A co-designed conceptual model for implementing falls prevention programmes for community-dwelling older adults in Singapore: a systems thinking approach

Introduction
Implementing falls prevention programmes in the community presents numerous challenges. We sought to understand the dynamics between the determinants influencing implementation to develop a common conceptual model describing the complexities of implementing falls prevention programmes in Singapore.

Methods
A full-day group model building workshop with a series of structured activities was organised with 31 multidisciplinary stakeholders. Stakeholders who attended include healthcare professionals of different specialities (i.e. geriatrics, rehabilitation medicine, physiotherapy, nursing), community-based voluntary welfare organisations, researchers and policymakers.

Results
A causal loop diagram was developed to illustrate the determinants influencing implementation of community-based fall prevention programmes. It revealed factors driving key implementation and service outcomes in supply and demand of such programmes. Determinants of these outcomes were synthesised into four themes: (i) structural factors affecting the management and resource allocation for community-based falls prevention programmes, (ii) participation in programmes affected by older adults’ willingness and ability to participate, (iii) perceived value as a composite of costs and benefits, and (iv) social support and exercise self-efficacy motivating long-term adherence. Furthermore, in our analysis of feedback relationships, two organisational behaviours were identified: unsustainable growth due to resource constraints (Limits to Growth) and tensions between executing symptomatic or fundamental solutions (Eroding Goals). Stakeholders also explored strategies for effective implementation.

Conclusions
A conceptual model describing the dynamics of implementing community-based fall prevention programmes was developed. This informed the formulation of a National Falls Prevention Framework, a priority action step for the effective implementation of these programmes in Singapore.