Perceptions of Facilitators and Barriers to Implementation of Falls Prevention Programs in Primary Health Care Settings in China

Importance Falls have become a major public health issue in China with population aging. Although falls prevention for older community-dwelling people has been included in the National Essential Public Health Service Package since 2009, there is limited understanding of the implementation of this program. Objective To identify the associated factors and provide recommendations to inform the better implementation of falls prevention in the Chinese primary health care system. Design, Setting, and Participants This qualitative study was conducted in 3 purposively selected cities in China from March 1 to June 7, 2021. Health administrators from the local health commission or bureau, staff members from local Centers for Disease Control and Prevention and primary health care facilities and community-dwelling older people were recruited, using a combination of purposive sampling and snowball sampling. Main Outcomes and Measures In-depth interviews were conducted with health administrators and focus groups with other participants. Data analysis followed the guidance of the Consolidated Framework for Implementation Research. Study outcomes included facilitators and barriers of implementing falls prevention for older people in the Chinese primary health care settings. A framework with recommendations was developed to inform the future intervention implementation. Results Among a total of 130 participants interviewed, 77 (59.2%) were female and the mean (SD) age was 47.4 (16.7) years. Clear recognition of the challenges and benefits of falls prevention, adaptive regionally tailored guidance plans, and continuous governmental policy and financial support were the major facilitators, whereas the major barriers consisted of insufficient confidence in delivering interventions and poor understanding of the falls burden, low recognition of the importance of falls prevention, limited multisectoral collaboration, and weak financial incentives. A 7-strategy embedded framework—including data-driven surveillance, audit and feedback, implementation strategy, workforce strengthening, community empowerment, internal services integration, and external enabling environment—was developed to foster successful implementation. Conclusions and Relevance This qualitative study identified major facilitators and barriers to the implementation of falls prevention for older people at the primary care level, which have the potential to contribute to better implementation of falls prevention for older people in the Chinese primary health care system.

a. If any, how successful have these policies been in addressing the falls burden of older people? b. If any, have these policies been integrated into the delivery of health management service for older people?
4. What interventions have been taken to prevent falls for older people in your area? 5. Could you tell us something below about the formulation of interventions that have been taken to prevent falls for older people in your area?
a. Are these interventions uniformly formulated by higher authorities, or designed within your organization?
b. Do your staff have different views on these interventions? c. Is there any extrinsic incentive for these interventions? For example, goal-sharing awards, performance reviews, promotions, and raises in salary, increased stature or respect. 3. Can you talk something about following items related to the falls prevention for older people in your area? a. Epidemiological status: do you know any falls burden in your area, e.g., incidence, prevalence, mortality, disability and falls-related injury b. Risk factors: do you know any risk factor of falls in older population? c. Risk assessment: do you know any method or tool used to assess the risk of falls for older people? d. Prevention measures: do you know any measure that could be adopted by older people to prevent falls? e. Guidelines: do you know any domestic or international guideline related to falls prevention? f. Treatment: do you know any treatment for older people after falls? g. Rehabilitation: do you know any rehabilitation for older people after falls? 4. Do you understand the needs of older residents in the community for falls prevention? a. Are there any barriers to meet these needs? If yes, how to overcome these barriers? b. Are there any facilitators to meet these needs? If yes, how to leverage these facilitators?
5. What interventions have been taken to prevent fall prevention for older residents in your area? a. Are these interventions uniformly formulated by higher authorities, or are they designed within your organization?
6. What is the desired goal of these interventions?
7. Do you think these interventions can achieve the desired goal? • Continuous policy and financial support from central and local governments. • Region-tailored guidance plan was available and refined on an annual basis • Service providers recognized the perceived major challenges of implementing the intervention.
• Service providers hesitated to provide current interventions due to the lack of confidence in the evidence strength and quality. • No performance assessment indicators defined.
• Poor integration within the health management for older people and with other service items in the NEPHSP. • No dedicated budget allocated to falls prevention for older people.

Outer setting
• Service providers realized that more local older residents would need fall-prevention service. • Older people with prior experience of fall-related injuries had a good awareness of falls prevention. • National health policies required the scale-up of falls prevention for older people.
• Service providers had poor understanding of specific needs for falls prevention among local older residents, while PHC providers perceived falls not as an independent health issue. • Older people had limited knowledge of falls prevention and traditionally viewed falls as an inevitable accident in life. • Illiterate older people had poor accessibility of easy-tounderstand health educational information on falls prevention. In addition, older people had a weak willingness to accept fallprevention intervention due to the unforeseen health gain from the current service. • Limited collaboration with other government departments, civil societies, private sectors, and academic institutions. • An absence of a national action plan or guideline for falls prevention for community-dwelling older people. • No financial incentives from outside of the organizations provided to the service providers.

Inner setting
• The organizations of service providers shared central elements of culture in valuing PHC and had mature structural characteristics, secure networks and reliable communications. • Service providers recognized the perceived values of falls prevention to improve older people's health.
• Service providers did not realize the growing burden of falls among local older people due to the lack of data support, and failed to prioritize falls prevention within the NEPHSP. • Low financial incentives within PHC institutions.
• The lack of training and capacity building resources provided to the PHC providers.

Characteristics of individuals
• Most service providers' positive attitudes towards the implementation of fall-prevention intervention were consistent with their organization's mission and values.
• Service providers were not well equipped with professional knowledge and skills to implement fall-prevention interventions. • PHC providers with less working experience had low confidence in implementing fall-prevention interventions based on their own capabilities