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

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

Parent perspectives:The value of trained dogs in animal assisted therapy for children and adolescents with Autism Spectrum Disorder

Dogs may elicit positive therapy outcomes for children with Autism Spectrum Disorder (ASD). Despite growing research into Animal Assisted Therapy (AAT) for ASD, the parent perspective has not yet been fully engaged. This study aimed to explore parent perspectives regarding AAT. Sixteen semi-structured interviews were conducted with parents following their child's completion of an AAT program. Thematic analysis, line by line coding and consensus theme refinement were used for data analysis. Three themes emerged. Parents valued that the dogs supported their child: stress and anxiety management; engagement and participation; and social-communication. Parents valued the dogs as having a calming effect that facilitated child participation in several life-skill activities and social-communication. Future studies should investigate how best to target AAT with dogs for children with ASD.Assistance Dogs Australi

The experience of Malaysian occupational therapists in conducting home assessments and home visits with older clients

Introduction: Home visits are complex processes for clients and occupational therapists. Despite the benefits of home visits, the numbers of home visits being conducted are decreasing in international settings due to service constraints or client reluctance. Published international studies may not be applicable to Malaysia due to cultural and geo-demographic differences relating to the home context. This study aimed to explore the experience of occupational therapists in Malaysia in conducting home visits. Materials and Methods: A focus group discussion was conducted with seven occupational therapists in one teaching hospital in Kuala Lumpur. The group session was audio-recorded, transcribed, summarised and analysed using thematic analysis. Results: Themes developed were: i) client factors inhibiting effective service provision, ii) uninformed policies and guidelines, and iii) professional identity and growth. Conclusions: Our study has revealed major challenges for Malaysian occupational therapists with regards to conducting home visits. Future studies should now evaluate factors underlying reluctance to participate in home visits and effective strategies to overcome these difficulties

Adult experiences of constraint-induced movement therapy programmes : A qualitative study using the Theoretical Domains Framework and Capability, Opportunity, Motivation - Behaviour system

Aim: To explore the experiences of adults who completed a constraint-induced movement therapy (CIMT) programme, and the barriers and enablers to their participation. Methods: Qualitative design using semi-structured interviews. Stroke and brain injury survivors (n = 45) who had completed CIMT as part of their usual rehabilitation were interviewed 1 month post-CIMT. Interviews were audio-recorded, transcribed and imported into Nvivo for analysis. Inductive coding was used to identify initial themes. Themes were then deductively mapped to the Capability, Opportunity, Motivation – Behaviour system, a behaviour change model, to identify barriers and enablers to CIMT programme adherence and engagement. Results: Enablers influencing participation included being provided with education about the programme (Capability – psychological), seeing improvements in arm function (Motivation – reflective), being committed to the programme (Motivation – reflective) and having strong social support from staff, family and allied health students (Opportunity – social). The structured programme was a motivator and offered a way to fill the time, particularly during inpatient rehabilitation (Opportunity – physical). Barriers to participation included experiencing physical and mental fatigue (Capability – physical) and frustration early in the CIMT programme (Motivation – automatic), and finding exercises boring and repetitive (Motivation – automatic). Conclusion: Therapist provision of educational supports for CIMT participants and their families is important to maximise CIMT programme uptake. During CIMT delivery, we recommend the provision of positive feedback and coaching in alignment with CIMT principles, and the inclusion of social supports such as group-based programmes to enhance participant adherence

Home hazards with fear of falling: findings from the baseline study of the Malaysian Elders Longitudinal Research (MELoR)

Background: Fear of falling (FoF) is a common issue among older people, impacting on psychological health, functional performance and mortality. Many factors associated with fear of falling have been investigated but little is known about the role of home hazards. Home hazards can be due to unsafe environmental and functional features. This study is aims to evaluate the association between home hazards with fear of falling among community-dwelling individuals aged 55 years and over. Methods: Baseline data with 1,489 older individuals from the Malaysian Elders Longitudinal Research (MELoR) study were analyzed. Home visits for interview and observations in the home were conducted with the participants. FoF was established with a single-item question and home hazards with the Home Falls and Accidents Screening Tool (HOME FAST). Results: The majority (76.4%) of older participants experienced FoF. The history of falls was not associated with FoF (p = 0.868), but FoF was associated with participants limiting their daily activities (p < 0.001). Home hazards were less likely (p = 0.023) and functional issues were more likely (p < 0.001) to be associated with a high degree of FoF. However, both home hazards domains were not associated with activity restriction due to FoF. Conclusions: Education about home hazards from the perspective of person-environment interaction may encourage home hazards management and reduce FoF which should be evaluated in future studies

Best care options for older prisoners with dementia – a scoping review

Introduction: The prisoner population is ageing and consideration is needed for how to best support those with age-related health conditions in the system. Existing work practices and organisational structures often fail to meet the needs of prisoners with dementia, and prison staff experience high levels of burden due to these prisoners’ increased needs. Little is known about the best method of responding to the needs of this growing sub-population of prisoners. Method: A scoping review was conducted to answer the question: What are the perceived best care options for prisoners with dementia? To be included, publications had to be publicly available, reported on research findings, or viewed opinions and commentaries on care practices relevant to older prisoners with dementia. Searches were conducted in eleven databases to identify relevant publications. Data from the included publications were extracted and summarised into themes. Results: Eight themes were identified that could support better care practices for prisoners with dementia: (1) early and ongoing screening for older prisoners; (2) specialised services; (3) specialised units; (4) programs/activities; (5) adaptations to current contexts; (6) early release or parole for older prisoners with dementia deemed at low risk of re-offending; and (7) training younger prisoners (8) as well as staff to assist older prisoners with dementia. Besides practical strategies improving care practice, costs, prison-specific resources and staff skills were highlighted as care barriers across all themes. A lack of empirical evidence supported these findings. Conclusion: One of the implications of the international ageing prison population is higher numbers of people incarcerated with dementia. Suggestions for best care approaches for prisoners with dementia now need to move from opinion to empirical approaches to guide practice

Providing education on evidence-based practice improved knowledge but did not change behaviour: a before and after study

BACKGROUND: Many health professionals lack the skills to find and appraise published research. This lack of skills and associated knowledge needs to be addressed, and practice habits need to change, for evidence-based practice to occur. The aim of this before and after study was to evaluate the effect of a multifaceted intervention on the knowledge, skills, attitudes and behaviour of allied health professionals. METHODS: 114 self-selected occupational therapists were recruited. The intervention included a 2-day workshop combined with outreach support for eight months. Support involved email and telephone contact and a workplace visit. Measures were collected at baseline, post-workshop, and eight months later. The primary outcome was knowledge, measured using the Adapted Fresno Test of Evidence-Based Practice (total score 0 to 156). Secondary outcomes were attitude to evidence-based practice (% reporting improved skills and confidence; % reporting barriers), and behaviour measured using an activity diary (% engaging/not engaging in search and appraisal activities), and assignment completion. RESULTS: Post-workshop, there were significant gains in knowledge which were maintained at follow-up. The mean difference in the Adapted Fresno Test total score was 20.6 points (95% CI, 15.6 to 25.5). The change from post-workshop to follow-up was small and non-significant (mean difference 1.2 points, 95% CI, -6.0 to 8.5). Fewer participants reported lack of searching and appraisal skills as barriers to evidence-based practice over time (searching = 61%, 53%, 24%; appraisal 60%, 65%, 41%). These differences were statistically significant (p = 0.0001 and 0.010 respectively). Behaviour changed little. Pre-workshop, 6% engaged in critical appraisal increasing to 18% post-workshop and 18% at follow-up. Nearly two thirds (60%) were not reading any research literature at follow-up. Twenty-three participants (20.2%) completed their assignment. CONCLUSION: Evidence-based practice skills and knowledge improved markedly with a targetted education intervention and outreach support. However, changes in behaviour were small, based on the frequency of searching and appraisal activities. Allied health educators should focus more on post-workshop skill development, particularly appraisal, and help learners to establish new routines and priorities around evidence-based practice. Learners also need to know that behaviour change of this nature may take months, even years

The reliability of an outcome measure for animal assisted therapy in youth with Autism Spectrum Disorder

A reliable outcome measure is crucial to understand the impact of emerging interventions, such as animal assisted therapy (AAT) for individuals diagnosed with Autism Spectrum Disorder (ASD). A video analysis tool was created to measure the impact of AAT on people with ASD by recording the frequency and duration of positive, play and negative behaviours. This study aimed to determine the inter-rater and test re-test reliability of the video analysis tool and to investigate if session complexity and eater factors influenced the reliability of the tool in this population. Following training in the use of the tool, 23 occupational therapy students from an Australian metropolitan university rated a simple or complex video-recorded AAT session on two occasions. The raters also completed a survey to obtain demographic information. Expert raters determined acceptable score ranges which were compared with collected data in SPSS to determine Intraclaas Correlation Coefficients ( ICC). The ICCs of the video analysis tool were 0.84 (simple session) and 0.894 (complex session ) for inter-rather and 0.84 (simple session) and 0.89 (complex session) for test re-test reliability. The percentage agreement was similar regardless of session complexity and rater experience with children and ASD but varied across subscales and rater animal experience. This study indicates the video analysis tool has potential as a reliable outcome measure for AAT with individuals with ASD, however further research utilising increased sample sizes is required to establish the effectiveness of the tool.Assistance Dogs Australi