Journal of Aging and Physical Activity, 2016, 24, 45  -52 http://dx.doi.org/10.1123/japa.2014-0143 © 2016 Human Kinetics, Inc.

ORIGINAL RESEARCH

Key Factors Influencing Implementation of Falls Prevention Exercise Programs in the Community Lesley Day, Margaret J. Trotter, Alex Donaldson, Keith D. Hill, and Caroline F. Finch The study aim was to evaluate the implementation of group- and home-based exercise falls prevention programs delivered through community health agencies to community-dwelling older people. Interviews with program staff were guided by the Diffusion of Innovations theory. Highly consistent themes emerged for the two types of programs. Both had high overall compatibility, high relative advantage, good observability and high inherent trialability—all factors known to strengthen implementation. The level of complexity and low financial compatibility emerged as the strongest potential inhibitors to program implementation in the context examined. The two main factors contributing to complexity were the need to challenge balance safely across a broad range of capability, and practical considerations associated with program delivery. A range of strategies to provide more technical support for exercise program leaders to tailor balance challenge for exercise program leaders may enhance implementation of falls prevention exercise programs. Keywords: facilitators, barriers, elderly, exercise therapy, community health care

Falling during normal daily activities becomes increasingly likely with aging, as changes in musculoskeletal and neurological systems impact on balance and posture (Lord, Sherrington, Menz, & Close, 2007). The effect of these changes is exacerbated by some disease processes that become increasingly common among older people. While the incidence of falls varies between countries, global population aging means that falls in older adults will become an increasing source of mortality, disability, and poor health in the years ahead (World Health Organization, 2007). Between 28% and 39% of people aged 65 years and over fall each year, and 11–21% experience multiple falls (Lord et al., 2007). Adverse health outcomes can follow a fall, including fractures and other injuries; decreased confidence, mobility, and independence; erosion of overall health status; decreased quality of life; and potentially a move to residential aged care (Cumming, Salked, Thomas, & Szonyi, 2000; Kiel, O’Sullivan, Teno, & Mor, 1991; Salkeld et al., 2000; Tinetti & Williams, 1998). There are evidence-based solutions for falls prevention, particularly among community-dwelling older people (Gillespie et al., 2012). Most of these interventions target high-risk groups (e.g., those with a falls history, low vitamin D, vision impairment, taking psychotropic medication), or require delivery by health professionals (e.g., home safety interventions, individually-tailored multifactorial interventions, cataract surgery or insertion of a pacemaker). Importantly, balance-enhancing exercise has also been shown to be effective in a review of more than 50 randomized controlled trials involving a total of 13,264 participants (Gillespie et al., 2012). Unlike many falls prevention interventions, this type of intervention is well suited to population level delivery.

Day and Trotter are with the Falls Prevention Research Unit, Monash Injury Research Institute, Monash University, Melbourne, Australia. Donaldson and Finch are with the Australian Centre for Research into Injury in Sport and its Prevention, Federation University, Ballarat, Australia. Hill is with the School of Physiotherapy and Exercise Science, Curtin University, Bentley, Australia. Address author correspondence to Lesley Day at lesley. [email protected].

Population level uptake of balance-enhancing exercise among community-dwelling older people in Australia is relatively low. Between 12% and 22% of community-dwelling people aged 65 years and over participate in such exercise, and a lower proportion (8% to 15%) complete the recommended number of sessions per week (Merom et al., 2012). This illustrates the need to understand both the factors that motivate older adults to participate in falls prevention exercise, and the challenges faced at the community level by practitioners and agencies responsible for implementing exercise-based interventions. While there has been some work on the former (Haines, Day, Hill, Clemson, & Finch, 2014; McPhate, Simek, & Haines, 2013; Simek, McPhate, & Haines, 2012; Yardley et al., 2006; Yardley et al., 2008), there has been less work on the latter, despite recognition that this information is needed to drive the widespread use of effective programs (Fixsen, Scott, Blasé, Naoom, & Wagar, 2011; Noonan, Sleet, & Stevens, 2011). Recent reviews of the evaluation of evidence-based falls prevention program implementation have highlighted a number of limitations. Quantitative approaches have predominated, limiting in-depth analysis of program delivery contexts. Such approaches also limit the understanding of the factors that influence adoption and implementation, particularly at the organizational level (Goodwin et al., 2011). A recent review of 19 qualitative research studies that examined implementation of fall prevention interventions among community-dwelling older people found that none of these had examined adoption or implementation in community health organizations (Child et al., 2012). In Victoria, the second most populous state in Australia, the (former) Department of Health (DOH) funded coalitions of community agencies to deliver either group- or home-based exercise programs to community-dwelling older adults over a two-year period from 2011. This provided an opportunity to study the implementation of these programs in the community health context. An evaluation of these programs was undertaken, guided by the RE-AIM framework (Day et al., 2011). This paper reports on the evaluation of the implementation dimension—one of the five dimensions of the RE-AIM framework (Glasgow, Vogt, & Boles, 1999). This focus on implementation outcomes—factors associated with how the exercise programs were put in place and delivered—is distinct from client 45

46  Day et al.

outcomes such as compliance, changes in physical performance, or falls occurrence. Information about such implementation outcomes is important in understanding the reasons for successful or unsuccessful client outcomes (Proctor et al., 2011).

Data Collection and Analysis

Methods Setting

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total of 501 older people participated in the home-based programs across the two PCPs. Detailed written program delivery guidelines were provided to the PCPs for both the NoFalls and Otago Exercise Programs.

The exercise programs were delivered through the community health services that are members of local coalitions known as Primary Care Partnerships (PCPs). These PCPs include community health services, hospitals, and local family medical practitioners, and are funded by the State Government to improve access to services and provide continuity of care. The DOH invited four PCPs covering the eastern and southern metropolitan regions of the capital city, Melbourne, to apply for two-year funding to deliver fall prevention exercise programs to community-dwelling older people. Two PCPs in the eastern region (PCP GA and PCP GB) delivered group-based exercise programs in six local government districts with a combined population of approximately 903,000. Two PCPs in the southern region (PCP HA and PCP HB) delivered home-based exercise programs in seven local government districts with a combined population of approximately 825,000.

Exercise Interventions Group-Based.  Based on current evidence, the DOH stipulated that the group-based exercise programs be delivered for a minimum of 15 weeks, should challenge balance, and include at least one component of strength, flexibility, or endurance. The target group was ambulatory people aged 70 years and over living at home. People with debilitating conditions that precluded physical activity and those with profound visual impairment were excluded. Both PCP GA and GB based their programs on the NoFalls Exercise Program, which involves weekly 1-hr exercise classes designed by a physiotherapist to improve flexibility, leg strength, and balance (Day et al., 2002; Vincent, 2003). The PCP GB also offered a tai-chi program led by a master tai-chi instructor and a group-based version of the Otago Exercise Program. The latter program incorporates strength, balance, and walking components and is normally an individuallyprescribed home-based program (Accident Compensation Corporation, 2007; Robertson, Campbell, Gardner, & Devlin, 2002). All programs offered weekly classes and encouraged daily practice. Physiotherapists were employed to deliver the program at each of the four community health services in PCP GA. PCP GB employed physiotherapists and specialist instructors to deliver the program through three services. A total of 685 older people participated in the group-based exercise programs across the two PCPs. Individual Home-Based.  The DOH stipulated that the homebased exercise program be based on the Otago Exercise Program (Robertson et al., 2002) and the target group be those aged 80 years and over living in their own homes. Participants were to receive six home visits for exercise prescription and supervision, and monthly phone calls for motivation and problem solving, over a six-month period. The PCPs were asked to focus on older adults who were not interested in participating in group exercise and to exclude those who were already receiving physiotherapy. The PCP HA employed one physiotherapist to cover all aspects of the program delivered through one community health service. The PCP HB employed a combination of physiotherapists and allied health assistants to implement the program through three community health services. A

Given the limited understanding of how to implement efficacious interventions and the characteristics of settings that support successful implementation (Damschroder et al., 2009; Noonan et al., 2011), the program evaluation scope was extended to include an exploration of the implementation process itself guided by the Diffusion of Innovations (DOI) (Rogers, 2003) theory. The DOI theory has been used to examine why and how innovations have been adopted in a variety of fields, including health promotion and health service delivery (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004). By examining the falls prevention programs as the innovations and the PCPs as the implementers, DOI theory provided a structure for investigating the implementation dimension of the RE-AIM framework. Semistructured interview questions for program staff were developed around the DOI-specified attributes of innovations—compatibility, relative advantage, complexity, trialability, and observability (Rogers, 2003). The term ’participants’ refers to the program staff interviewed for this study, not the people taking part in the exercise programs. Participants answered 19 main open-ended questions and additional prompt questions where necessary. As the interviews were semistructured, the order of the main questions depended on responses to earlier questions. Program coordinators were interviewed individually and program delivery staff were interviewed as a group for each PCP. The exception to this was PCP HA, for which the project coordinator and the only staff member involved were interviewed together. Consensus responses were not developed, as each participant was asked to respond in direct relation to their own program. Some participants discussed issues among themselves, to share information. The interviews were scheduled to maximize staff experience with these programs, and to minimize the impact of staff that departed before program end. Two staff members who departed before the interviews were interviewed individually over the phone. Nine interviews involving five coordinators and 12 delivery staff were conducted. Interview participants had spent between four and 18 months on the programs at the time of the interviews and had between three and 35 years of experience working with older people (Table 1). The same member of the research team conducted all interviews. Each interview took approximately 60 min and was audio taped. Responses from each participant interviewed in a group were transcribed separately. The interviewer then reviewed each transcript while listening to the audio tapes for clarification where necessary to produce a final version of each transcript. Each transcript, representing one participant, was coded and a deductive content analysis (Elo & Kyngäs, 2008) was undertaken against the five DOI attributes of innovations. As the interviews were organized according to these five attributes, coding involved checking that responses within each section were relevant to the DOI attribute, and reallocating them if an alternative was more appropriate. Responses for each of the DOI attributes were then analyzed for themes using an inductive approach. The transcripts for staff involved in the group- and homebased programs were coded and analyzed separately. For parsimonious reporting, themes common to both program types are reported together, while differences are noted. Care was taken to ensure that only comments relating to program implementation and the usual

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Table 1  Participating Program Staff for Group- and Home-Based Falls Prevention Exercise Implementation Primary Care Partnership (PCP) and Program Type

Participants (n)

Roles

PCP A group exercise (GA)

Coordinator (1)

Physiotherapist

Staff (5)

Physiotherapists (4) Allied health assistant (1)

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PCP B group exercise (GB)

Time on Program (Months)

Experience at Organization (Years)

Experience Working with Older People (Years)

15

2

20

10–15

3–15

5–35

18

8.5

28

12–18

3–15

15–20

18

13

13

Coordinator (1)

Physiotherapist

Staff (3)

Physiotherapists (2) Allied health assistant (1)

PCP A home exercise (HA)

Coordinator (1)

Occupational therapist

Staff (1)

Physiotherapist

18

8

20

PCP B home exercise (HB)

Coordinator (2)

Physiotherapists (2)

4.5, 13

0.7, 1

20, 21

Staff (3)

Physiotherapists (3) Allied health assistant (1)

11–12

1–9

3–30

practice environment were coded and analyzed. Comments relating to client outcomes or the demands of being involved in the project evaluation were excluded. The study was approved by the Monash University Human Research Ethics Committee.

Results The results are presented according to the five specified attributes of innovations according to DOI theory: compatibility, relative advantage, complexity, trialability, and observability.

Compatibility Compatibility refers to the extent to which an innovation (in this case, the falls prevention exercise programs) is perceived as fitting with the practices, values, and needs of the implementer (in this case, the PCPs and the delivery staff) (Rogers, 2003). Innovations that are more compatible are more likely to be implemented (Greenhalgh et al., 2004). Participants were asked a series of questions to establish their perceptions of the compatibility of the particular exercise program with their organization as a whole, with their own individual values and practices, and with their client base. Organizational Compatibility.  Participants from both group- and

home-based programs reported that the programs were compatible with their organization’s existing practices and values given similar falls prevention programs were already being delivered. However, some participants noted that other programs were affected because of prioritizing staff allocation to the exercise programs. As one participant put it: “...we had to stop doing a whole lot of other things that we would normally do.” Participants reported that having staff with previous experience in running similar programs was highly advantageous, reducing the time required for training and allowing the programs to get underway more rapidly. The involvement of staff with existing strong contacts with other agencies and community groups was also seen as beneficial, particularly in terms of recruitment and interagency communication. Participants from both group- and home-based programs indicated that the time required fluctuated depending on the program stage. This was not necessarily compatible with the way their organizations usually managed staffing levels and hours. The participants interviewed were employed to work for a fixed number of hours

(often 15–22 hr per week) for the project’s duration. Therefore, from their perspective, the time allocated was insufficient at some stages and sufficient or excessive at others. As might be expected, participants from all PCPs viewed the project’s commencement as a time when their allocated hours were particularly insufficient. For example, one participant indicated: “I think you need more hours at the beginning. And perhaps less hours once the project’s up and running, but then there’ll be a bulge of hours again.” Participants from the group-based programs reported that they used volunteers, exercise students, and allied health support staff in addition to the staff allocated to the program. Both PCPs found it difficult to obtain sufficiently-trained volunteers, requiring additional time to address training needs. Participants from both the group- and home-based programs indicated that the program content was highly compatible with programs previously delivered by their organizations, the main difference being the delivery method (home versus group). For example, one agency implementing group-based programs had previously undertaken mainly home visits, while another agency implementing home-based programs had previously been delivering group-based programs. There appeared to be incompatibility between the program’s funding arrangements and existing organizational budgets. Participants reported that the available funding was insufficient for safe and effective delivery (e.g., for interpreters, or clinical support staff for group exercise programs). Some participants commented that the available funding was insufficient for number of hours needed to deliver and administer the program. Individual Practitioner Compatibility.  Participants reported that

program content was compatible with their personal skill sets and previous experience in delivering similar programs. However, some participants who worked in multiple roles felt that their involvement in delivering the exercise program negatively affected their other roles. For example, one participant reported feeling: “...like I’m very out of touch with what’s happening because I just haven’t had the time….it has taken over.” Participants reported often feeling under pressure and needing to “juggle” other commitments. The nature of the programs made it difficult to take personal or sick leave and participants reported that taking leave resulted in major backlogs of client follow-up calls and appointments. This was difficult to deal with while also conducting initial appointments for new clients. Participants from three of the four PCPs also indicated they worked significant amounts of overtime to accommodate program needs.

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Client Compatibility.  Participants from group-based programs felt

that the programs were reaching similar clients to those that their other programs attracted. The exception was the tai chi programs that appeared to be more attractive to clients under 70 years of age and to those with higher physical function. Participants who had delivered home-based programs felt these programs attracted a greater range of clients than previous programs, including clients who felt too frail to attend group classes or could not participate for financial reasons. In all PCPs, the programs were viewed as fulfilling the needs of particular target client groups, and therefore can be considered compatible in that respect.

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Relative Advantage Relative advantage refers to the extent to which an innovation is perceived by potential implementers as having advantages over current practice and any alternatives (Rogers, 2003). Clear, unambiguous relative advantage is necessary but not sufficient for implementation (Greenhalgh et al., 2004). The more advantageous an innovation is perceived to be, the more likely its implementation (Greenhalgh et al., 2004). Participants were asked a series of questions to establish how the programs compared with other falls prevention programs available and in what ways, if any, the programs were advantageous. Five types of advantage were identified: economic, program structure, networking and engagement, professional development, and trust building. Participants from PCP GB felt that there was an economic advantage in delivering the group-based exercise program because program costs were minimal compared with the costs of a fallrelated injury or hospitalization. In contrast, the other PCP delivering group-based programs pointed out that the true program costs were greater than funding provided, and delivering the program was financially detrimental to the organization. The two PCPs that delivered home-based programs felt that there would be lower costs associated with center-based programs compared with home-based programs due to the time lost in traveling between each location. They did acknowledge, however, that although home-based programs cost more, they could reach people who were unable or unwilling to attend group-based programs. The highly-structured nature of the programs based on the NoFalls or Otago Exercise Programs was seen as an advantage over other programs by all participants, as it made the programs easier to administer and use with different staff and clients. In addition, participants delivering home-based programs found the illustrative booklets of the Otago Exercise Program useful in demonstrating, and reminding clients of, their prescribed exercises. Similarly, participants from PCP GB reported that the NoFalls booklet and other tools provided were helpful, although those from PCP GA reported that the tools provided for the NoFalls program were a little out of date. Participants who delivered home-based programs felt it was an advantage visiting people in their homes. This allowed adaptation of the exercises according to the specific home environment and ensured that exercises were being performed safely. Participants from all PCPs in which multiple agencies were involved viewed the improved partnerships and cooperation with the other PCP member agencies as an important advantage of the programs. For example: What worked well was the partnership side of the project. That worked really well. Because I think it’s really built on existing networks. The partnerships that we formed. We built on partnerships that were already existing, say from previous projects. So, we’ve been able to utilize that. Or we’ve created a whole lot of new ones that would be useful for future projects.

A related advantage identified by participants from both the group and home-based exercise PCPs was the improved falls prevention profile and image of the participating agencies. Some participants saw the opportunity to participate in training courses afforded by the programs as advantageous in terms of their professional development. For example, the ‘NoFalls Train the trainer’ course was considered useful. Participants who delivered home-based programs reported that the program length enabled them to develop trust with their clients. This allowed practitioners to discuss and encourage other falls prevention behaviors outside the exercise program itself.

Complexity The complexity of an innovation refers to the degree to which it is perceived as relatively difficult to understand, implement, and use (Rogers, 2003). The more complex an innovation is perceived to be, the less likely it is to be implemented. Participants were asked a series of questions to establish how complex they considered the content and the delivery of the exercise programs. Program Content.  Participants from both kinds of programs identified that obtaining a suitable level of challenge for older people was a major source of complexity in relation to program content, even with the instructions and tools provided. Participants reported people dropping out if the challenge level was too low. Conversely, programs had to be modified for clients who were too frail to participate fully in the prescribed exercises. A number of participants mentioned wanting different versions of the programs and tools to meet the needs of different clients, as illustrated by this quote:

…it would be nice if we had the money to set up a very basic manual for the program, what I’m doing now, and a more active one [sic]. I’d love to have had that. If we start from scratch now, that’s what I would love to have. And like a set manual for what I would say for the very limited mobility clients and [one for the] more active. Because the range of physical abilities alone is huge in the eighty plus age group. In general, most participants reported that they used the exercise programs as guidelines and then applied their professional skills and knowledge to adjust the programs when necessary. For example, in the group-based programs, participants mentioned removing the thigh stretch exercise from their NoFalls routines for safety reasons. Participants considered that the risk of getting caught in a chair and falling during this exercise was too high given the orthopedic footwear many clients wore when exercising. Participants also reported that they did not use free weights and stopped clients using weights for safety reasons. Some clients also experienced hip and knee stiffness and pain that required modification of the program. Participants from three of the four PCPs reported that they were comfortable with modifying the programs and did not find this particularly complex to do given their skill level. Program Implementation.  The nature of available venues, particularly the flooring and the space available to store equipment, added a layer of complexity to implementing the group-based exercise programs for those services not using their own facilities. Smaller venues meant fewer clients could be accommodated and a lack of storage space resulted in weights and other equipment having to be stored offsite and transported to and from the venue. The times at which these venues were available and the frequency with which the groups could book the venue also added complexity. The majority of participants indicated that they had difficulty fitting the entire

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program into the time slot available to them. Large group numbers, especially when clients did not have English as a first language and required interpreters, also made it more difficult to administer and monitor the program. Some programs used volunteers and students to ensure an appropriate ratio of clients to staff. Travel and moving heavy equipment added complexity to the implementation of both group- and home-based programs. The time spent traveling between venues had not always been budgeted for, and, especially in the home-based programs, this time was substantial. It was not always possible to know in advance exactly when transport would be needed so some participants in the homebased programs found it difficult to book work cars. Practitioners delivering the home-based programs identified travel as a potential threat to their health and safety as they felt very rushed traveling between appointments. They were also restricted in their access to toilets and some reported drinking less water and subsequently feeling dehydrated because of this. Transporting heavy weights and wobble boards in and out of vehicles was also considered an injury risk to the practitioner. For the PCPs delivering home-based programs, there were issues with clients thinking the participants would return more regularly than the program specified. At times, this resulted in discouragement and discontentment with the program when clients realized they would receive phone calls rather than home visits. For example: … when I called them even though it had been explained to them several times and at the eight week visit I would again say, ‘Now, this is the last visit that I’ll be coming to see you’ When I call them for three months ‘Oh and when are you coming again?’, or ‘What time are you coming today?’ And often that was a point with some where their motivation decreased a little bit. Recruitment coordination was reported to be a complex element of the programs, particularly when those recruiting and scheduling client appointments were not the same people as those delivering the program. This issue is illustrated by the following quote: Sometimes we had problems recruiting because Falls was coordinated by the OTs, not the physios. But the physios had to do all the work but the OTs organized it. And they like to be very organized and they set everything well in advance. Little do they know what other work we’re doing or whatever at the time and then we have to sort of stop our own projects to run what they’ve decided when they’ve decided we’re going to do it. Cognitive impairment and English language skills among some clients increased implementation complexity. Some programs did not have a budget for interpreters and, in the home-based programs, staff were not always able to take interpreters with them. Translated documents were available in a range of languages, however, some clients were unable to read in their own language. It emerged that steering committees could play a useful role in managing program complexity. For example, a participant reported that her PCP’s steering committee: “has been good at clarifying issues, getting feedback on the problems of the highs and lows of the project within each agency. And for me to sort of feedback you know, how everyone’s going and the sharing of ideas.”

Observability Observability refers to the extent to which the benefits of the innovation are visible (Rogers, 2003). The more observable the benefits, the more likely the innovation will be implemented. The following

findings reflect the participants’ subjective perspectives on the observable benefits of the delivered programs. Participants were very specific that they could not objectively say whether there had been any improvement to clients’ strength and balance. However, participants from all PCPs reported anecdotal evidence that the programs were helping participants. Participants reported that clients had informed them that they had been able to put their skills into practice and avoid a fall, or felt they had better balance. Clients and their families also informed participants about improvements in confidence and the ability to do things they had previously had to stop doing. Participants considered that their organization’s capacity to address falls prevention had improved. The group-based programs provided a pathway for clients to join other programs. The establishment of stronger connections with other agencies and community groups was seen as likely to enhance capacity through increased referrals and establishing future programs. Participants delivering the home-based programs felt their PCP’s capacity had improved because they were now addressing a gap in care (i.e., those unable to attend group classes) and experienced an increase in internal referrals.

Trialability Trialability refers to the extent to which aspects of the innovation can be tried before implementation of the innovation (Rogers, 2003). Increased trialability increases the likelihood of implementation. This attribute of DOI theory is the least relevant to this study because the types of programs the PCPs could use were so strongly prescribed by the funding organization. Once the PCPs had been selected, the proposed programs were initiated without any trial stages. Nonetheless, three of the four programs reported being familiar with the exercises already and could therefore be reasonably considered to have ‘trialled’ the exercises previously. They indicated that this made it easy for them to pick up the programs. However, one of the PCPs delivering group-based programs noted that the exercise program had not been previously delivered at external venues.

Discussion The findings from this study indicate that both group- and home-based exercise programs had high overall compatibility, high relative advantage, good observability, and high inherent trialability—all of which are likely to strengthen program implementation. Complexity and one aspect of compatibility (low financial compatibility) associated with both program types emerged as the strongest potential inhibitors of implementation in the context examined. There was high consistency in themes emerging from the two types of exercise programs. Compatibility was high at the organizational and practitioner levels and good at the client level for both group- and home-based programs. However, it was clear that the programs were not particularly compatible with organizations’ financial models. A related observation was that the organizational climate (heavy workloads, lack of cover for leave) meant some practitioners had to work in ways that were not compatible with their own values. It should be noted however, that this was not necessarily related to the nature of the exercise programs themselves, but rather to the community health services sector more broadly. Despite the reporting of a range of relative advantages, the likely higher impact on reducing falls by implementing evidencebased programs was not explicitly mentioned by participants. This may have been because this was a specified criterion for program

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50  Day et al.

funding. Some disparity in the perceived relative economic advantage of group-based exercise programs was noted between the two PCPs delivering these programs. This was mainly due to different perspectives—participants from one PCP responded from a societal perspective while those from the other PCP responded from their organization’s perspective. This highlights a disconnect between where the costs for exercise programs may be incurred in Australia’s health and health promotion systems (participants, community delivery agency, health insurer, government) and where the direct financial benefits of falls reduction accrue (health insurer, government). Two key factors contributed to complexity. Firstly, a key component of falls prevention exercise is providing sufficient, but safe, balance challenge (Sherrington et al., 2011). This increases complexity when practitioners are working from a specified program curriculum and have clients with a wide range of capabilities. The nature of the particular exercise programs used in this study combined with the skill of practitioners experienced in working with older people allows for a certain degree of adaptation such as providing more or less balance challenge. Reinvention has been shown to enhance implementation (Greenhalgh et al., 2004). The importance of adequately trained staff who are confident to deliver an intervention to older people has been highlighted in previous falls intervention implementation studies (Shubert, Altpeter, & Busby-Whitehead, 2011; Zachary, Casteel, Nocera, & Runyan, 2012). This need to provide adequate safe balance challenge may not necessarily impede implementation when experienced practitioners are involved, as was the case in this study. However, if practitioners cannot provide the necessary range of balance challenge, program effectiveness will be reduced, particularly if clients stop doing the exercises. There have been attempts to combine two different falls prevention exercise programs to broaden the range of clients for whom a particular exercise program may be suitable. For example, Yang and colleagues (2012) combined the Otago exercise program with another commercially available program that had more exercises with increased balance challenge. This program was successful in improving balance and mobility outcomes in older people with mild balance impairment (Yang et al., 2012). Secondly, there were many practical difficulties and complexities associated with implementing both programs. Participants from both programs reported issues concerning client recruitment, class and visit scheduling, storage and transport of equipment, and travel to either venues or clients’ homes. In addition, group-based program participants reported difficulties in locating suitable venues and needing volunteers and students to supervise the numbers of people in the groups. Participants from the home-based programs reported concerns about their occupational health and safety and managing client expectations regarding the frequency and length of home visits. These task-related issues may impede adoption and implementation (Greenhalgh et al., 2004). Certainly these kinds of practical issues have previously been reported as barriers to implementation of falls prevention programs (Child et al., 2012). The primary benefits of the exercise programs, including improved strength and balance, and prevention of falls among clients, are not readily observable by practitioners in the short-term, unless specifically measured, which is not common in community practice. However, both client benefits (e.g., improved functional outcomes) and organizational benefits (e.g., enhanced capacity) were observed by participants. Given that observability of the benefits of falls interventions has been noted as a facilitator of implementation (Goodwin et al., 2011), perhaps simple reliable measures of strength and balance should be incorporated into existing programs. This

may serve to enhance program implementation and client compliance and maintenance of falls prevention exercises. DOI theory focuses on the innovation itself, yet there are many other influences on the uptake of new initiatives (Blasé, Van Dyke, Fixsen, & Bailey, 2012; Durlak & DuPre, 2008; Greenhalgh et al., 2004; Wandersman et al., 2008). In their description of implementation stages, Blasé and colleagues (2012) define implementation drivers as the processes required to implement, sustain, and improve effective interventions. The drivers, which are effectively leverage points in a system, are grouped into three interactive domains: competency drivers are mechanisms which develop and sustain the ability and competence of staff to deliver the intervention; organizational drivers are mechanisms which develop and sustain the organizational environment required to support program implementation; and leadership drivers are strategies which facilitate leadership responses to implementation challenges. This study primarily identified implementation challenges within the organizational drivers domain (e.g., scheduling of classes and visits, storage and transport of equipment, organizing travel to classes and homes), and very few challenges associated with the innovation itself (i.e., the exercise programs). It is clear that competency drivers are important for falls exercise programs and these may be more relevant if less experienced exercise providers are involved, as noted above. Future implementation of falls prevention exercise programs in the community health sector may benefit from strong organizational planning to ensure there are facilitative administrative processes and decision support systems in place to support the implementation of evidence-based programs. Many of the themes and issues identified in this study are consistent with those previously identified in relation to the adoption of innovations within health service delivery organizations rather than to an innovation itself (Greenhalgh et al., 2004). These include the outer context (incentives and mandates), system antecedents for innovation (preexisting knowledge and skills base, enablement of knowledge sharing via internal and external networks), system readiness for innovation (innovation-system fit), and the implementation process itself (dedicated resources, internal communication, external collaboration, reinvention/development). Some of these themes are shared with physical activity implementation more broadly where incentives and mandates, preexisting knowledge and skills base, system readiness, external collaboration, and availability of resources have been noted as factors enabling successful implementation of physical activity interventions in primary care and community settings (Ballew et al., 2010; Josyula & Lyle, 2013). Although this study was intended to explore implementation of exercise programs within community health settings, some of the issues identified are also likely to influence sustainability. In fact, six of the 12 factors associated with sustainability we identified in a recent literature review (Hill et al., 2011) also emerged in this study. The high overall compatibility (particularly organizational compatibility), high relative advantage, and good observability identified in this study are likely to enhance sustainability as well as support implementation. Additional key indicators for sustainability are organizational capacity in the form of preexisting skills and knowledge, and capacity building in the form of training and experience. Adaptability was apparent in the use of local volunteers for groupbased exercise programs and allied health assistants to support physiotherapists for home-based exercise programs. However, the low financial compatibility with community health organizations that mainly rely on external funding to implement these types of programs is a threat to sustainability and is a common reason for the inability to sustain programs (Hill et al., 2011).

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Conclusion

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Limitations There were three variations in the interview methods that could have influenced the responses. Firstly, our protocol called for individual interviews with the program coordinators to allow them the freedom to respond without program delivery staff present. We were able to implement this protocol for four of the five program coordinators. It is possible that some of the responses of the program coordinator who was interviewed at the same time as her staff member were influenced by the latter’s presence. Secondly, all but one of the 12 delivery staff were interviewed in a group for efficiency. This raised the potential for participant responses to be influenced by the presence of others. However, as the participants were answering for their own programs based on their own experience, it is unlikely that the response would have been affected by the presence of other participants. Thirdly, one coordinator and one program delivery staff member were interviewed by telephone rather than with the face-to-face approach used for the majority of participants. While there have been mixed findings on the comparability of telephone and face-to-face interviews for qualitative research (Sturges and Hanrahan 2004), it is possible that these two interviews could have yielded data with less depth than the face-to-face interviews (Irvine, Drew, & Sainsbury, 2012). The transcripts were coded by the interviewer, and not independently checked. As the interviews were organized in sections according to the five DOI innovation attributes, many of the responses were in effect precoded. Coding also involved analyzing for themes within these attributes, and for this aspect of the coding our study relied on one coder’s interpretation. The coder has extensive experience in the thematic analysis of qualitative data, having performed similar analyses of interview and narrative data arising from a range of settings.

Implications for Practice or Policy A key finding of this study is the complexity in ensuring sufficient, but safe, balance challenge for clients with a wide range of capabilities. There is some evidence that improving the feasibility and workability of innovations improves the chances of successful implementation (Greenhalgh et al., 2004). Consequently, a range of strategies to provide more technical support in tailoring balance challenge for exercise program leaders may enhance implementation of falls prevention exercise programs. Measures such as accredited professional education programs, online training, and an online bank of exercises that progressively challenge balance may be helpful. This could be a role for the professional associations for physiotherapists, exercise physiologists, and fitness leaders. Promotion and support of accredited training programs may not only reduce complexity, but also enhance the relative advantage of falls prevention exercise programs since the opportunity to participate in training was a positive feature for the study’s participants. Promotion and measurement of other more observable health benefits, such as improved functional capacity and confidence, to health professionals may help to counterbalance the difficulty in observing falls prevention outcomes, thereby enhancing implementation. Given that many of the implementation challenges were associated with organizational drivers, improved cost-benefit and economic evaluations may demonstrate economic benefits more clearly. However, as the immediate economic benefits accrue to the State Government rather than community health services, these services will continue to rely on external revenue sources to fund local level delivery of fall prevention exercise programs.

This study has identified features of falls prevention exercise program delivery that are likely to both enhance and impede implementation in the community health setting. These findings will be useful for exercise program delivery planning in the future. Importantly, innovations and new programs always need to be implemented in wider systems and broader societal contexts. Features of the system, context and innovation, and their interaction, together determine the success or failure of implementation (Ballew et al., 2010; Greenhalgh et al., 2004; Wandersman et al., 2008).

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