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Sustainability of community-based fall prevention programs:A systematic review

Meryl Lovarini a,⁎, Lindy Clemson b, Catherine Dean c

a Discipline of Occupational Therapy, Faculty of Health Sciences, The University of Sydney, 75 East Street, Lidcombe, NSW 2141, Australiab Ageing, Work and Health Research Unit and Centre for Population Ageing, The University of Sydney, 75 East Street, Lidcombe, NSW 2141, Australiac Department of Health Professions, Physiotherapy Program, Faculty of Human Services, Macquarie University, Balaclava Road, North Ryde, NSW 2109, Australia

a b s t r a c ta r t i c l e i n f o

Article history:Received 1 February 2013Received in revised form 30 June 2013Accepted 14 August 2013Available online 28 August 2013

Keywords:Knowledge translationEvidence-based practiceAccidental fallsTranslational research

Background: Fall prevention programs may be implemented but not sustained. We conducted a systematicreview to identify any theories, models, frameworks, influencing factors or interventions for sustaining fallprevention programs in the community.Methods: Peer-reviewed publications describing, investigating, or eval-uating programsustainabilitywere accessed. A narrative reviewwas conducted to compare and synthesize studyfindings. Results: Nineteen publications were included. Three conceptual frameworks were identified describinghow programs may be better sustained. While ongoing financial support and the participation of older peoplewere commonly reported influences, other factors specific to the type of program and settingwere also reported.Planning, training, and collaboration between program stakeholders may facilitate sustainable programs. Impacton industry:Organizations can use thesefindingswhen planning for sustainable programs. Howevermore robustempirical studies are needed to confirm the value of conceptual frameworks, the critical factors and most effec-tive interventions for sustaining community-based fall prevention programs.

© 2013 National Safety Council and Elsevier Ltd. All rights reserved.

1. Introduction

The effectiveness of interventions to prevent falls among older peo-ple living in the community is well established (American GeriatricsSociety & British Geriatrics Society, 2011; Australian Commission onSafety & Quality in Health Care, 2009; Gillespie et al., 2012). The use ofsuch interventions however, appears limited. Few older people areasked by their medical practitioner about falls or offered interventionsto prevent falls (Wenger et al., 2003). Despite the high and recurrentuse of healthcare services by older people entering emergency depart-ments following a fall (Close et al., 2012; Hartholt et al., 2011;Woolcott, Khan, Mitrovic, Anis, & Marra, 2011), treatments usuallyfocus on the injuries sustainedwith little consideration given to the pre-vention of future falls (Kalula, de Villiers, Ross, & Ferreira, 2006; Milleret al., 2009; Salter et al., 2006). Few community-based organizationsregularly offer fall prevention services (Laing, Silver, York, & Phelan,2011) and it has been shown that fall prevention programs fundedinitially from research grants or as demonstration projects were notsustained beyond the project timeframe (Shekelle et al., 2003). Therate of falls has not changed over time (Gribbin, Hubbard, Smith,Gladman, & Lewis, 2009; Hill et al., 2002) and fall-related hospitaliza-tion rates are increasing (Hartholt et al., 2010).With projected increases

in the population of older people, falls will remain a serious health issuefor a growing number of older people (World Health Organisation,2007). The focus therefore, must now shift to understanding how fallprevention interventions shown to be effective in research can be trans-lated into effective and sustainable programs in practice (Close, 2005;Edwards, 2011; Stevens, Baldwin, Ballesteros, Noonan, & Sleet, 2010).

Studies conducted to date on the translation of fall prevention re-search into practice have focused on the factors influencing programparticipation by older people (Bunn, Dickinson, Barnett-Page, McInnes,& Horton, 2008; Child et al., 2012; Dickinson et al., 2011; Høst,Hendriksen, & Borup, 2011), barriers and facilitators to program imple-mentation by health professionals (Child et al., 2012; Jones, Ghosh,Horn, Smith, & Vogt, 2011), and the evaluation of methods to improvethe implementation of fall prevention programs in practice (Goodwin,Jones-Hughes, Thompson-Coon, Boddy, & Stein, 2011; Tinetti et al.,2008). Despite a growing understanding of the issues surrounding theuptake and implementation of community-based fall prevention pro-grams, factors impacting on the sustained use of such programs inpractice are less understood (Clemson, Finch, Hill, & Lewin, 2010).

Program sustainability can be defined as the continued use of pro-grams by organizations over time to achieve desired health outcomes(Scheirer & Dearing, 2011). Although linked, program sustainabilitycan be distinguished from the phases of programadoption (the decisionof an organization to use a new program) and program implementation(the process of putting the program into usewithin a particular setting;Rabin, Brownson, Haire-Joshu, Kreuter, & Weaver, 2008). Program

Journal of Safety Research 47 (2013) 9–17

⁎ Corresponding author. Tel.: +61 2 9351 9373; fax: +61 2 9351 9197.E-mail addresses: meryl.lovarini@sydney.edu.au (M. Lovarini),

lindy.clemson@sydney.edu.au (L. Clemson), catherine.dean@mq.edu.au (C. Dean).

0022-4375/$ – see front matter © 2013 National Safety Council and Elsevier Ltd. All rights reserved.http://dx.doi.org/10.1016/j.jsr.2013.08.004

Contents lists available at ScienceDirect

Journal of Safety Research

j ourna l homepage: www.e lsev ie r .com/ locate / js r

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sustainability is an important consideration to ensure that investmentsin time, resources, and people are not wasted (Pluye, Potvin, & Denis,2004). A range of factors may influence program sustainability inhealthcare settings. The nature of the program, the context withinwhich the program is implemented, the processes used to sustain theprogram, and the organizational capacity have been identified in onereview as possible influences on whether programs are sustained(Wiltsey-Stirman et al., 2012). Despite these findings, uncertaintyremains as to how health programs can be successfully sustained overtime given the diversity of definitions, conceptual frameworks, studymethods, timeframes, and outcomes measured in each of the studiesincluded in the review. To compound the uncertainty, the sustainabilityof fall prevention programs has not been the focus of reviews conductedto date within the broader literature on program sustainability (Gruenet al., 2008; Scheirer, 2005; Wiltsey-Stirman et al., 2012).

We systematically reviewed the published literature to: (a) identifyany theories, models, or frameworks that have been developed for thesustainability of community-based fall prevention programs; (b) deter-mine which factors affect program sustainability; and (c) ascertain ifany interventions are effective for promoting, enhancing, or achievingprogram sustainability.

2. Methods

We conducted a systematic review based on methods for reviewingstudies of diverse designs (Centre for Reviews andDissemination, 2009;Higgins & Green, 2009; Liberati et al., 2009).

2.1. Inclusion and exclusion criteria

We included publications from the peer-reviewed scientific litera-ture and set no restrictions on the type of study design or researchmethods used. No limits on language, publication date, or publicationstatuswere imposed, other than those limits inherentwithin the designof each database searched.

Any publications referring to interventions or programs that aimedto reduce the risk of falls, rate of falls, or the effect of or exposure toany risk factor for falling were included. Publications referring to oldermen and women aged 65 years and over and living in the communitywere included. In accordancewith other systematic reviews, we includ-ed publications if the participants were described as elderly, seniors, orolder adults, if 50% and over of the total number of participants wereaged 65 years and over and were living either at home or in similarresidences such as independent living units in retirement villages(Gillespie et al., 2009). Publications referring to hospitals or formalresidential aged care settings (such as hostels and nursing homes)were excluded, given the specific nature of these settings compared tothe broader community (Gillespie et al., 2009).

Any publications investigating the sustainability of fall preventionprograms, relevant to the three review objectives were included.Program sustainability can be evaluated at the level of organization orindividual (Glasgow, Vogt, & Boles, 1999). Given our review objectives,we defined program sustainability as the continuation of programs byorganizations over time (Pluye et al., 2004; Scheirer & Dearing, 2011;Shediac-Rizkallah & Bone, 1998). Thus, publications referring to the on-going effect of the program on individuals participating in the program,rather than the sustainability of the program itself, were excluded.

2.2. Searches

Publicationswere identified by searching electronic databases, scan-ning the reference lists of included publications, and from the personalcollections of the authors. The Medline, Embase, Cochrane Database ofSystematic Reviews, Cochrane Central Register of Controlled Trials,PubMed, Cinahl, OTseeker, PEDro, AMED, PsycINFO, and Ageline data-bases were searched at the end of August 2011. We did not search the

“grey literature” as our aim was to only include publications from thepeer-reviewed scientific literature. The search strategy was first pilotedand then refined for each database. Multiple terms and phrases previ-ously used in the literature for the concept of program sustainabilitywere included in the search (Supplementary file 1). All searches wereconducted by one author.

2.3. Publication selection and data extraction

After removal of duplicates, each publication was screened by titleand abstract for relevance. The full text of each relevant publicationwas then independently assessed for eligibility by two authors using astandard form. Any uncertainties or discrepancies were resolved byconsensus. For all included publications, we extracted the followingdata: the country, publication type, and the aspect of program sustain-ability addressed in the publication. For empirical studies we extractedadditional data: the study aim, setting, population, intervention,research methods, and main study findings. One author extractedthe data which were checked for accuracy by a second.

2.4. Study quality assessment and data analysis

Assessment of study quality was limited to empirical study designsfor which quality assessment was appropriate. We used quality assess-ment criteria specific to each study design, based on a previous system-atic review of publications of multiple study designs (Greenhalgh,Robert, Bate, Macfarlane, & Kyriakidou, 2005). One author conductedthe quality assessments that were verified by a second. To analyze thedata we first categorized the publications according to each of thethree review objectives and summarized relevant data from each publi-cation into evidence tables.We conducted a narrative review to synthe-size the data and identify similarities and differences in findings acrosspublications (Verbeek, Ruotsalainen, &Hoving, 2012). Given thehetero-geneity of the includedpublications itwasnot possible or appropriate tocalculate summary measures across studies or conduct a meta-analysis.

3. Results

Fig. 1 shows the publication selection and exclusion process. Of the132 potentially relevant publications identified, 113 were excluded(Supplementary file 2), leaving 19 publications included in the review.Table 1 summarizes key characteristics of the included publicationsaccording to each of the review objectives. Publications were from theUnited States (US) (n = 8), Australia (n = 7), Canada (n = 2), andthe United Kingdom (UK) (n = 2), published from 1998 to 2011, withmost published after 2002. We included four publications that werenot specific to the community setting, but were clearly relevant toolder people living in the community. For most publications we wereunable to determine if 50% or more of the participants were aged65 years and over. Hence we included publications if they referred toolder people, older adults, the elderly or seniors. For many of the includ-ed publications, program sustainability was not the primary focus butwas referred to in someway. Thus, when extracting thedata, we focusedonly on the parts of the publication relevant to program sustainability.

Three of the included publications were related to the Stay on YourFeet (SOYF) fall prevention program in Australia (Barnett et al., 2003,2004; van Beurden, Barnett, Molyneaux, & Eakin, 2003). Two publica-tions were related to the same fall prevention demonstration projectin Canada (Hanson, Salmoni, & Volpe, 2009; Hanson & Salmoni, 2011),while another two publicationswere related to the Telecare fall preven-tion project in the United States (Ganz, Yano, Saliba, & Shekelle, 2009;Miake-Lye et al., 2011).

Fifteen of the included publications were empirical studies whilefour were descriptive in nature. The empirical studies includedprogram/project evaluations (n = 5), survey studies (n = 4),qualitative studies (n = 2), study protocols or designs (n = 2),

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one dissemination study, and one single group study using a pre-test/post-test design. Assessment of study quality was appropriate forseven of the empirical studies including the four survey studies(Barnett et al., 2003, 2004; Hughes, 2002; van Beurden et al., 2003),two qualitative studies (Hanson et al., 2009; Hanson & Salmoni, 2011),and the dissemination study (Baker, Gottschalk, & Bianco, 2007).

3.1. Theories, models or frameworks for program sustainability

Three publications described different conceptual frameworksor models for program sustainability (Supplementary file 3). TheKnowledge Dissemination and Utilization Framework was proposedas a potential framework to maximize the utilization of researchfindings in practice (Farkas, Jette, Tennstedt, Haley, & Quinn, 2003).Derived from the field of education and curriculum development,the framework focuses on the development of strategies aimed atincreasing exposure to research knowledge, improving experienceand expertise in the use of that knowledge and facilitating thecontinuation or ‘embedding’ of knowledge use over time. Using theKnowledge Dissemination and Utilization Framework as a guide, arange of strategies aimed at sustained implementation of the Matterof Balance fear of falling program by community organizations wasdeveloped, with the authors reporting the continuation of the pro-gram in one state in the United States.

The use of the Innovative Care for Chronic Conditions (ICCC) Frame-work was suggested as a potential guide to enable better coordination,facilitation, implementation, and sustainability of fall prevention pro-grams (Ganz, Alkema, & Wu, 2008). Developed by the World HealthOrganisation with the aim of better health outcomes, the ICCCFramework comprises a set of principles linking the activities ofconsumers, community service providers and healthcare professionals,

framed within a positive policy environment. In demonstrating theapplicability of the ICCC Framework to fall prevention programsshown to be effective in both the United States and internationally,the authors suggested that service providers may evaluate theirown programs against the principles of the framework to enablethe development of appropriate strategies aimed at program imple-mentation and sustainability.

A model encompassing policy development, research, and servicedelivery aimed at a state-wide sustainable fall prevention system wasdescribed in one publication (Rose, Alkema, Choi, Nishita, & Pynoos,2007). Developed as a public–private partnership, The Fall PreventionCenter for Excellence was established in California in 2005. To facilitatesustainable fall prevention programs, the Center has, to date, developedfall prevention resources aimed at consumers and health professionals,established the StopFalls Network to link organizations involved infall prevention, offered funding to assist community organizations indeveloping or expanding programs, and initiated research evaluatinghow effective and sustainable programs can be delivered within thecommunity.

3.2. Factors affecting program sustainability

Nine publications reported on factors affecting program sustainabil-ity (Supplementary file 4). One publication described the developmentof a database containing information on fall prevention programs oper-ating within Australia (Gilsenan, Hill, & Kerse, 1999). Each program in-cluded in the database was rated against factors thought by the authorsto contribute to program sustainability such as the presence of perma-nent program funding and staff or inclusion of the program as a coreactivity of the organization. No data were provided regarding how

Full-text publications excluded (n=104)

• Not sustainability (n=76)• Not fall prevention (n=20)• Not community setting (n=7)• No English translation (n=1)

Additional records identified through other

sources (n=11)

Records after duplicates removed (n=4767)

Records screened (n=4767)

Full-text publications assessed for eligibility

(n=123)

Publications included in the review (n=19)

Records identified through database

searching (n=8128)

Records excluded (n= 4635)

Records for eligibility assessment (n=132)

Full-text publications excluded (n= 9)

• Government report (n=3)• Dissertation (n=2)• Magazine article (n=2)• Previous versions of same review (n=2)

Fig. 1. Publication selection and inclusion.

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each program listed in the database rated according to the programsustainability criteria.

Eight publications were empirical studies reporting how programsustainability is defined (Hanson et al., 2009), the challenges and bar-riers to program sustainability (Baker et al., 2007; Hanson & Salmoni,2011; Kramer, Vivrette, & Rubenstein, 2011; Miake-Lye et al., 2011),and factors considered important for program sustainability (Bagnall,Monk, Gimson, Saul, & Farmiloe, 1998; Hedley, Suckley, Robinson, &Dawson, 2010; Peel, Travers, Bell, & Smith, 2010). Assessment of studyquality was appropriate for three studies only. Both qualitative studies(Hanson et al., 2009; Hanson & Salmoni, 2011) met 9 of 11 qualitycriteria, while the dissemination study (Baker et al., 2007) met 11 ofthe 16 criteria (Supplementary file 5).

3.2.1. Defining program sustainabilityOne qualitative study investigating how stakeholders involved with

three community-based fall prevention demonstration projects inOntario, Canada, defined program sustainability found that stakeholderdefinitions varied both within and across the three programs, with def-initions ranging from the continuation of the entire program over time,the continuation of successful elements of the programonly, the contin-uation of the programwithout financial assistance, or the lasting impactof the program (Hanson et al., 2009).

3.2.2. Challenges and barriers to program sustainabilityBarriers to program sustainability were reported in two program

evaluation studies (Kramer et al., 2011; Miake-Lye et al., 2011), onedissemination study (Baker et al., 2007), and one qualitative study(Hanson & Salmoni, 2011). A lack of sufficient program funding or re-sources was reported as a barrier to sustainability in all four studies.

Challenges in engaging older people and a lack of program support byhealth professionals and other stakeholders were reported in threestudies (Baker et al., 2007; Hanson & Salmoni, 2011; Miake-Lye et al.,2011).

Barriers specific to the program type or context were also reported.Challenges in tailoring the intervention, modifying existing practices,and determining responsibility for the program were reported in adissemination study investigating the integration of the Step-by-Stepprogram in senior centers in Connecticut in the United States (Bakeret al., 2007). Fragmentation of programs once project funding ceased,a lack of leaders to promote and co-ordinate programs, and a relianceon volunteers were barriers reported by stakeholders involved inthree fall prevention projects in Ontario, Canada (Hanson & Salmoni,2011). Reported threats to sustainability of the multi-componentInSTEP fall prevention program conducted in six seniors and commu-nity centers in Los Angeles in the United States, included a lack ofqualified instructors and the need to address risk and liability issuesspecific to each setting and program component (Kramer et al., 2011).Large staff caseloads and service duplication were reported barriersto the continuation of the Telecare fall prevention pilot project inLos Angeles in the United States (Miake-Lye et al., 2011).

3.2.3. Factors considered important for program sustainabilityDifferent supporting factors were reported in three studies. In one

project evaluation study conducted in Townsville, Australia, local ser-vice providers were supported by a community health service to imple-ment the Gentle Exercise Project, a strategy developedwithin a broaderfall prevention program(Bagnall et al., 1998). Factors considered centralto the sustainability of the project included service provider involve-ment in program identification and development, making the program

Table 1Key characteristics of included publications (n = 19).

Publication Country Relevance toreview objective

Publication type Aspect of program sustainability addressed in the publication

Farkas et al. (2003) United States 1 Descriptive Description and application of a conceptual framework to the Matter ofBalance program

Ganz et al. (2008) United States 1 Descriptive Description and application of a conceptual framework for coordinating andsustainability fall prevention initiatives

Rose et al. (2007) United States 1 Descriptive Description of a policy, research & service delivery model and infrastructure forfall prevention in California

Gilsenan et al. (1999) Australia 2 Descriptive Description of a database containing fall prevention interventions rated againstfactors thought to contribute to program sustainability

Hanson et al. (2009) Canada 2 Qualitative study Program stakeholders' definitions for program sustainabilityKramer et al. (2011) United States 2 Program evaluation Perspectives of community-based centers' on the sustainability of a pilot fall

prevention programPeel et al. (2010) Australia 2 Pilot project evaluation Factors affecting sustainability of a pilot fall prevention projectBagnall et al. (1998) Australia 2, 3 Project evaluation Factors considered central for sustainability of a fall prevention project, the use

of early planning activities to promote project sustainabilityBaker et al. (2007) United States 2, 3 Dissemination study Challenges in embedding and integrating a fall-risk management program,

strategies used to embed and integrate the falls-risk management programHanson and Salmoni (2011) Canada 2.3 Qualitative study Barriers to fall prevention program sustainability, actions taken to promote

program sustainabilityHedley et al. (2010) United Kingdom 2, 3 Program evaluation Factors contributing to sustainability of the Staying Steady program,

recommendations to enhance program sustainabilityMiake-Lye et al. (2011) United States 2, 3 Project evaluation Facilitators and barriers to sustainability of the Telecare fall prevention

project, sustainability of the Telecare project at 18 monthsBarnett et al. (2004) Australia 3 Survey study Sustainability of the Stay On Your Feet fall prevention activities by community

health staff, councils, access committees and older peopleBarnett et al. (2003) Australia 3 Survey study Sustainability of the Stay On Your Feet fall prevention activities by general

practitionersDay et al. (2011) Australia 3 Study protocol The development, implementation and evaluation of sustainability guidelines

for the incorporation of fall prevention strategies into agency work programsGanz et al. (2009) United States 3 Design of a quality

improvement programThe use of theory to develop a sustainable fall prevention program includingevaluation of the Telecare project, a project developed within the fallprevention program

Hughes (2002) United Kingdom 3 Survey study Strategies used by organizations engaged in fall prevention programsLi et al. (2008) United States 3 Single group, pre-post study Maintenance of a Tai Chi fall prevention programvan Beurden et al. (2003) Australia 3 Survey study Sustainability of the Stay On Your Feet fall prevention activities by

community pharmacists

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core business of the service provider, having minimal program start-upcosts, and adopting a user-pays approach at programoutset. Evidence ofbenefit to program participants along with program adherence and ac-ceptability of the program to older people were considered key contrib-utors to program sustainability in one study evaluating the StayingSteady program conducted in Newcastle upon Tyne in the UK (Hedleyet al., 2010). In one project conducted in Queensland, Australia, sixFalls Safety Officers were appointed for one year with the aim of en-hancing the capacity of health service providers to deliver coordinatedfall prevention activities (Peel et al., 2010). Ongoing funding fordedicated project staff and continuity of fall prevention educationdelivered in flexible formats were identified as potential facilitatorsfor sustainability of the project.

3.3. Interventions for promoting, enhancing or achievingprogram sustainability

Twelve publications, all empirical studies, related to interventionsfor program sustainability (Supplementary file 6). Of these, seven stud-ies described (Day et al., 2011; Ganz et al., 2009; Hanson & Salmoni,2011; Hedley et al., 2010) or evaluated (Bagnall et al., 1998; Bakeret al., 2007; Miake-Lye et al., 2011) specific interventions to facilitateprogram sustainability, while five studies solely evaluatedwhether pro-grams were sustained over time (Barnett et al., 2003, 2004; Hughes,2002; Li et al., 2008; van Beurden et al., 2003).

3.3.1. Description of interventions to facilitate program sustainabilityFour studies proposed, described, or recommended different inter-

ventions to facilitate program sustainability. Designs included a studyprotocol (Day et al., 2011), a quality improvement study (Ganz et al.,2009), a program evaluation (Hedley et al., 2010), and one qualitativestudy (Hanson & Salmoni, 2011). Assessment of study quality wasappropriate only for the study conducted by Hanson and Salmoni(2011), which met 9 of 11 quality criteria (Supplementary file 5).

The use of guidelines and training to facilitate program sustainabilitywas proposed in one study protocol (Day et al., 2011). In the study,program sustainability guidelines will be developed and trialed withcommunity agencies from Victoria, Australia to assist them in planningand delivering sustainable fall prevention programs.

The use of theory to guide the development and implementation of asustainable fall prevention program by a large healthcare service inLos Angeles was described in one quality improvement study (Ganzet al., 2009). Drawing on elements from multiple theories includingthe diffusion of innovation theory and organizational theory, the pro-gram involved the engagement of leaders within the organization andthe development ofwork groupswith the aimof developing sustainablelocal fall prevention projects. The Telecare projectwas developed as oneinitiative within the programwith the study authors reporting continu-ation of the project beyond the initial six-month study timeframe.

One study conducted inNewcastle upon Tyne in theUK, aimed to es-tablish a sustainable preventative exercise program for older people atrisk of falls (Hedley et al., 2010). The Staying Steady program consistedof a combination of center and home-based exercises delivered by anexercise instructor to five participants over a 32-week period. Recom-mendations to enhance program sustainability were made based onchanges in clinical outcomes at program end and interviews conductedwith the participants and instructor. These included: the maintenanceof a whole of community approach to fall prevention by linking localservices, the recognition of the health benefits associated with programparticipation, the continuation of the program in leisure-based settings,the provision of training for instructors, the identification of a centralprogram coordinator, and the development of strategies to promoteexercise adherence.

In a qualitative study conducted in Canada, 45 stakeholders involvedwith three different fall prevention demonstration projects fundedfor a two-year period, were interviewed within one year of funding

termination (Hanson & Salmoni, 2011). Stakeholders, includinghealthcare professionals, health service administrators, communityvolunteers, and older people were asked about any actions taken topromote program sustainability. Reported actions included developingpartnerships and networking with others, acquiring knowledge, skillsand resources to increase program capacity, the strategic use of fundingand materials, changes in procedures and policies, and generatingsupport for the program.

3.3.2. Evaluation of interventions to facilitate program sustainabilityThree studies evaluated different multi-component interventions

for improving the likelihood of program sustainability. Designs includedtwo project evaluation studies (Bagnall et al., 1998; Miake-Lye et al.,2011) and one dissemination study (Baker et al., 2007) that met 11 of16 quality criteria (Supplementary file 5).

In one project evaluation study conducted in Townsville, Australia, avariety of early planning strategies were implemented with the aim ofdeveloping sustainable and self-funding exercise classes conducted bylocal service providers (Bagnall et al., 1998). Strategies included usingalready trained instructors, existing equipment, free venues, and charg-ing a modest fee to participants, with the authors reporting the sustain-ability of classes at 18 months after commencement.

The Telecare fall prevention project (Miake-Lye et al., 2011) devel-oped in Los Angeles, was the first project to be developed within thetheory-based fall prevention quality improvement program describedby Ganz and colleagues (2009). The project consisted of a telephoneservice in which a nurse identified fall risk factors for referred patients,and then organized appropriate referrals to other services such as a fallsclinic or home care. The project discontinued after 18 months due to theretirement of the project ‘champion,’ an increase in workload due toservice expansion, and competing organizational priorities.

A multi-strategic intervention, Step-by-Step, was used to assist nineseniors' centers in Connecticut in the United States, in sustaining a fallrisk management program (Baker et al., 2007). Strategies included atraining program, the formation of work groups to develop implemen-tation methods, identify barriers and develop solutions, and the devel-opment of collaborative relationships between the researchers, theseniors' centers, and local health providers. After 18 months, seven ofthe nine centers were sustaining the program in full (n = 5) or in amodified format (n = 2).

3.3.3. Evaluation of program sustainability in the absence of a facilitatingintervention

Five studies solely evaluatedwhether programswere sustained overtime. That is, none of the programswere supported by specific interven-tions aimed at improving the likelihood of sustainability. Designsincluded four survey studies (Barnett et al., 2003, 2004; Hughes, 2002;van Beurden et al., 2003) and one single group pre–post study design(Li et al., 2008). Of the survey studies one met 10 of 13 assessmentcriteria (Hughes, 2002), two studies met eight criteria (Barnett et al.,2003; van Beurden et al., 2003), and one study met six criteria(Barnett et al., 2004; Supplementary file 5).

Three survey studies evaluated sustainability of the Stay on YourFeet (SOYF) fall prevention program five years after the program wasconducted in the northern rivers area of New South Wales, Australia(Barnett et al., 2003, 2004; van Beurden et al., 2003). A large publichealth fall prevention program, SOYF comprised awareness raising inthe community, community education, policy development, engage-ment of health professionals, and interventions targeting older people.Findings from the three studies indicated that some SOYF related activ-ities were sustained by community health professionals, that there waslimited use of SOYF related activities by community pharmacists, andthat none of the current fall prevention practices of general practi-tioners, councils, or access committees related directly to the SOYF pro-gram. Strategies for sustaining SOYF activities by community healthprofessionals included making the activity part of the usual work role

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and ensuring that the activity was compatible with other projects,prioritized, and adequately resourced (Barnett et al., 2004).

As part of a larger survey, one study reported the strategies used by13 primary health care organizations in London in the UK, engaged infall prevention activities (Hughes, 2002). Ten of the 13 organizationsreported commencement of activities within the previous three yearsutilizing four strategies such as the creation of fall prevention workingparties, appointment of fall prevention co-ordinators, trainingprograms,and program evaluations.

The maintenance of a Tai Chi fall prevention program conducted insix senior's centers in Oregon in the United States was reported in onestudy (Li et al., 2008). Program maintenance was measured accordingto each center's intention to continue the program at the completionof the 12 week program, with five of the six centers reporting a contin-uation of the program at study end.

4. Discussion

This is the first systematic review of the published literature on thesustainability of community-based fall prevention programs. Our aimswere to identify theories, models, frameworks, influencing factors andeffective interventions for sustaining community-based fall preventionprograms. This review focused specifically on the sustained implemen-tation and continued use of community-based fall prevention programsby organizations over time. As such, this review complements and ex-tends on previous reviews that have focused on factors and methodsfor effective program implementation (Child et al., 2012; Goodwinet al., 2011).

We found no theories developed specifically or empirically to guidethe sustainability of community-based fall prevention programs. Theuse of knowledge translation and organizational theories to develop asustainable fall prevention program was described in only one studyin this review (Ganz et al., 2009) with one project developed withinthis program ceasing after 18 months (Miake-Lye et al., 2011). Whilethe use of theory has been advocated to guide program sustainability,little is known about which theories can best facilitate this processand inwhich settings (Wiltsey-Stirman et al., 2012). Only one substantialtheory, the Normalisation Process Theory [NPT] has been developed toexplain how new health practices may be sustained in everyday practice(May & Finch, 2009).With a focus on the factors and processes needed tosuccessfully embed complex interventions into routine use, the NPT hasbeen used as a theoretical framework to develop and evaluate sustainablemodels of maternity care (Forster, Newton, McLachlan, & Willis, 2011)and analyze the integration of computer decision support systems inhealthcare settings (Pope et al., 2013). Given the growing application ofthe NPT to guide and evaluate sustainable health care programs, theNPT should be considered in future studies as a potential theoreticalframework to better understand and explain how community-based fallprevention programs can be sustained.

Threemodels or frameworks for conceptualizing how fall preventionprograms may be better coordinated, delivered, and sustained in com-munity settingswere identified in this review. However none of the pro-posed models or frameworks offer sufficient detail for how programsmay be sustained at the organizational level or highlight the factorscritical to this process. As well, none were derived from fall preventionresearch or developed directly from the experiences of those engagedin fall prevention activities. Other conceptual models and frameworksfor the sustainability of health care programs have been proposed inthe broader health literature (Gruen et al., 2008; Scheirer & Dearing,2011). These alternate models and frameworks may also be potentiallyuseful in guiding the sustainability of community-based fall preventionprograms. However, most program sustainability models and frame-works developed to date have been based on reviews of the literatureor professional consensus and none as yet have been subject to formalevaluation. Hence, their relevance, applicability, and usefulness in

guiding the sustainability of community-based fall prevention programsare yet to be determined.

More recently, the RE-AIM Framework has been proposed as apotentially useful model to guide and measure the translation offall prevention interventions in the community (Shubert, Altpeter, &Busby-Whitehead, 2011). Working with one community organization,Schubert and colleagues used the RE-AIM framework to evaluate thereach (R), efficacy (E), adoption (A), implementation (I), and mainte-nance (M) of a group-based exercise program shown to improvebalance and reduce falls among community dwelling older people.In evaluating program maintenance, the study findings indicatedthat the program was sustained by the organization beyond theone-year funded project timeframe and had been integrated into theorganization's regular programming. Although longer term results arenot yet available, these preliminary findings suggest that the use ofthe RE-AIM framework may have a positive impact on program sus-tainability. As such, further studies investigating the value of thisframework in guiding the development and evaluation of sustain-able community-based fall prevention programs are warranted.

Differences in how program sustainability is defined by programstakeholders were found in one study in this review; a finding consis-tent with the broader program sustainability literature (Pluye et al.,2004; St. Leger, 2005). Variations in definition have important implica-tions for how program sustainability is conceptualized, studied, andmeasured and as such can limit advancement of knowledge in thisarea (Wiltsey-Stirman et al., 2012). The inclusion of agreed terms anddefinitions for program sustainability in current fall prevention taxon-omiesmay facilitate consistency in definition and enable better compar-isons of studies on this topic (Lamb et al., 2011; Lamb, Jorstad-Stein,Hauer, & Becker, 2005).

In this review, we found a variety of factors that may influence thesustainability of community-based fall prevention programs. Ongoingfinancial support and the participation of older people were the mostcommonly reported influences. However, different types and combina-tions of factors were reported, suggesting that different factors mayinfluence program sustainability in differentways depending on the na-ture of the program, those involved and the context within which theprogram is conducted. The influence of factors related to the program,the setting and the broader operating context in enhancing or limitingprogram sustainability has been reported in the broader programsustainability literature (Wiltsey-Stirman et al., 2012). For example,evidence of program effectiveness, the ability to integrate the programinto existing structures, having a balance of internal and externalfunding, the engagement of program champions, and the ability tomake program adaptations were important factors reported in onestudy for improving the sustainability of a community-based physicalactivity program for older people (Estabrooks et al., 2011). Similarsupporting factors were found in a review of public health programsconducted in Canada and the United States (Scheirer, 2005). Thus,while it is likely that a range of factors will influence the sustainabilityof community-based fall prevention programs, we were not able todetermine from the studies included in this review which factors orcombination of factors were the most critical.

Three studies in our review investigated the sustainability of thesame program five years after initial program implementation andfound that program activities were in large part reduced or ceased en-tirely. These findings suggest that programs do not sustain themselvesand require a supporting intervention if they are to continue overtime. Despite this, we identified only three studies evaluating the effec-tiveness of interventions to facilitate the sustainability of community-based fall prevention programs, none of which were controlled trials.Results from two studies, both conducted over 18 months, suggestthat interventions involving planning (Bagnall et al., 1998) and a combi-nation of training and collaborative partnerships between researchersand program stakeholders (Baker et al., 2007)may have a positive effecton program sustainability. Early planning to target factors that may

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influence program sustainability has been recommended by others(Maher, Gustafson, & Evans, 2007; Pluye, Potvin, Denis, Pelletier, &Mannoni, 2005). The use of sustainability action plans has beenshown to positively impact on the intent of some organizations tosustain locally based physical activity programs beyond the periodof initial program funding (Estabrooks et al., 2011) and a range of plan-ning resources are available (National Center for Injury Prevention andControl, 2008). Training and collaborative approaches have been shownto improve the delivery and implementation of fall prevention pro-grams by health professionals (Goodwin et al., 2011). It is feasible,therefore, that similar approaches could facilitate program sustainabili-ty. Other interventions for facilitating program sustainability have beenreported in the broader health literature such as embedding the pro-gram into organizational policies (Swerrisen & Crisp, 2004) and theuse of program networks (Cheadle, Egger, LoGerfo, Schwartz, & Harris,2010). Thus, a range of interventions may potentially be effective infacilitating community-based fall prevention programs. While earlyplanning, training, and collaborative approaches may have value infacilitating sustainable programs, evaluation studies using more rigor-ous study designs are needed to confirm the effectiveness of these andother approaches.

In this review we developed broad inclusion criteria to enable acomprehensive review of the published literature, searched multipledatabases and data sources, and incorporated numerous search termsand phrases into our search strategies. Relevant publicationswere inde-pendently assessed for inclusion by two reviewers. Data extraction andquality assessments were conducted by one reviewer and checked foraccuracy by a second.

Despite these strengths, we encountered some challenges inconducting this review, which may limit interpretation of the find-ings. For some publications we found it difficult to determine ifprogram sustainability was the primary focus. Also, the publica-tions included in our review differed considerably in nature andstudy design, making the synthesis of findings difficult. Despitethe high quality of some of the empirical studies included in ourreview, we did not identify studies utilizing robust designs for eval-uating associations between specific factors and program sustain-ability or the effectiveness of interventions for achieving programsustainability.

Our review focused on the sustained implementation of community-based fall prevention programs by organizations over time. As such, wedid not include studies investigating whether the effects of the programwere sustained at the individual level (Dzewaltowski, Glasgow, Klesges,Estabrooks, & Brock, 2004). Yet the findings from one study includedin this review indicated that seeing the benefits of the program forparticipating individuals may be an important influence on programsustainability at the organizational level (Hedley et al., 2010). That is,organizations may be more likely to sustain the program if there areclear and ongoing benefits for those participating. Therefore, the impor-tance of the relationship between sustained programbenefits for the in-dividual and sustained programs over time by organizations requiresevaluation in future studies.

Challenges in maintaining program fidelity were reported in twostudies in this review (Baker et al., 2007; Kramer et al., 2011). Programfidelity is an important consideration since there may be little advan-tage in sustaining programs that deviate substantially from thoseshown to be effective in efficacy studies (Hasson, 2010). However, ithas been shown that adapting evidence-based practices to suit localcircumstances may lead to sustained practice by mental health agen-cies (Swain, Whitley, McHugo, & Drake, 2010). Thus, future studiesconcerning the translation of community-based fall prevention pro-grams should also evaluate the nature and effect of program adaptationon program sustainability.While we acknowledge the need for a reviewof studies investigating program sustainability in other environmentssuch as hospitals and residential aged care, the exploration of thistopic in these settings was beyond the scope of this review.

5. Conclusions

The past decade has seen a growth in the number of publicationsrelevant to the sustainability of community-based fall preventionprograms, indicating a growing recognition of the importance of thisissue. Despite these developments, current research on this topic is dis-parate in nature and of varyingmethodological quality. As a first step, toimprove coherence and use of research in this area, consistency in howprogram sustainability is defined and described is required. To betterguide the sustainability process and to underpin the development of in-terventions aimed at facilitating program sustainability, the usefulnessand applicability of existing sustainability theories and conceptualframeworks to community-based fall prevention programsneed testing.

Based on a limited number of studies, ongoing financial support andtheparticipation of older people appear important influences onwheth-er fall prevention programs are sustained by community organizations.However, other influencing factors specific to the program type andcontext were also identified in this review. Hence, to better understandthese influences, future studies incorporating more robust studydesigns should focus on identifying and quantifying the critical factorsor combinations of factors impacting on the sustainability of fall preven-tion programs in the community. Few studies have evaluated interven-tions aimed at facilitating sustained community-based fall preventionprograms. Planning for sustainability, training, and collaborations be-tween researchers and program stakeholders appear promising inter-ventions but further evaluation using more robust empirical studydesigns is needed to confirm the effectiveness of these approaches.

6. Impact on industry

To facilitate sustainable community-based fall prevention programswe currently recommend that organizations plan at program outset toidentify potential barriers and enablers influencing program sustain-ability, identify sources of ongoing financial support for the program,actively seek the support and participation of older people, obtain ap-propriate program training, and develop collaborative partnerships be-tween program stakeholders such as program researchers and otherhealth care and service providers.

Supplementary data to this article can be found online at http://dx.doi.org/10.1016/j.jsr.2013.08.004.

Acknowledgments

This research was supported by an Australian GovernmentDepartment of Health and Ageing Falls and Injury PreventionCommunity Grant and a University of Sydney Postgraduate Award.

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Meryl Lovarini is a Lecturer inOccupational Therapywithin the Faculty of Health Sciencesat The University of Sydney. Her research interests include ageing, falls prevention amongolder people and the translation of evidence into practice. Meryl recently completed herPhD on the sustainability of a community-based falls prevention programs. She was therecipient of scholarships from the Australian Government and The University of Sydneyto complete her PhD research. She has several peer-reviewed publications focussing onevidence-based practice and occupational therapy.

Lindy Clemson is a Professor in Ageing and Occupational Therapy and a National Healthand Medical Research Council (NHMRC) Career Development Research Fellow at theAgeing,Work &Health Research Unit, TheUniversity of Sydney. She is also an investigatorwith the Centre of Excellence in Population Ageing Research. Professor Clemson is anoccupational therapist with a PhD in epidemiology. Her specific focus is on the physicalenvironment, functional capacity and adaptation, daily life activity and enablingparticipation. Her major research focus investigates falls prevention with olderpeople and participation issues for people with dementia.

Catherine Dean is an Associate Professor in neurological physiotherapy at MacquarieUniversity. She is also the inaugural Director and Head of the Physiotherapy Program aswell as the Head of the Department of Health Professions. She has been the recipient ofprestigious scholarships to undertake Masters, Doctoral and Post-doctoral studies. Herresearch interests are developing and testing of rehabilitation strategies to prevent falls,increase activity, and participation after stroke, translating evidence into practice andclinical education. She has over 50 publications, two with over 130 citations and over$2.4 million in grants for research and education.

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