Falls among older people are a public

Transcription

1 INJURY AND HARM Integrating proven falls prevention interventions into government programs Lesley Day, 1 Alex Donaldson, 1 Catherine Thompson, 2 Margaret Thomas 2 Falls among older people are a public health priority for Australia. 1 The effect of an ageing population on the number of older people admitted to hospital following a fall has been compounded by an increasing age-standardised rate of hospitalised fall injuries resulting in increased demand for acute health, rehabilitative and long term care services. 1 In , 78,600 people aged 65 years and over experienced a fall-related hospitalisation; nearly 11,000 more than would have been the case if the age-standardised rate had remained at the level. 2 Over this time, the rate of patient days increased by 3% per year with 10% of bed days for older people being attributable to an injurious fall. 2 In , the direct cost to the health care system was $648 million. 3 The most recent incidence data released indicates that the burden is continuing to rise, with 83,800 fall-related hospitalisations in this group in There is a substantial, and expanding, evidence base for efficacious falls interventions, especially for older people living in their own homes who constitute the largest proportion of fall-related hospitalisations. 2 In Australia, state governments, through their population health and health promotion frameworks, have focussed on implementing evidencebased falls prevention interventions over the past decade, while local community health and other services have also embraced this challenge. 5 Clearly, the implementation efforts have not yet had the desired impact on this population health challenge. Abstract Objective: To identify Department of Health programs with high potential to integrate evidence-based interventions to prevent falls among older people. Methods: Broad consultation within the Department followed by structured decision making. This work was informed by an analysis of Victorian hospital separations data and a Cochrane Systematic Review to identify relevant target groups and interventions. Ranking of the integration potential of interventions for a broad range of Department program areas was achieved through a facilitated workshop. A short list of program areas was then developed and scored, using pre-defined criteria, for their match with the interventions. Results: The ranked order of interventions, from most to least suitable for integration, were: multifactorial risk assessment and intervention; multi-component group exercise; medication review; occupational therapy-based home safety; home-based exercise; and first eye cataract surgery. Four of six program areas had a strong match (a score of 75% of the maximum score) with one or more of three interventions. Two program areas (Primary Care Partnerships, and Home and Community Care) had strong matches with three interventions (group- and homebased exercise; occupational therapy-based home safety) and were selected as priority areas. The Hospital Admissions Risk Program had strong and good matches respectively with homebased exercise and medication review, and was also selected. Conclusions: Our systematic methods identified Department programs with strong potential for integration of proven falls prevention interventions. Implications: Matching departmental programs and evidence-based interventions for integration may lead to more efficient resource allocation for falls prevention in Victoria. Key words: falls prevention, implementation, evidence integration While falls prevention program implementation has occurred at the practice and to a lesser extent policy levels, there has been little accompanying research on implementation methods and their effectiveness, despite the recognition of its need. 6,7 Group- and home-based exercise programs are perhaps the simplest evidence-based interventions to translate from the research to practice setting, and there are examples of this having been achieved successfully Falls prevention training for health care professionals and community health workers appears to be effective in changing practice, while the evidence is less clear in relation to changing client management in primary care practice, community-awareness programs and peerled programs There are limitations with this fledgling area of falls prevention implementation research. To date, there has been little attention given 1. Falls Prevention Research Unit, Monash Injury Research Institute, Monash University, Victoria 2. Ageing and Aged Care Branch, Department of Health, Victoria Correspondence to: Associate Professor Lesley Day, Monash Injury Research Institute, Building 70 Monash University, Wellington Road, Clayton, VIC 3800; lesley.day@monash.edu Submitted: April 2013; Revision requested: May 2013; Accepted: August 2013 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2014; 38:122-7; doi: / Australian and New Zealand Journal of Public Health 2014 vol. 38 no. 2

2 Injury and Harm Integration of falls interventions to implementation at the broader population level, with many studies restricted to individual organisations, small area clusters of organisations or low density population local levels. The focus has tended to concentrate on implementation of additional programs and engaging dedicated staff, rather than on integrating proven falls prevention strategies into existing programs and services. In addition, the description of implementation methods employed in these studies often lacks the detail required to inform the planning and implementation of population level programs. Falls prevention has been a priority for the Victorian State Government since 1994, 16 and in 1995, the Victorian Department of Health established a Falls Prevention Program with a dedicated recurrent budget up until 2010/11. Falls prevention activity supported by the Ageing and Aged Care Branch (AACB) has typically used a multi-intervention approach delivered as specifically finitely funded add-on projects with limited integration with existing programs. Recently, the AACB entered into a partnership with a number of researchers to re-orient the approach to preventing falls among older people and improve the translation of research evidence. 17 A key mechanism for facilitating translation is improved communication between researchers, policy makers and practitioners, and the partnership structures created the opportunity to jointly explore the systems and processes involved in translating the substantive falls prevention evidence base into policy and practice. 18 One objective of the partnership was to investigate reasons why proven interventions may not be adopted, and to explore modifications that may be needed to facilitate adoption in real world policy Cochrane systematic review Select relevant evidence based interventions Identify broad range of relevant DH program areas Workshop Ranking of interventions by program areas Identify target groups by falls hospitalisation data analysis environments and service systems. The partnership recognised the importance of selecting the most appropriate interventions for differing contexts. It was anticipated that the improved communication generated by the partnership would yield benefits noted in the literature, such as improved leadership and infrastructure and increased capacity to facilitate uptake of falls prevention interventions. 18 Consistent with the notion that integrating interventions within existing programs and services is likely to be more effective in the longer term than establishing stand-alone programs, 19 a key aspect of this partnership was to identify low cost opportunities to incorporate evidence-based falls prevention interventions into existing AACB and Department of Health programs. This paper describes the process used to identify Department of Health policies and programs with high potential for integration of evidence-based falls prevention interventions. This addresses a recently identified need to investigate matching efficacious interventions with delivery systems and implementers. 7 It is also consistent with empirical research demonstrating that effective implementation is positively correlated with the extent to which proposed programs match an organisation s existing mission, priorities and practices. 20 Methods The methodological approach was to funnel the output of a broad consultation through a structured decision-making process (Figure 1) to identify the program areas that represented the best opportunity to integrate Figure 1: Structural decision-making process to identify program areas with potential for integration. Short list of DH program areas Narrowed to program areas ranking the interventions in the top 4 Scoring of match Implementation feasibility Selection of interventions for scoring evidence-based activities most suited to the sub-groups of older people who account for the greatest burden on the relevant health care system. The evidence-based falls prevention interventions for older people living in their own homes selected for inclusion in this study were those identified by the latest Cochrane review available at the time as most promising, 21 and considered by the research team to be applicable to significant proportions of older people in Australia. These were: multi-component group- and homebased exercise; multifactorial intervention (a combination of interventions based on individual assessment of falls risk factors); occupational therapy (OT) based home safety intervention for those at higher risk of falling; gradual withdrawal of psychotropic medication; medication review; and first eye cataract surgery. 21 Interventions not included were: vitamin D supplementation for those with low vitamin D levels; anti-slip shoe devices for icy conditions; and pacemakers for those with carotid sinus hypersensitivity, as these interventions were considered to be applicable to only a small proportion of older people living in their own homes in Victoria. In a parallel project of this research partnership, 17 some factors were identified as being independently associated with both the frequency of hospital admission and a longer length of stay among older people living in their own homes and who have fallen. These were: older age; currently un-partnered; having fallen at home; and having sustained a fracture (unpublished results). Factors associated only with the frequency of hospital admission included: female; born in an English-speaking country; no private health insurance but relatively socially advantaged; and no reported comorbid disease (unpublished results). Factors associated only with a longer hospital stay included: living in a socially disadvantaged area; and reporting a co-morbid condition (unpublished results). These factors were used to describe the target group and to guide selection of the evidence-based interventions at various points in the decision-making process. Broad consultation Broad consultation to identify suitable Department of Health program areas for 2014 vol. 38 no. 2 Australian and New Zealand Journal of Public Health 123

3 Day et al. Article integration of evidence-based fall prevention interventions was achieved by holding a workshop with program staff from these areas (Figure 1, stage 1). Program areas where, in principle, it was thought there would be some degree of fit with the previously identified interventions and target groups were identified by two authors (CT, MT). These included: acute health programs (emergency care, hospital inpatient); sub-acute and continuing care programs; community support programs; population health programs; and public housing programs. Forty-five people (from 25 Department units) were invited to participate in the workshop representing a mix of those working at the relevant policy and program direction level, and those working at the program delivery interface. It was considered that the invited participants could give an informed opinion on the potential for integration of falls prevention interventions based on their knowledge of the implementation context. In addition, the consultation was intended to start a process of communicating about, and discovering the potential benefits of, integrating evidence-based falls prevention interventions into existing Department programs, thereby initiating commitment to future integration. Invitations to attend the workshop were accompanied by information about the background to the project, the policy context, potential benefits of including activities to prevent falls among older people in other areas of the Department, and a summary of the seven evidence-based falls interventions. Thus, the consultation was confined to those falls prevention interventions where there is strong evidence for efficacy, as the Department wanted to maximise the use of finite resources by investing in those activities most likely to have an effect. The workshop was led by an external facilitator. The primary question posed to the participants was Which proven fall prevention interventions are suitable for integrating into your Department of Health program area? Participants were asked to consider this question before ranking the seven interventions in order of suitability, and giving their reasons for their highest and two lowest selections. This was followed by small group discussions and reporting back on the reasons for the first selection and the two lowest ranked interventions. Structured decision-making process Policy analysis can aid the selection of policies or programs from a suite of alternatives by systematising the process. 22 This requires identifying the values that are to guide the selection. In this application, there was one over-riding value: the fit between evidencebased falls interventions and Department programs. We chose a structured decisionmaking process to ensure systematic and objective consideration of the relative value of the various interventions being considered. 7,22 The structured decisionmaking process consisted of two steps (Figure 1, stage 2). First, a shortlist of Department program areas was selected for more detailed analysis based on two principles. The program area should: 1) concentrate on delivering services to the targeted sub-groups of older people living in their own homes and likely to experience a fall-related hospitalisation; and 2) be one for which the AACB has potential influence to effect activity and funding related to falls prevention and therefore more likelihood of being able to effect change. This produced a list of six program areas. Second, characteristics of the program areas and the interventions were scored by all four authors for the degree of match. The scoring exercise was restricted to the four interventions group-based exercise, home-based exercise, OT mediated home safety intervention, and medication review considered by the authors to be most relevant to the targeted sub-groups with reasonable implementation feasibility. Although there is good evidence that multifactorial interventions reduce fall rates regardless of baseline falls risk, there is considerable heterogeneity among the various relevant trials and results may vary depending on a country s health system, and according to whether the intervention is based on active treatment or education and referral. 23,24 The uncertainty about implementation feasibility in the specific context led to the decision to exclude the multifactorial intervention from further consideration in this project. Sustained withdrawal of psychotropic medication is relevant for consideration for about 20% of community-dwelling older people, 25 and is difficult to achieve in practice. 26 Similarly, expediting cataract surgery in the public acute care system in Victoria was deemed likely to be difficult to influence. The scoring exercise was further restricted to those program areas that had ranked these interventions in their top four during the initial workshop (Figure 1). A list of characteristics that describe the key features of both the Department program areas and falls interventions was developed (Table 1). These were then used to populate tables summarising the six program areas and the four interventions (see Table 2 for a list of program areas and interventions). The Department program areas were then scored for their match with the interventions. Each characteristic was scored on a scale from 0 (for no match) to 2 for an exact match. Definitions for partial and complete matches for each characteristic were developed. The scoring was undertaken by group consensus among the four authors. Scores for the seven characteristics were summed to a total score (maximum possible score = 14). The project was approved by the Monash University Human Research Ethics Committee. Table 1: Key features of Victorian Department of Health program areas and falls interventions and the corresponding match scoring parameter. Program characteristics Intervention characteristics Scoring parameter Age range of program participants Age group for which intervention Extent to which age groups match is suitable Setting Setting Extent to which settings match or could be linked Eligibility criteria Eligibility criteria Extent to which criteria match Main service provided or program content Intervention details Extent to which service and intervention match, referral pathways exist or delivery could be influenced Program delivery agent Intervention delivery agent Extent to which agents match or links, or influence with agents exists Other health benefits of participation in intervention Health disbenefits of intervention Extent to which other health benefits of intervention would be directly beneficial to program area Extent to which disbenefits of intervention would be a direct disbenefit to program area 124 Australian and New Zealand Journal of Public Health 2014 vol. 38 no. 2

4 Injury and Harm Integration of falls interventions Results The workshop was attended by 22 participants covering 24 of the intended 25 Department of Helath program areas. One policy officer from the population health area did not rank the interventions, stating that all were important from their program perspective. In addition, some only ranked those interventions that were relevant to their area, and others gave some interventions equal ranking. Overall, the multifactorial intervention was ranked as most suitable for integration with 13 of 20 participants (65%) allocating first or second ranking to it. The most common reason for a high ranking was that the multifactorial approach was to some extent already being adopted within the programs and was seen to link with existing practices, and would use existing resources. Other common reasons included: a good match between the principles of the intervention and the guiding principles of their program or policy priority; a good match between the appropriate target group and the program client base; the potential for other health benefits; and that integration of this type of intervention was within their sphere of influence. Less common reasons included: a match between the intervention and falls aetiology; feasibility in relation to likely uptake; and confidence that the intervention would deliver benefits. Conversely, first eye cataract surgery was ranked as the least suitable with only one of the 16 participants who ranked this intervention (6%) allocating first or second ranking to it, and eight (50%) allocating sixth or seventh ranking to it. In the group discussion, participants noted that this intervention was not within their sphere of influence, lacked confidence in actually being able to expedite surgery within the Victorian system, perceived the intervention as costly, and had concerns about equity of access. Similarly, gradual withdrawal of psychotropic medication was allocated a low ranking with only two of the 18 participants who ranked this intervention (11%) allocating first or second ranking to it. Again, participants noted that this was not within their sphere of influence (although they could initiate the process, they could not actually effect the intervention itself). There were concerns about widespread applicability, the potential adverse effect on mental health, and the implementation challenge of withdrawing these types of medications. The rankings of the other interventions were spread between these two extremes: group exercise was ranked as first or second by eight of 16 participants (50%), medication review by eight of 18 participants (44%), occupational therapy-based home safety intervention by seven of 19 participants (37%), and home-based exercise by six of 17 participants (35%). The structured decision-making process revealed that four of the six program areas had a strong match (i.e. a score of 75% of the maximum possible score) with one or more of three interventions (Table 2). Two program areas (Primary Care Partnerships, and Home and Community Care) had strong matches with three interventions (multicomponent group- and home-based exercise, and occupational therapy-based home safety) and these were selected as priority areas for integration. Since the Hospital Admission Risk Program had a strong match with home-based exercise, and a good match with medication review, this was also targeted as a priority area. One program area had been Table 2: Match between Victorian Department of Health programs and four evidence-based falls interventions (total maximum score = 14). Department of Health Program Multi-component home-based exercise program Multi-component group-based exercise program Occupational therapy home safety intervention for those at high risk Medication review and adjustment Hospital Admission Risk Program 10.5 N/A* Seniors 'Go For Your Life' N/A Primary Care Partnerships N/A Home and Community Care Ambulance and Emergency Programs N/A N/A Emergency Care Improvement and Innovation Clinical Network N/A N/A N/A 7.0 *N/A indicates that scoring was not undertaken as the intervention was not ranked highly enough by the program area during a consultative workshop dismantled (Seniors Go for your life ), and the remaining two areas had weaker matches with one or two interventions and were therefore considered to be less of a priority. Discussion Our consultative and structured decisionmaking process enabled the identification of three Department of Health program areas that have strong matches with selected proven falls prevention interventions, leading to the prioritisation of integration of these interventions into these program areas. Two of the programs, the Hospital Admission Risk Program (for those with chronic disease and complex care needs) and Primary Care Partnerships (for local communities), share a common principle of integration and coordination of hospital, medical, allied health and community services to improve health outcomes for clients. The third program, Home and Community Care, provides basic support and maintenance services to people living at home and whose capacity for independent living is at risk. The ranking of the multifactorial intervention relative to group exercise was somewhat unexpected, given the complexities of implementation for the former and the relative ease of implementation for the latter. The most common reason for the high ranking ascribed to the multifactorial intervention was that this approach was already being implemented to some extent within the program areas, and therefore could readily link with existing practices and resources. While for an individual older person there may not necessarily be a specific co-ordinated multifactorial program, the range of services with a falls risk element available to at-risk older people may add up to a multifactorial approach. In this instance, integration may be more effective in the real world service system because of raised awareness in the older person and service providers at the time of an episode of care. This maps very well to the dimension of compatibility, a key factor driving successful diffusion of innovation and implementation. 20,27 In fact, all the common reasons that participants gave for this high ranking map to factors associated with successful implementation, including: compatibility; skill proficiency; self-efficacy; and perceived benefits of the intervention. 20 While the workshop participants identified that the multifactorial approach was already 2014 vol. 38 no. 2 Australian and New Zealand Journal of Public Health 125

5 Day et al. Article being adopted in their program areas, it is not clear whether this includes active treatment for the identified risk factors, rather than simply referral for treatment without follow up. Although the evidence overall suggests that multifactorial interventions are effective in reducing fall rates, there is considerable heterogeneity between individual studies. 23 Given the uncertainty surrounding the factors underlying the effectiveness of multifactorial interventions, 23 we did not select this intervention for the match scoring. However, there may be some potential to improve the potency of current practice by introducing an active follow-up component. Our exclusion of the multifactorial intervention from the match scoring, despite the results of the workshop, could be seen as an anomaly with the consultation process. Our main interest in the consultation was in identifying the Department of Health programs where integration of proven falls interventions was most likely to succeed, rather than seeking advice regarding which interventions should be the main focus. The consultation did directly inform the program areas we selected for the match scoring (Figure 1). We consulted broadly on the proven falls interventions, prior to our selection of a smaller number of interventions, to allow for opportunities we may not have predicted. If consultation was limited to that smaller number of interventions, an indirect and perhaps valuable outcome from the workshop may have been missed. This was the opportunity of raising awareness among Department of Health program managers and staff about the profile of falls prevention among older people, increasing knowledge about evidence-based interventions, and initiating the idea of integration across a wide range of Department programs, in an interactive setting. Although the response rate from invited individuals for the workshop was relatively low (49%), all except one of the invited Department units were represented, providing an excellent coverage of relevant areas and confidence in the extent of the consultation. Our process of consultation followed by structured decision making resulted in several positive outcomes. First, the workshop provided the opportunity to bring together falls prevention evidence and relevant stakeholders in a participatory process to consider the evidence in the context of their Department program areas central features of the Evidence Integration Triangle, a model designed to facilitate implementation by research-practitionercommunity partnerships. 28 Second, there are now very clear and focused directions for the Department of Health to pursue. Third, the Department is well positioned to further the cause of integration of the selected interventions into the priority program areas, since fundamental principles of health promotion and diffusion of innovations relevance to the implementation context; compatibility with culture, values and practices of the intended adopters; and early participatory engagement of stakeholders have been observed. 27,29 Finally, although it is too early to judge whether our process was effective in achieving integration, anecdotal evidence noticed after the workshop suggests that its early and participatory nature has engendered a degree of commitment to the integration process. While there was one clear over-riding value in our analysis the fit between evidencebased falls interventions and Department programs we did consider other values relevant to policy analysis, 22 perhaps in a less systematic way. Effectiveness was inherent in our process, reflected by placing evidencebased interventions as the starting point. Vertical equity was introduced by our focus on programs targeting the kinds of older people likely to be admitted to hospital. Implementation feasibility was considered at the point of selecting interventions for scoring. Preferences of older people for the various falls interventions are being examined in a parallel study within our research partnership, 17 the results of which will be incorporated into the ongoing integration activities. Cost, a key value in most policy analysis, has not yet been considered. Given that integration of falls interventions into existing programs is the goal, the incremental cost may not necessarily be substantial. Cost may best be considered during further engagement with the relevant Department programs after the exact activities necessary for integration become clear. Our experience suggests that it is important to have clear objectives for the consultation process and to communicate these well at the beginning. There are also likely to be additional benefits to consultation, such as engendering commitment to the ultimate goal. The prospect of integration in Victoria is being pursued following a long period of specific falls prevention funded activity leading to some acceptance of falls prevention as a justifiable inclusion in health programs and services. It is likely that this facilitated our consultations regarding integration of falls prevention interventions within the Department of Health. While the importance of applying a socio-ecological approach to health promotion, including injury prevention, is well noted in the literature, 30,31 the health promotion field has been generally slow to incorporate modification of institutional environments, policies or services into the traditional focus on individual or intrapersonal level. 32 Looking at this from the perspective of implementation science, many interventions focus on the practitioner competency side of Fixsen et al. s triangular model of implementation drivers while paying less attention to the organisational and leadership components. 33 The work published here contributes to closing this gap in the area of falls prevention and demonstrates the steps in moving from identifying the ideal interventions proven in randomised controlled trials to integration of implementable solutions for the falls prevention challenge in Victoria. References 1. National Public Health Partnership. The National Falls Prevention for Older People Plan: 2004 Onwards. Canberra (AUST): Commonwealth Department of Health; Bradley C. Hospitalisations Due to Falls by Older People, Australia. Canberra (AUST): Australian Insitute of Health and Welfare; Bradley C. Hospitalisations Due to Falls by Older People, Australia. Canberra (AUST): Australian Institute of Health and Welfare; Bradley C. Hospitalisations Due to Falls by Older People, Australia Cataogue No.: INJCAT70. Canberra (AUST): Australian Institute of Health and Welfare; Clemson L, Finch CF, Hill KD, Lewin G. Fall prevention policies in Australia: policies and activities. Clin Geriatr Med. 2010;26(4): Tetroe JM, Graham ID, Scott V. What does it mean to transform knowledge into action in falls prevention research? Perspectives from the Canadian Institutes of Health. J Safety Res. 2011;42(6): Noonan RK, Sleet DA, Stevens JA. Closing the Gap: A research agenda to acceleate the adoption and effective use of proven older adult fall prevention strategies. J Safety Res. 2011;42(6): Filiatrault J, Parisien M, Laforest S, Genest C, Gauvin L, Fournier M, et al. Implementing a Community-Based Falls-Prevention Program: from Drawing Board to Reality. Can J Aging. 2007;26(3): Li F, Harmer P, Glasgow R, Mack K, Sleet D, Fisher J. Translation of an effective Tai Chi intervention into a community-based fall prevention program. Am J Public Health. 2008;98(7): Australian and New Zealand Journal of Public Health 2014 vol. 38 no. 2

6 Injury and Harm Integration of falls interventions 10. York S, Shumway-Cook A, Silver I, Morrison A. A translational research evaluation of the Stay Active and Independent for Life (SAIL) community-based fall prevention exercise and education program. Health Promot Pract. 2011;12(6): Goodwin V, Jones-Hughes T, Thompson-Coon J, Boddy K, Stein K. Implementing the evidence for falls among community-dwelling older people: A systematic review. J Safety Res. 2011;42(6): Waters D, Hale L, Robertson L, Hale B, Herbison P. Evaluation of a peer-led falls prevention program for older adults. Arch Phys Med Rehabil. 2011;92(10): Weerdesteyn V, Smulders E, Riiken H, Duysens J. Preserved effectiveness of a falls prevention exercise program after implementation in daily clinical practice. J Am Geriatr Soc. 2009;57(11): Scott VJ, Votova K, Gallagher E. Falls Prevention Training for Community Health Workers: Strategies and Actions for Independent Living (SAIL). J Gerontol Nurs. 2006;32(10): Ganz DA, Yano EM, Saliba D, Shekelle PG. Design of a continuous quality improvement program to prevent falls among community-dwelling older adults in an integrated healthcare system. BMC Health Serv Res. 2009;9(206): Department of Health and Community Services. Taking Injury Prevention Forward: Strategic Directions for Victoria for Melbourne (AUST): State Government of Victoria; Day L, Finch CF, Hill KD, Haines TP, Clemson L, Thomas M, et al. A protocol for evidence-based targeting and evaluation of statewide strategies for preventing falls among community-dwelling older people in Victoria, Australia. Injury Prev. 2011;17(2):e3. doi: / ip Bugeja L, McClure RJ, Ozanne-Smith J. The public policy approach to injury prevention. Injury Prev. 2011;17: Speechley M. Knowledge translation for falls prevention: The view from Canada. J Safety Res. 2011;42: Durlak J, DuPre E. Implementation Matters: A Review of Research on the Influence of Implementation on Program Outcomes and the Factors Affecting Implementation. Am J Community Psychol (41): Gillespie L, Robertson M, Gillespie W, Lamb S, Gates S, Cumming R, et al. Interventions for preventing falls in older people living in the community (Cochrane Review). In: Cochrane Database of Systematic Rerviews; Issue 9, Art No.: CD Chichester (UK): John Wiley; Runyan CW. Using the Haddon matrix: introducing the third dimension. Injury Prev. 1998;4: Gillespie L, Robertson L, Gillespie W, Sherrington C, Gates S, Clemson L, et al. Interventions for preventing falls in older people living in the community (Cochrane Review). In: Cochrane Database of Systematic Rerviews; Issue 11, Art No.: CD Chichester (UK): John Wiley; Gates S, Fisher J, Cooke M, YH C, Lamb S. Multifactoral assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis. BMJ. 2008;336: Australian Bureau of Statistics National Health Survey: Summary of Results. Canberra (AUST): ABS; Campbell A, Robertson M, Gardner M, Norton R, Buchner D. Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomised controlled trial. J Am Geriatr Soc. 1999;47(7): Rogers E. Diffusion of Innovations. New York (NY): NY Free Press; Glasgow R. An evidence integration triangle for aligning science with policy and practice. Am J Prev Med. 2012;42(6): Bartholomew LK, Parcel GS, Kok G, Gottlieb NH, Fernandez ME. Planning Health Promotion Programs: An Intervention Mapping Approach. 3rd ed. Hoboken (NJ): Jossey-Bass; McLeroy K, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q (15): Hanson D, Hanson J, Vardon P, McFarlane K, Lloyd J, Muller R. The injury iceberg: An ecological approach to planning sustainable community safety interventions. Health Promot J Austr. 2005;6(1): Golden S, Earp J. Social Ecological Approaches to Individuals and Their Contexts: Twenty Years of Health Education and Behaviour Health Promotion Interventions. Health Educ Behav. 2012;39(3): Kelly B, Perkins DF. Handbook of Implementation Science for Psychology in Education. New York (NY): Cambridge University Press; vol. 38 no. 2 Australian and New Zealand Journal of Public Health 127