Summary For this assignment you will use the Quantitative and the Qualitative article that you submitted for week 4 assignment that were related to your we

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  • For this assignment you will use the Quantitative and the Qualitative article that you submitted for week 4 assignment that were related to your week 2 picot question.
  • Only articles you uploaded and used in week 4 (Quantitative or Qualitative) are to be submitted. Articles must be current (within the last 5 years). All articles must be related to the field of nursing and related to the topic list from week 2.
  • Write a summary (one to two pages)
  • In the summary identify differences in article designs and research methods. Describe the differences in your articles designs and methods. Carefully review the rubric before you submit. This summary is using your own words to examine the differences specifically between the articles.
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RESEARCH Open Access

Qualitative research to inform economic
modelling: a case study in older people’s
views on implementing the NICE falls
prevention guideline
Joseph Kwon1* , Yujin Lee2 , Tracey Young1 , Hazel Squires1 and Janet Harris1


Background: High prevalence of falls among older persons makes falls prevention a public health priority. Yet
community-based falls prevention face complexity in implementation and any commissioning strategy should be
subject to economic evaluation to ensure cost-effective use of healthcare resources. The study aims to capture the
views of older people on implementing the National Institute for Health and Care Excellence (NICE) guideline on
community-based falls prevention and explore how the qualitative data can be used to inform commissioning
strategies and conceptual modelling of falls prevention economic evaluation in the local area of Sheffield.

Methods: Focus group and interview participants (n = 27) were recruited from Sheffield, England, and comprised
falls prevention service users and eligible non-users of varying falls risks. Topics concerned key components of the
NICE-recommended falls prevention pathway, including falls risk screening, multifactorial risk assessment and
treatment uptake and adherence. Views on other topics concerning falls prevention were also invited. Framework
analysis was applied for data analysis, involving data familiarisation, identifying themes, indexing, charting and
mapping and interpretation. The qualitative data were mapped to three frameworks: (1) facilitators and barriers to
implementing the NICE-recommended pathway and contextual factors; (2) intervention-related causal mechanisms
for formulating commissioning strategies spanning context, priority setting, need, supply and demand; and (3)
methodological and evaluative challenges for public health economic modelling.

Results: Two cross-component factors were identified: health motives of older persons; and professional
competence. Participants highlighted the need for intersectoral approaches and prioritising the vulnerable groups.
The local commissioning strategy should consider the socioeconomic, linguistic, geographical, legal and cultural
contexts, priority setting challenges, supply-side mechanisms spanning provider, organisation, funding and policy
(including intersectoral) and health and non-health demand motives. Methodological and evaluative challenges
identified included: incorporating non-health outcomes and societal intervention costs; considering dynamic
complexity; considering social determinants of health; and conducting equity analyses.

© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
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* Correspondence: [email protected]
1School of Health and Related Research, University of Sheffield, Regent Court
(ScHARR), 30 Regent Street, Sheffield, England S1 4DA
Full list of author information is available at the end of the article

Kwon et al. BMC Health Services Research (2021) 21:1020

Conclusions: Holistic qualitative research can inform how commissioned falls prevention pathways can be feasible
and effective. Qualitative data can inform commissioning strategies and conceptual modelling for economic
evaluations of falls prevention and other geriatric interventions. This would improve the structural validity of
quantitative models used to inform geriatric public health policies.

Keywords: Falls, Falls risk, Falls prevention, National Institute for health and care excellence guideline,
Implementation, Qualitative research, Facilitators and barriers, Economic model, Public health

Falls among older people impose significant morbidity
and mortality burdens [1]. Around 30% of community-
dwelling persons aged 65+ fall each year [2]. Falls can re-
sult in fatal or debilitating injuries such as hip fractures
[3], provoke fear of further falls [4], and induce func-
tional decline [5]. They also impose substantial burdens
on care systems through hospitalisations and long-term
care admissions [6] and on informal caregivers [7]. Falls
prevention is hence a public health priority [8].
The rationale for intervention is further supported by

randomised controlled trial (RCT) findings that diverse
community-based falls prevention interventions signifi-
cantly reduce the number of falls and fallers [9, 10]. In
England and Wales, the National Institute for Health
and Care Excellence (NICE) clinical guideline 161
(CG161) is the normative reference point for local clin-
ical practice [2]. This recommends that persons aged
65+ receive falls risk screening at routine visits to health
and social care professionals; those screened to be at
high risk would then be referred to multidisciplinary falls
risk assessment and tailored treatments, including exer-
cise, home assessment and modification (HAM), medica-
tion modification and vision improvements [2]. These
treatments may also be delivered individually as single-
component interventions [11–13], either as substitutes
for the multifactorial intervention or as non-mutually
exclusive complements [14, 15]. These interactions be-
tween screening and treatment components, the multi-
factorial risk profile of falls as a geriatric syndrome [16],
and the wider environmental risk factors [17, 18] intro-
duce substantial complexity to falls prevention [19, 20].
Due to this complexity, community-based falls preven-

tion strategies face significant implementation challenges
[21–24]. For example, a recent survey of English GPs
found that only 31% routinely screened their older pa-
tients for falls history; the median annual number of re-
ferrals to falls prevention services per GP was just 10
[25]. Implementation quality can be suboptimal even in
RCT settings. For example, the uptake rate for a UK trial
of falls prevention exercise was 6% [26]; adherence to
different components of multifactorial interventions is as
low as 28% [27]; and 16% of participants withdraw from
falls prevention exercise at trial conclusion [28]. Low im-
plementation reduces the effectiveness and population

reach/impact of falls prevention [20]. Accordingly, NICE
CG161 incorporated a systematic synthesis of older peo-
ple’s views on the facilitators and barriers to falls preven-
tion (covering the period 1990–2003), but found no
study that explored their views on multifactorial pack-
ages (p. 101) [2]. More recent qualitative works have
likewise focused on specific components of the falls pre-
vention pathway, including receptiveness to falls preven-
tion advice [29], falls risk assessment [30], and exercise
uptake [31, 32] and adherence [33]. This is an important
evidence gap given that complexity results from the
interaction of facilitators and barriers across different
pathway components. A more holistic approach to quali-
tative research with current or potential falls prevention
service users is warranted.
Health economic evaluation is a comparative analysis

of alternative healthcare strategies in terms of costs and
consequences with the purpose of informing the efficient
use of scarce resources under a constrained healthcare
budget [34]; it can also incorporate further decisional
criteria beyond cost-effectiveness, such as reduction in
social inequities of health, according to stakeholder pref-
erence [35–37]. One vehicle for economic evaluation is
decision modelling that represents the key causal mecha-
nisms of a decision problem in mathematical and statis-
tical/probabilistic relationships [34]. Decision models are
particularly well-suited for considering all relevant costs
and effects of interventions over long time horizons, and
for evaluating ‘what-if’ scenarios for the full target popu-
lation of the decision-making jurisdiction [38]. One such
scenario is the commissioning of implementation re-
sources to change current local practice into a form ap-
proaching the NICE-recommended pathway.
A de novo economic model is likely required if the

existing economic models or evidence are insufficient
for informing local decision-making: e.g., due to unreal-
istic representation of local practice and/or shortcom-
ings in characterising the key causal mechanisms.
Currently, the decision model developed to inform
CG161 [39] evaluates a multifactorial intervention for
the national population and may not be locally generalis-
able; while the locally applicable Public Health England
Return on Investment tool [11] only evaluates single-
component interventions. This presents a rationale for
developing a de novo model evaluating the cost-

Kwon et al. BMC Health Services Research (2021) 21:1020 Page 2 of 19

effectiveness relative to current practice (and wider deci-
sional outcomes) of a strategy that locally implements
the NICE-recommended pathway.
Qualitative research with current and potential con-

sumers of health services can contribute to economic
modelling in two important ways [40, 41]: (a) eliciting
appropriate commissioning strategies; and (b) under-
standing the key methodological and evaluative chal-
lenges to public health economic modelling.
Concerning (a), the model-evaluated commissioning

strategy should fully reflect the complex network of
intervention-related casual mechanisms influencing im-
plementation. Several frameworks exist to capture such
complexity [40], including the Context and Implementa-
tion of Complex Interventions (CICI) framework [20]
which was developed as part of the INTEGRATE-HTA
project to consider a comprehensive set of factors influ-
encing the assessment of complex health technologies
[19]. CICI distinguishes between contextual factors (e.g.,
socio-cultural, legal) and implementation mechanisms
(e.g., professionals, organisations) that shape implemen-
tation quality. Priority-setting challenges – e.g., reducing
social inequities of health [35] – also arise from the im-
plementation context [40]. Given the CICI framework’s
lack of focus on demand-side mechanisms (e.g., motiva-
tions of the older persons to engage in healthy behaviour
[42]), it could be supplemented by the health needs as-
sessment (HNA) framework that incorporates demand,
supply and need/eligibility as distinct yet overlapping do-
mains [43]. Inductive qualitative data analysis could
commence with themes sourced from this combined
framework, and thereafter interact with new themes
emerging from the data to arrive at the final thematic
framework informing the commissioning strategies [44,
Concerning (b), the nature of falls being a public

health problem faced by a broad spectrum of older pop-
ulations – rather than a clinical problem faced by a well-
defined, narrow patient group – presents further com-
plexity to model development [41]. According to a sys-
tematic methodological review, the key methodological
challenges to public health economic modelling include:
(i) capturing non-health outcomes and societal interven-
tion costs; (ii) considering dynamic complexity in health
determinants and intervention need; (iii) considering
theories and models of human behaviour based on
psychology and sociology; and (iv) considering social de-
terminants of health and issues of equity [46]. Address-
ing such challenges is part of the INTEGRATE-HTA
recommendations (see chapter 3) [19], and is necessary
for improving the structural validity of the decision
model [41]. The same inductive analysis can identify
how these challenges relate to the local decision problem
and hence to the decision model structure [41].

In all, a de novo qualitative study of older people is
warranted, first to holistically explore the facilitators and
barriers for implementing the NICE-recommended falls
prevention pathway, and second to proactively use the
resulting qualitative data to inform economic modelling.
The latter would improve upon the siloed approach that
is widely prevalent in the literature, whereby qualitative
research is conducted and interpreted separately from
economic evaluation, even when both designs are in-
cluded in the same project [39, 47, 48].

Aim and objectives
The study aims to capture the subjective views of older
people on implementing the NICE CG161 guideline on
community-based falls prevention and use the qualita-
tive data to inform the development of a conceptual falls
prevention economic model. The latter would guide
commissioning decisions in a local health economy seek-
ing to implement CG161, Sheffield being one such set-
ting. The research objectives are to:

1. Identify the facilitators and barriers for implementing
key components of the CG161 community-based falls
prevention pathway – including falls risk screening
and assessment, falls risk awareness, and uptake and
adherence of treatments within multifactorial inter-
vention – and contextual factors influencing the
pathway implementation in Sheffield.

2. Inform potential local commissioning strategies on
falls prevention by understanding the causal
mechanisms in context, supply, need and demand
that influence implementation.

3. Identify the methodological and evaluative
challenges associated with developing a public
health economic model of falls prevention in the
local context.

Given the aim of informing a model applicable to a
local health economy, the identified qualitative themes
would likely be locally specific. Hence, the main target
audience (outside of Sheffield) are economic modellers
and qualitative researchers (and commissioners sponsor-
ing them) interested in applying the methodology used
in this case study to other local health economies and
public health areas. That said, the facilitators and bar-
riers identified under the first objective would be gener-
alisable to other urban community settings in England
and Wales and hence be of interest to professionals and
patient groups seeking to improve the implementation
of local falls prevention.

The qualitative research involved focus groups and inter-
views with older persons living in the community. The

Kwon et al. BMC Health Services Research (2021) 21:1020 Page 3 of 19

ethics approval was obtained from the Research Ethics
Committee at the School of Health and Related Re-
search, University of Sheffield (ref. 025248). Written
consent was obtained from willing participants.

Target population and sampling
The target population comprised persons aged 65+ in
Sheffield, England, and persons aged 50–64 who are at
high falls risk. The latter group was included to explore
the rationale for earlier prevention as is currently recom-
mended for inpatient settings by CG161 [2]. Purposive
sampling covered multiple categories of participant char-
acteristics in terms of falls risk and service use as illus-
trated in Fig. 1.
According to CG161, those with a history of fall(s) re-

quiring medical attention or recurrent falls in the past
year and/or mobility and balance problems were defined
as high-risk [2]. Low-risk individuals were sampled be-
cause they are still eligible for falls risk screening and/or
interested in early prevention.
Recruitment continued until all participant categories

were covered and themes saturated. Specifically, two
focus groups (FG1, FG2) were formed from two separate
cohorts enrolled in Dance to Health, a falls prevention
programme that combines evidence-based Otago and
Falls Management Exercise components in dance rou-
tines [49, 50]; these groups contained high and low risk
service users. Two further groups (FG3, FG4) were
formed from a Patient and Public Involvement group
meeting regularly at the Northern General Hospital and
a social group meeting at Zest Community, a local social
enterprise offering leisure, health and work support ser-
vices to diverse age groups; these contained high and

low risk service non-users. Two interview participants
were recruited from Dance to Health and Zest
Focus groups were held directly before/after the regu-

lar meetings. Community organisation staff confirmed
before research commencement whether their members
could give informed consent. One participant declared
memory problems while another a recent diagnosis of
Alzheimer’s disease; but both were regular attendees of
community groups and expressed confidence in partici-
pating. After obtaining written consents, questionnaires
were administered to collect data on demographics, falls
history and fear of falling, current physical activity, and
contact with falls prevention services.
Focus group participants were previously acquainted

from attending the same activity and were comfortable
sharing their experiences in the group. The main inter-
viewer (JK) introduced himself and his PhD project aim
and presented himself as someone wanting to learn from
the participants. Participants were motivated to help the
interviewer understand their perspective on falls and
falls prevention. For interviews, around 15 min were
spent for the participants and the interviewer to become
acquainted in conversing (at interviewees’ homes) before
the research commenced.

Discussion topics
The main discussion topics were structured around the
sequential steps of the proactive prevention pathway rec-
ommended by CG161 [2], namely: (i) falls risk screening/
assessment by professionals; (ii) participant suggestions on
raising falls risk awareness in the community; (iii) initial
uptake of different treatments; and (iv) long-term

Fig. 1 Categories for study participant characteristics

Kwon et al. BMC Health Services Research (2021) 21:1020 Page 4 of 19

adherence to treatments. The pathway is proactive in that
it is initiated by professional referral of high-risk individ-
uals after falls risk screening. If mentioned by participants,
two further pathways were discussed: the reactive pathway
– where older persons are referred to falls prevention by
professionals after medical attention for a fall, which is
also recommended by CG161 (see recommendations, and [2]; and the self-referred path-
way – where older persons enrol in falls prevention with-
out professional referral.
A simplified graphical summary of the proactive

pathway, as shown in Fig. 2, was used to explain the
main topics to participants. Four treatment types –
exercise, HAM, medication change and vision im-
provement – were explained while emphasising that
other types exist, such as chiropody. It was also
highlighted that a reactive pathway after a serious fall
is commonly used, and that a self-referred pathway is
recommended by experts [51]. Further contextual fac-
tors influencing falls risk and prevention (e.g., safety
of pedestrian walks in Winter) were actively explored
as they emerged during discussion.

Data collection
Recorded audio data were transcribed and anonymised.
The questionnaire data were similarly transferred to an
Excel spreadsheet and anonymised. Both data were
stored securely in the University designated folder.

Data analysis
A framework analysis was employed for the analysis of
obtained data [44, 45]. The approach involved five
stages: (a) familiarisation – which involves repeated lis-
tening to audio and reading of transcripts for immersion
in the data; (b) identifying a thematic framework –
which is based on an a priori set of issues related to the
research objectives and themes emerging from the data;
(c) indexing – which systematically applies the thematic

framework to the transcripts; (d) charting – which ‘lifts’
the data from the transcripts and rearranges them (e.g.,
in a tabular format) according to the thematic frame-
work; and (e) mapping and interpretation – which seeks
associations and develops policy-related strategies from
the charted data based on a priori issues and emerging
themes. Stages (a) to (c) were conducted independently
by two authors (JK and YL). All authors contributed to
stages (d) and (e).
From stage (b) onwards, three frameworks related to

the research objectives were constructed using a priori
concepts and themes emerging from the data:

(I) Framework to understand the facilitators and
barriers to components of the NICE CG161 falls
prevention pathway and cross-component and con-
textual factors.

(II) Framework to inform potential commissioning
strategies by accounting for causal mechanisms in
context, priority setting, need/eligibility, supply and

(III)Framework to understand the key methodological
challenges to public health economic model

Framework (I): facilitators and barriers and cross-
component and contextual factors
This framework closely followed the structure of the dis-
cussion topics and charted the main themes identified
from the data. Facilitators and barriers for the pathway
implementation that emerged from the data were ar-
ranged by a priori thematic categories corresponding to
the NICE CG161 pathway components – i.e., (i) falls risk
screening/assessment by professionals; (ii) raising falls
risk awareness; (iii) initial uptake of treatments; and (iv)
long-term adherence to treatments. Cross-component
factors – i.e., facilitators and barriers influencing mul-
tiple pathway components – were highlighted.

Fig. 2 Graphical summary of the recommended falls prevention guideline used to introduce the discussion topics to focus group and
interview participants

Kwon et al. BMC Health Services Research (2021) 21:1020 Page 5 of 19

Additional contextual factors influencing the pathway
implementation were noted as they emerged from the

Framework (II): potential commissioning strategies
This framework rearranged the main themes under Frame-
work (I) into a format that guides commissioning strategies
(actual or model-evaluated). An a priori CICI-HNA frame-
work was constructed that combined the thematic categor-
ies within the CICI [20] and the HNA frameworks [43].
This is illustrated in Fig. A in Supplementary Material with
accompanying descriptions. In brief, the CICI framework
distinguished between implementation context (e.g., socio-
economic, legal) and mechanisms (e.g., provider, funding)
[20]. The HNA framework distinguished between supply,
demand and need/eligibility [43]: supply corresponded to
the CICI implementation mechanisms; demand encom-
passed personal and external factors influencing uptake/ad-
herence decisions (e.g., health-related motives for healthy
behaviour [42], community marketing, self-efficacy promo-
tions [52, 53]); need/eligibility was determined by normative
clinical and public health guidelines and intervention stud-
ies that demonstrated a group’s ability to benefit from an
intervention [43]. Further thematic categories that emerged
from the data were noted (e.g., priority setting challenges
that contextualised commissioning [35]). The mapped
themes informed commissioning strategies by highlighting
which CICI-HNA factors were modifiable – i.e., lie within
the decision space which is defined by the stakeholders in-
volved, decision time horizon and budget/capacity con-
straints – and to what extent.

Framework (III): challenges for public health economic
The thematic categories of key methodological chal-
lenges for public health economic modelling were taken
from a systematic methodological review [46]: (i) captur-
ing non-health outcomes and societal intervention costs;
(ii) considering dynamic complexity in health determi-
nants and intervention need; (iii) considering theories
and models of human behaviour based on psychology
and sociology; and (iv) considering social determinants
of health and issues of equity. Additional challenges as-
sociated with economic modelling and evaluation were
also identified from the emerging data.

Participant characteristics
Twenty-seven persons participated in research across
four focus groups (FG1–4) and two interviews (INT1–2)
between October 2019 and January 2020. Table 1 sum-
marises their characteristics.
Regarding current access to falls prevention, 11 re-

ported having spoken to a professional about falls risk.

Nevertheless, 21 reported recent use of services with
some falls prevention properties [9], suggesting that the
main falls prevention pathway under current practice is
self-referral by older persons. Of the 21 users, 13 re-
ported accessing multiple interventions. The most widely
accessed services were physiotherapy and falls education.

Framework (I): facilitators and barriers and cross-
component and contextual factors
Table 2 summarises the identified facilitators and bar-
riers to implementation by pathway component. The
themes are numbered to facilitate re-mapping to later
frameworks. Table A in Supplementary Material shows
the direct transcript quotes for each theme. Figure B in
Supplementary Material graphically illustrates how
themes were mapped from qualitative data to Frame-
work (I) and subsequently re-mapped to Frameworks
(II) and (III).

Falls risk screening and assessment by professionals
Factors influencing falls risk screening and assessment
by professionals could be divided into three groups: (A)
professional competence; (B) system-wide approaches
and resources; and (C) motivation and awareness of
older persons. Participants were aware of the importance
of professional competence in conducting the falls risk
screening, particularly incompetence as barriers. For ex-
ample, one participant had noticed the narrow scope of
professional risk assessment:

(FG1) “I’d think it was important if somebody went
to a health professional, the health professional would
check on a whole lot of background information
apart from immediate health thing – you know, what
is your living, housing situation.” (Theme [1–6])

Nevertheless, participants were also aware of the impact
of system-level approaches and resources beyond indi-
vidual professional competence and made suggestions
on improvement. One such suggestion was to adopt a
proactive, data-based approach to risk screening akin to
mass vaccination:

(FG1) “And with regards to hooking people in,
when flu jab time comes up, we all get a text or a
message or we get told that we need a flu jab. So,
follow that lead, really. I’m sure there’s a record
showing age groups and then tell them ‘Look, this
service is available. Come on in!’” (Theme [1, 2])

Moreover, a few comments suggested that older person’s
motivation to maintain health would facilitate profes-
sional efforts to discuss falls risk and prevention:

Kwon et al. BMC Health Services Research (2021) 21:1020 Page 6 of 19

Table 1 Summary of participant characteristics
Field Variable N (%)

Demographics Sex Female 20 (74)

Male 7 (26)

Age < 60 5 (19)

60–64 1 (4)

65–69 5 (19)

70–74 5 (19)

75–79 7 (26)

80–84 2 (7)

85–89 1 (4)

> = 90 1 (4)

Fall history and fear of falling Experienced fall in previous year Yes 14 (52)

No 13 (48)

Number of falls in previous year 0 13 (48)

1 6 (22)

2 4 (15)

3+ 4 (15)

Whether fall(s) required medical attentiona (% among fallers) Yes 8 (57)

No 6 (43)

Fall resulted in fracture (% among fallers) Yes 3 (21)

How worried are you about falling while walking or balancing? 1 Never 4 (15)

2 Hardly 5 (19)

3 Sometimes 11 (41)

4 Often 4 (15)

5 All the time 3 (11)

Current physical activity level Currently engaged in some exercise group/activityb Yes 19 (70)

No 8 (30)

History of falls risk screening Whether spoken to a GP or other professionals about risk of falling in previous year Yes 11 (41)

No 16 (59)

If yes, where was it? (% among Yes for previous question) GP 5 (45)

Social care 0 (0)

Falls clinic 3 (27)

A&E 0 (0)

Hospital 2 (18)

Other 1 (9)

Falls prevention service use in past year Type of falls prevention service usec Physiotherapy 12

Occupational therapy 1

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