventions, it was not clear which types of interventions were the most effective for enhancing the likelihood of program sustainability. These findings suggested that the influences on program sustainability were not well understood and as such it remained unclear how community-based falls prevention programs could be sustained over time. The second and main study in this thesis, aimed to explore the factors influencing the sustainability of a community falls prevention program and to develop an understanding and explanation for how such programs can be sustained by organisations over time. To address these aims a qualitative study was conducted using a grounded theory methodology. The study was conducted in Western Sydney, New South Wales, Australia. Forty-two interviews were conducted with 34 participants from 15 organisations implementing or supporting the Stepping On falls prevention program. Observations were recorded in 69 field-notes. Data were collected from February 2007 to November 2009 and analysed systematically according to recognised processes for constructing grounded theory. Participating organisations were from diverse service sectors including community health, welfare and local government. Based on a detailed analysis of the factors influencing program sustainability, a theory explaining how program sustainability can be achieved was developed. Program sustainability can be achieved in diverse and changing contexts providing three conditions are met. The program must provide benefits and value, committed and skilled people must be available and ongoing support that matches the needs of the organisation must be received. While the nature of the program benefits, the type of people involved and the kind of support required varies with each organisation and may vary over time due to changing circumstances affecting the organisation, all three conditions must be met to ensure that organisations have sufficient motivation and capacity to sustain the program. Organisations use a range of context-specific strategies to create, manage and control the conditions necessary for program sustainability. Working in partnership with others is a key strategy used by organisations to sustain the program. A network linking organisations with program partners, supporters, funders and experts may assist organisations in meeting the conditions necessary for achieving program sustainability, thus enhancing the motivation and capacity of organisations to sustain the program. These findings advance our understanding of how community-based falls prevention programs can be sustained over time. The complementary nature of the theory developed in this study with the broad-based perspectives offered by complexity theory offers a promising approach for optimising and achieving program sustainability. This study has resulted in a comprehensively developed and practical theory that can be applied in diverse and complex settings. The theory can now be used to guide practice, assist policy-makers and inform future research

Evaluation of Structural Change in Primary Care

National health systems are complex and new initiatives are continually being introduced. Well-established instruments exist for evaluating the outcomes of short-term projects and the introduction of new programs within the health system. However, large scale reform involving substantial structural change challenges the ability of existing tools to appropriately evaluate outcomes. In Australia, the National Disability Insurance Scheme (NDIS) and the Health Care Home (HCH) initiatives are examples of structural change although they are not widely recognised as such. This research makes an important contribution to knowledge by exploring structural change and using this exploration to develop new methods for evaluating structural change in the context of primary care in Australia