Older people's views of falls prevention interventions in six European countries
**‡? FL BISHOP, N BEYER, K HAUER, GIJM Authors: L YARDLEY,
**††KEMPEN, C PIOT-ZIEGLER, C TODD, T CUTTELOD,** M HORNE, K
‡ LANTA,* A ROSELL
Address correspondence to Lucy Yardley, School of Psychology, University of Southampton, Southampton, UK SO17 1BJ. E-mail: L.Yardley@soton.ac.uk
*School of Psychology, University of Southampton, Southampton, HANTS, UK SO17 1BJ. L Yardley: L.Yardley@soton.ac.uk; (44) 2380 594581. F Bishop:
email@example.com; (44) 2380 592581. K Lanta: firstname.lastname@example.org; (30)
‡ Institute of Sports Medicine Copenhagen and Department of Physiotherapy, Copenhagen University Hospital, Bispebjerg, Denmark. N Beyer: email@example.com; (45) 3531 3054. A Rosell: firstname.lastname@example.org; (45) 3881
? Robert-Bosch-Krankenhaus, Stuttgart and Bethanien-Krankenhaus, University of Heidelberg, Germany. K Hauer: email@example.com; (49) 711 81012231.
Department of Health Care Studies, Maastricht University, The Netherlands. G
Kempen: G.Kempen@ZW.unimaas.nl; (31) 43388 2292.
** Health Psychology, Project IRIS 8A, Institute of Psychology, University of Lausanne, Switzerland. C Piot-Ziegler: Chantal.Piot-Ziegler@unil.ch; (41) 21692
3826. T Cuttelod: Therese.Cuttelod@unil.ch; (41) 21692 3826.
†School of Nursing, Midwifery and Social Work, University of Manchester, UK. C Todd: Chris.Todd@man.ac.uk; (44) 161 2755336. M Horne:
Maria.Horne@manchester.ac.uk; (44) 161 2755591.
The authors are participants in the ProFaNE thematic network, which is a project in Key Action #6 (The Ageing Population and their Disabilities), part of the European Commission's Fifth Framework, Quality of Life and Management of Living Resources Programme, funded by the European Commission (QLRT-2001-02705). We wish to thank Vonca Schaffers (The Netherlands) for carrying out interviews and transcriptions, Anna Tremmel (Germany) for carrying out interviews, and all the interviewees for their participation.
Purpose. To identify factors common to a variety of populations and settings that may promote or inhibit uptake and adherence to falls-related interventions. Design and Methods. Semi-structured interviews to assess perceived advantages and barriers to taking part in falls-related interventions were carried out in six European countries with 69 people aged 68 to 97. The sample was selected to include people with very different experiences of participation or non-participation in falls-related interventions, but all were asked about interventions that included strength and balance training.
Results. Attitudes were similar in all countries and contexts. People were motivated to participate in strength and balance training by a wide range of perceived benefits (interest and enjoyment, improved health, mood, independence) and not just reduction of falling risk. Participation was also encouraged by a personal invitation from a health practitioner and social approval from family and friends. Barriers to participation included denial of falling risk, the belief that no additional falls prevention measures were necessary, practical barriers to attendance at groups (e.g. transport, effort, cost), and dislike of group activities.
Implications. Since many older people reject the idea that they are at risk of falling uptake of strength and balance training programmes may be promoted more effectively by maximizing and emphasizing their multiple positive benefits for health and wellbeing. A personal invitation from a health professional to participate is important, and it may also be helpful to provide home-based programmes for those who dislike or find it difficult to attend groups.
Falls, Prevention, Elderly, Refusal to Participate; Patient Compliance
Reducing the incidence of falls among older people is a public health priority. More than a third of people aged over 65 fall each year, and the incidence is higher among the very old and frail (Speechley & Tinetti, 1991). However, serious falls are also incurred by fit and active older people (Allander et al., 1998). Falls are consequently the most common cause of accidental injury among older people, which in turn can lead to permanent loss of function and even death (American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons Panel on Falls Prevention, 2001; Todd et al., 1995). In addition, falling and fear of falling are linked to elevated levels of psychological distress, restriction of activity and independence, and increased social isolation and use of health and social services (Bruce, Devine & Prince, 2002; Cumming, Salkeld, Thomas & Szonyi, 2000; Delbaere, Crombez, Vanderstraeten, Willems & Cambier, 2004; Howland et al., 1998; Murphy, Williams & Gill, 2002; Yardley & Smith, 2003).
There is a growing body of evidence that indicates that falls prevention programmes that include muscle strengthening and balance training exercises can significantly reduce incidence of falls (American Geriatrics Society et al., 2001; Chang et al., 2004; Gillespie et al., 2001; Skelton & Todd, 2004). However, although the efficacy of these programmes has been demonstrated, their effectiveness at reducing falling rates in the population depends crucially on rates of uptake and adherence. Although high rates of participation and adherence have been achieved (Barnett, Smith, Lord, Williams & Baumand, 2003; Tinetti et al., 1994), typically fewer than half of those invited to take part in falls prevention interventions in the
community take up the opportunity (Campbell et al., 1997; Robertson, Devlin, Gardner & Campbell, 2001; Stevens, Holman, Bennett & de Klerk, 2001). Uptake can be as low as 10% (Day et al., 2002; Fabacher et al., 1994), and there is then
further attrition through drop-out and non-adherence. It is therefore important to improve our understanding of how prevention programmes can be designed and presented so as to maximise acceptability and participation among older people.
Since exercises form a key component of successful interventions, the literature on factors motivating older people to undertake generic exercise and vigorous physical activity may prove relevant. Research suggests that most older people prefer to exercise at home, but with some professional guidance (Hillsdon, Thorogood, Anstiss & Morris, 1995; King et al., 2000). Uptake and adherence to interventions to encourage older adults to exercise is associated with a history of being physically active, lower levels of illness, greater self-efficacy (i.e. the belief that one is capable of exercising), and a perception that exercise improves wellbeing (Martin & Sinden, 2001). Barriers to exercising include pain, illness and fear of causing physical harm (Martin & Sinden, 2001; O'Brien Cousins, 2000; Resnick & Spellbring, 2000; Stead, Wimbush, Eadie & Teer, 1997), and low levels of social approval and support for exercising and vigorous physical activity in later life (Brawley, Rejeski & King, 2003; O'Brien Cousins & Janzen, 1998; Stead et al., 1997).
Predictors of uptake and adherence to interventions to reduce falls risk may differ from predictors of generic exercise for several reasons. In falls prevention interventions very specific physical activities are prescribed, often alongside other lifestyle and medical interventions, for the particular purpose of reducing risk of falling. Reported participation rates vary widely in published clinical trials, and this may be because of the content of the interventions (e.g. hazard reduction vs. exercise), the format of the intervention (e.g. group vs. home-based), how participation is encouraged (e.g. community action vs. health professional prescription) or how the population is sampled (e.g. unselected vs. high risk). For example, after having a
home-based assessment 87% of older people followed advice to see their doctor about a medical risk, 71% followed advice to modify their home to reduce hazards, but only 54% increased their activity as recommended, while one in three people followed advice to avoid drinking alcohol (Fabacher et al., 1994). In a multifactorial intervention among older people with cognitive impairment, nearly two-thirds of the sample adhered to strength and balance training exercises, whereas only half modified their medication and 39% reduced home hazards (Shaw et al., 2003). It is therefore difficult to identify what factors may have been responsible for varying rates of uptake and adherence in published interventions since they differ on a number of potentially relevant dimensions.
Qualitative studies carried out in the context of a variety of falls injury prevention programmes can help to explain the reasons for varying rates of participation in different types of interventions. Frail older people interviewed as hospital inpatients were often unaware that any form of exercise could help prevent falls, and viewed exercise as too vigorous an activity for them to undertake (Simpson, Darwin & Marsh, 2003). Conversely, community samples of older adults can be hostile to the idea of falls prevention chiefly because they assume that this will involve restricting activity (Commonwealth Department of Health and Aged Care, 2001; Yardley & Todd, 2005). Home hazard reduction is sometimes seen as intrusive interference into personal choices about lifestyle (Clemson, Cusick & Fozzard, 1999; Simpson et al., 2003), while use of hip protectors is influenced by concerns about comfort, convenience and appearance (Cameron & Quine, 1994).
While these studies have provided useful insights into motivations and concerns regarding participation in falls-related interventions, the context-sensitive nature of qualitative research means that it is problematic to generalise their findings
beyond the particular setting of each study. Moreover, these studies not only investigated a range of different interventions in different populations, but also used different interview questions and methods of analysis, which makes it more difficult to synthesise their findings (McInnes & Askie, 2004). The aim of the present study was therefore to identify factors promoting or inhibiting uptake and adherence that are common to a wide range of contexts, including different geographical and cultural settings, different community-living populations, and different experiences of falls-related interventions.
To achieve this aim we used the same semi-structured interview schedule in each of the diverse contexts we sampled, asking all participants about interventions that included strength and balance training, since this is a crucial component of successful falls prevention. Our interview questions were based on the Theory of Planned Behavior (Ajzen, 1991), a well-validated model that proposes that an individual‟s intentions and behavior are predicted by beliefs about the positive and negative consequences of carrying out the behavior, perceptions of what others think of the behavior, and perceived difficulties associated with carrying out the behavior. We then integrated the data from these diverse settings, using a thematic framework analysis (Ritchie & Spencer, 1994) in order to first identify all the themes emerging from the whole range of contexts, and then determine which contexts each of the themes occurred in. In our data collection and analysis we focused particularly on gaining insights into reasons for non-participation in interventions.
Design and procedure
Semi-structured interviews lasting generally between 30 and 60 minutes were carried out with community-living older adults in Denmark, Germany, Greece, Switzerland, The Netherlands, and the UK. Prior approval for carrying out the interviews was granted by the relevant local ethical committee in each country. The interviews were conducted in participants‟ own languages, and were audio-taped,
transcribed and then translated into English for an integrated analysis.
To maximise the diversity of views sampled, we interviewed people who had taken part in a variety of falls-related interventions (including people who had completed the intervention and who had not adhered to the intervention), people who had refused to take part in an intervention, and people who had not been offered a falls-related intervention. We also explicitly recruited people with a wide age range and living in different circumstances (e.g. in good and poor health, with and without a history of falling, from an urban and rural home, living alone or with family members, and with different levels of education).
The interview schedule we employed was developed collaboratively and then translated into the relevant European languages. The interview schedule was based on the Theory of Planned Behavior (Ajzen, 1991), and covered the following issues: experiences of falls-related interventions; thoughts and feelings about interventions; beliefs about the advantages and disadvantages of interventions; factors that encourage participation in interventions or make participation difficult; and views of other people concerning the interviewee's participation in interventions. People who had previously been offered interventions were asked about their attitudes towards