Network of Intervention-Related Casual Mechanisms Influencing Implementation
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Network of Intervention-Related Casual Mechanisms Influencing Implementation
strategy should fully reflect the complex network of intervention-related casual mechanisms influencing implementation. Several frameworks exist to capture such complexity [40], including the Context and Implementation of Complex Interventions (CICI) framework [20] which was developed as part of the INTEGRATE-HTA project to consider a comprehensive set of factors influencing the assessment of complex health technologies [19].
CICI distinguishes between contextual factors (e.g., socio-cultural, legal) and implementation mechanisms (e.g., professionals, organizations) that shape implementation quality. Priority-setting challenges – e.g., reducing social inequities of health [35] – also arise from the implementation context [40]. Given the CICI framework’s lack of focus on demand-side mechanisms (e.g., motivations of the older persons to engage in healthy behavior
[42]), it could be supplemented by the health needs assessment (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 populations – rather than a clinical problem faced by a well- defined, narrow patient group – presents further complexity to model development [41]. According to a systematic methodological review, the key methodological challenges to public health economic modelling include:
(I) capturing non-health outcomes and societal intervention costs; (ii) considering dynamic complexity in health determinants and intervention need; (iii) considering theories and models of human behavior based on psychology and sociology; and (iv) considering social determinants of health and issues of equity [46]. Addressing 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].
Aim and objectives 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:
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.
Inform potential local commissioning strategies on falls prevention by understanding the causal mechanisms in context, supply, need and demand that influence implementation.
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.
Discussion 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
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