Life Beyond the Fall: A Literature Review and Comparative Analysis of Two Qualitative and Quantitative Studies on Risks of Falls in Older Adults

By Adam J. Pearson

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  1. Introduction: Hazards of the Fall

Expressing a perennial sentiment common to many older adults, one 94 year-old participant in Yardley et al.’s (2006) qualitative study reported that “Before my fall, I never thought twice about moving around my home. Since I fell and broke my hip, though, things have changed; I feel like I live in a more dangerous place and although I try not to think about it, I’m afraid.”  In the course of their work with older adults, many geriatric social workers and psychologists report hearing stories much like hers (North & Fiske, 2015).  This is no surprise since falls are not only the leading cause of injuries and hospitalizations in older adults, but also one of their most commonly-reported fears (Denkinger et al., 2015; Kamińska et al., 2015).  This essay will delve into the interwoven strands that compose the literature, dynamics, and contextual factors that surround the issue of falls in the older adult population.  To begin, in a brief literature review, the prevalence of the issue as well as the risks, protective factors, and a series of research-supported interventions will be explored.  Thereafter, a qualitative study on older adults’ perceptions of fall prevention programs will be compared and contrasted with a quantitative study on the impacts of one such program on reducing the incidence of falls via a comparative table, after which a brief conclusion will be drawn.

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  1. Factors, Dimensions, and Interventions: A Literature Review

2. A. Statement and Prevalence of the Social Problem: Falls in Older Adults

According to the definition accepted for the purpose of epidemiological research, a fall is an event which results in an older adult coming to rest inadvertently on the ground, floor, or other lower level (Williams et al., 2015).  Global epidemiological statistics from the WHO indicates that every year falls happen to about 30% of adults aged over 65 and living in their own homes worldwide (Stevens et al., 2012; Williams et al., 2015).  In Canada, falls account for 85% of all injury-related hospitalizations among older adults, with an average stay lasting 21 days (Public Health Agency of Canada, 2014).  However, about 50% of those who experience falls opt not to report their falls either to their caregivers or medical staff out of fears of being hospitalized or seen as frail or incompetent (Kamińska et al., 2015; Tromp et al., 2001).

Moreover, older adults who live in public or private residences tend to experience falls more often than those living in their own homes; every year, falls happen to about 45% of people provided with long-term care, out of whom 40% experience multiple falls (Stevens et al., 2012; Tromp et al., 2001; Williams et al., 2015). Among older adults, falls are the leading cause of both fatal and nonfatal injuries (Kamińska et al., 2015). The consequences of fall-related injuries among adults over 65-years are far from trivial; they tend to include long-lasting disability, loss of autonomy, and lower quality of life (Williams et al., 2015).  Even in the absence of physical injuries, falls can have long-term psychological consequences, including depression and fear of falling, which can lead to restrictions in daily activities, declines in health and functioning, and increased risk of future falls (Gale et al., 2016).  Moreover, falls are the main cause of injury-related disability, morbidity and mortality among the geriatric population (Hashmi et al., 2014).

senior woman with home caregiver

  1. B. Risks and Dangers: Risk Factors Affecting Falls in Older Adults

Numerous risk factors have been identified in the literature as potentially predisposing older adults to falls. Many factors, including female gender, advancing age, gait and balance deficits, chronic disease such as Alzheimer’s and other forms of dementia, and medication use have all been associated with a higher risk of falling among older adults (Anderson et al., 2015; Chang & Do, 2015).  Furthermore, gender differences have been observed across several populations, with the majority of studies reporting higher rates of falling in elderly women than in elderly men (Chang & Do, 2015; Public Health Agency of Canada, 2014).  Gender disparities in fall rates might reflect differences in underlying health conditions, as well as lifestyle and behavioral factors (Leavy et al., 2015).  For example, significant reduction in bone mineral density after menopause has been frequently suggested to predispose women to a higher risk of falling and bone fracture (Chang & Do, 2015).  In addition, investigators in several studies noted gender differences in the associations between falls and certain risk factors, such as diabetes, bone and joint diseases, sleep deprivation, and vitamin D deficiency (Chang & Do, 2015; Leavy et al., 2015; Rouzi et al., 2015; Varghese et al., 2017; Zhang et al., 2017).

In addition, some studies have suggested that the mobility devices such as canes, walkers, and wheelchairs may cause as many or more falls as they prevent (Gell et al., 2015).  The situation is complex, however, since individuals who use mobility devices may already have a greater fall risk and the number of falls that mobility device use may prevent is difficult to estimate, but there is evidence of incorrect use of mobility devices by older adults, interference by canes and walkers with balance leading to risk of falls, impedance of lateral compensatory stepping movements with cane and walker use, and higher risk of severe injuries if a fall occurs while using a four-wheeled walker (de Mettellinge and Cambier, 2015; Gell et al., 2015).

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  1. C. Cushions for the Fall: Protective Factors Against Falls for Older Adults

In addition to risk factors, existing literature has revealed a set of protective factors that help mitigate the risk of falls in older adults.  Higher income, low alcohol consumption, high levels of physical activity and fitness, participation in step training, having close supervision from caregivers or health-care providers, being cognitively apt, sleeping well, having a stable gait, having strong balance, not having any loose rugs in one’s home, enjoying frequent friend interaction, having higher levels of education, and having support bars in one’s bathroom and bedroom were all found by various studies to be protective factors (Chang & Do, 2015; Dierking et al., 2016; Nicklett et al., 2017 B.; Okubo et al., 2017). In addition, older adults who are married tend to benefit from greater financial security, social integration, social support, and tangible assistance, all of which are protective factors against falls (Nicklett et al., 2017 A.).

Finally, one interesting study found that history of recent surgery was a significant protective factor against falls in older adults. The authors suggested the protective effect of recent surgery may be due to differences in how a surgical patient’s toileting is managed (Aryee et al., 2017). Toileting is the most common activity linked to injurious, implicated in 43.6% of documented falls (Aryee et al., 2017). Patients who have recently undergone surgery are more likely to toilet while in bed, either using bed pan or urinary catheter.  If in-bed toileting is indeed the reason for less falls after a surgery, health care professionals may be able to optimize toileting practices for at-risk patients, such as those with joint replacements, history of falls or receiving a risky medication as a way to prevent falls in these populations (Aryee et al., 2017).

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  1. D. Prevention and Response: Strategies and Interventions to Reduce Falls in Older Adults

Lastly, a number of prevention and intervention strategies have been proposed in the literature in order to respond to the serious risks posed by falls for older adults. In their fascinating meta-analysis, Guo et al. (2014) found that single exercise interventions can significantly reduce numbers of falls among older adults with and without cognitive impairment in institutional or non-institutional settings. In addition, they found that vitamin D and calcium supplementation, home visits, and environment modification can reduce the risk of falls among older adults in non-institutional settings (Guo et al., 2014). Exercise-related multiple interventions and multifactorial interventions may only be effective for preventing falls in older adults with cognitive impairments, since they found no significant differences in older adults without cognitive impairments (Guo et al., 2014). This finding was supported by Voukelatos et al.’s (2015) randomized controlled trial assessing the impacts of a multifactorial walking-based intervention on incidence of falls for older adults without cognitive impairments, who also did not find a significant decrease in falls as a result of the treatment. Encouragingly, however, a study by Okubo et al. (2017), which featured a systematic review and meta-analysis, revealed that step training improves reaction time, gait, and balance and reduces falls in older adults.

In addition, Guo et al.’s (2014) meta-analysis found that systematic fall prevention programs specifically designed for older adults without cognitive impairments were well-documented as being able to reduce falls.  They did not, however, find the same association between fall prevention programs and people with significant cognitive impairments, likely because the participants may not have remembered what they had learned in the programs after the training was completed (Guo et al., 2014).  Moreover, they also found that community-based fall prevention programs had a significant effect on lowering fall rates, while institution-based fall prevention programs did not (Guo et al., 2014).  Jung et al. (2009) found the same.

Finally, Gillespie et al. (2012) assessed the effects of interventions on reducing falls incidence in community-dwelling older adults and showed that intervention strategies such as multiple-component exercise interventions effectively reduce fall rate and risk of falling. In addition, they found that home-based exercises including more than one exercise category also achieved statistically significant reduction in fall rate and risk of falling (Gillespie et al., 2012). They also found that modifying home hazards to remove potential risks of falls (e.g. not having non-slip mats in the showers, not having protective bars, or having loose rugs in the home) can lower the risk and rates of falls in older adults, a finding that was substantiated by both Guo et al. (2014) and Jung et al. (2009).

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  1. Comparative Table: A Qualitative and Quantitative Study on Risks of Falls in Older Adults
Study Citation Information Yardley, L., Donovan-Hall, M., Francis, K., & Todd, C. (2006). Older people’s views of advice about falls prevention: a qualitative study. Health education research21(4), 508-517. Voukelatos, A., Merom, D., Sherrington, C., Rissel, C., Cumming, R. G., & Lord, S. R. (2015). The impact of a home-based walking program on falls in older people: the Easy Steps randomized controlled trial. Age and ageing44(3), 377-383.
Summary:
Rationale and Objectives
 The authors aimed to understand how older adults perceive fall prevention advice and how best to design communications that will encourage older adults to take action to prevent falls (Yardley et al., 2006).

Focus groups and interviews were carried out with 66 people aged 61–94 years who were recruited from a variety of settings, using fall prevention messages to stimulate discussion (Yardley et al., 2006).

The authors used a thematic analysis via constant comparison within a grounded theory methodology (GTM) approach to extract themes from the coded interviews from which they aimed to explore (Yardley et al., 2006).

 

 Although previous research had established that walking is the most popular form of exercise in older people, it was unclear whether walking could reduce falls or whether a specific walking program could result in a reduced incidence of falls in older adults.  As a result, 386 physically inactive older adults aged 65+ were randomly placed into an intervention or control group. The intervention group received a self-paced, 48-week walking program that involved three mailed printed manuals and telephone coaching. The control group received no program. Both groups were asked to monitor falls on monthly fall calendars over a 48-week period. They were also asked to self-report quality of life, falls efficacy, and exercise and walking levels. In addition, in a sub-sample (n=178) of participants, mobility, leg strength, and choice stepping reaction time were measured at four points within the trial: baseline, 12, 24, and 48 weeks (Voukelatos et al., 2015).
Variables: – Self-reported perceptions of fall-prevention advice designed for older adults.

– During analysis, themes and subcategories were coded as:
◙ Previous experience of falls prevention advice:
– Denied receiving advice about falls prevention.
– Mentioned advice relevant to reducing risk (e.g. slow down, take care, home modifications).
◙ Positive statements about advice:
– The advice is helpful (e.g. it is good to acknowledge and talk about the problem, new tips are given, useful reminder to exercise).
◙ Qualifications:
– The advice is appreciated just as information, will not be acted on.
– The advice is useful for others (e.g. older, fallers, disabled, fearful).
– The advice is not suitable for everyone, and needs to be modified to suit individual circumstances.
◙ Negative statements about advice:
– The advice is common sense, risks are already known from experience.
– The advice is authoritarian and patronizing in tone (ie. ageist).
– The advice makes older people responsible for preventing falls, but falls are inevitable, accidents due to chance.
– The advice can make you feel anxious, depressed.
◙ Recommendations for improving advice:
– Promote and support exercise as constructive means of falls prevention.
– Incorporate into general health promotion activities, ensure enjoyable.
– Frame advice as tentative, positive suggestions and give explanations/rationale (Yardley et al., 2006).

IV: Receiving the 48-Week Walking Program or not receiving the Walking Program

Primary DV: Frequency of falls (fall rate) in a 48-week period as measured by monthly fall calendars filled out by participants.

Secondary DV1: Self-reported quality of life

Secondary DV2: Self-reported falls efficacy

 

Secondary DV3: Self-reported exercise and walking levels

And in sub-sample (n = 178):
Secondary DV4: Mobility

Secondary DV5: Leg strength

 

Secondary DV1: Choice stepping reaction time

Summary:
Major Findings
The authors’ analysis suggested that the participants tended to view “fall prevention” as meaning hazard reduction, use of aids for support, and placing restrictions on their activities. 65 out of 66 participants described being unaware that risk of falls could be reduced through exercises to improve strength and balance.

The participants tended to interpret fall prevention advice as useful in principle or for others, but not personally relevant to them. The interviewees suggested that they did not find the advice meaningful when they interpreted it as “common sense,” necessary for older or more disabled individuals, and potentially patronizing, distressing, and ageist (Yardley et al., 2006).

The researchers’ primary interpretation of the contribution of their research was that it revealed that older adults tend to reject fall prevention advice, not out of ignorance of their risk of falling, but because they see it as threatening their autonomy and identity.

Therefore, they suggest that messages that focus on the positive benefits of improving balance and strength may be more acceptable to older adults since they focus on enhancing and empowering their identity and autonomy (Yardley et al., 2006).

Surprisingly, the researchers found that there was no difference in fall rates between the intervention and control groups in the follow-up period (IRR=0.88, 95% CI: 0.60–1.29) (Voukelatos et al., 2015).

By the end of the study, however, intervention group participants spent significantly more time exercising in general, and specifically walking for exercise (median 1.69 versus 0.75 h/week, P<0.001).

The researchers’ interpretation of their findings in light of other research was that a walking programme is ineffective in preventing falls and that recommending walking as a fall prevention strategy for older people is questionable advice.

The post hoc sub-group analysis indicated that the intervention showed trends for contrasting effects for those aged 65–74 years (IRR=0.70; 95% CI: 0.43–1.12, P=0.14), and those aged 75 year and over (IRR=1.19; 95% CI: 0.61– 2.33, P=0.61) but no significant interaction effect was evident (P=0.19). There were also no significant differences between the two age groups in the impact of the intervention on the proportion of fallers or multiple fallers

 

On the positive side, however, the researchers added that walking, increases physical activity levels in previously inactive older adults (Voukelatos et al., 2015).

Design:
Type
Qualitative, Exploratory Quantitative, Explanatory
Design:
Subtype
Focus-group and group and individual-based interviewing applying a grounded theory methodology (GTM) with constant comparison Experimental – a parallel-group Randomized Controlled Trial (RCT)
Design:
Timeframe
The 60-90 minute focus groups and one-on-one interviews were conducted and completed in 2005-2006. While each participant’s trial lasted 48 weeks, the study began in August 2009 and was completed in October 2012.
Sampling:
Sample Size (n)
 

n = 66

 

n = 386

Intervention Group:
n = 192

Control Group:
n = 193

Sub-group of Intervention and Control group participants who received physical performance testing due to living within 50 km of the testing center:
n = 178

 

Sampling:
Participants
– A total of 66 people aged between 61 and 94 years were recruited from sheltered accommodation (31) (i.e. housing for independently living older people that provides varying degrees of support), church groups (12), retirement and senior citizen clubs (11), leisure centres (9) and the local community (3).

– The researchers sought community-dwelling participants from diverse settings in order to ensure representation of healthy and frail men and women with a wide age range and living in very different circumstances. Consequently, they also drew on sheltered accommodation provision for people with differing health and socio-economic profiles (e.g. largely independent versus closely monitored, means-tested charity provision versus high-cost privately purchased provision).

Participants were recruited from community-dwelling people aged 65 years and over from the greater Sydney region, Australia. The average age of study participants was 73.2 years (range: 65–90) and most participants were female (74%, n=285).

–          The groups were balanced across demographic, socioeconomic and outcome measure variables to ensure greater representativeness and generalizability (Voukelatos et al., 2015).

Sampling:
Inclusion Criteria
– Adults aged 60+ were included to participate in the study from diverse living conditions, whether physically active or inactive, and clients of diverse ranges of ability (e.g. clients who could not leave their homes were identified one-on-one using the same questions and materials as in the focus groups). Otherwise, the inclusion criteria were intentionally broad to recruit the largest range of participants for this exploratory qualitative study. – To be eligible for participation in the study, people had to be: inactive (i.e. <120 min of exercise per week); mobile (i.e. able to walk at least 50 m with minimal aid); and, able to communicate in English.
Sampling:
Exclusion Criteria
– Adults aged less than 60 years old were excluded from the study. Otherwise, due to the exploratory nature of the study, no other strict controls on exclusion criteria were used by the researchers (Yardley et al., 2006). – People were excluded if they: had a medical condition precluding participation in the study (e.g. dementia, Parkinson’s disease, stroke, debilitating arthritis, severe vision impairment); or, were participating in another research study (Voukelatos et al., 2015).
Sampling:
Recruiting Method
– The researchers used a combination of availability / convenience sampling and nonprobability quasi-quota sampling.

 

– The participants were recruited because they were easy to access from the settings that the researchers contacted.

 

–          At the same time, the researchers made a deliberate effort to recruit participants from settings in a quasi-quota nonprobability sampling method that allowed them to include participants from (1) sheltered accommodations, (2) church groups, (3) retirement and senior citizen clubs, (4) leisure centers, and (5) the local community.

–          Recruiting was done using flyers and oral advertisements (Yardley et al., 2006).

– The researchers partly used availability / convenience nonprobability sampling to develop an initial sample which they then sifted through their inclusion and exclusion criteria and randomly assigned the remaining included participants to the Control and Experimental groups.  However, they also attempted to use some random sampling from the Australian Electoral Roll to the extent that they were able to do so and to which participants were willing to participate.
– Participants were recruited from community-dwelling people aged 65 years and over from the greater Sydney region, Australia. Recruitment methods included paid advertisements and editorials in community newspapers, personal and professional referrals and sampling from the Australian electoral roll.
– Participants were selected for the physical performance testing on the basis of proximity to the study centre (i.e. they lived 50 km away from it and so could access it easily) – findings from these participants are not likely to be generalizable since people who live in the same are likely to have more similar characteristics to one another than they do to people from the same population who live farther away.
Measurement:
Tools used
– The researchers used a set of questions they developed themselves and audiotaped their interviews for later coding and interpretation.

– No standardized or previously validated / reliable tools were used.

– A ‘general health status questionnaire’ was administered at baseline and at the end of the trial. The questionnaire gathered demographic information and used validated sub-questionnaires to gather information on the secondary dependent variables (the Australian Quality of Life questionnaire (AQoL) for quality of life measures, the Falls Efficacy Scale-International (FES-I) for falls efficacy measures, and the Incidental and Planned Exercise Questionnaire (IPEQ) for recording average exercise walking levels (Voukelatos et al., 2015).

– Falls were defined as “unexpected events in which participants came to rest on the ground, floor, or lower level” and were recorded through monthly fall calendars
– Physical performance measures for the subgroup who lived within 50 km of the testing centre were gathered using a portable electronic dynamometer, and mobility was assessed using the short physical performance battery (SPPB), a standardized measure of lower extremity physical performance.
– The 48-week intervention given to the intervention group was grounded in five constructs derived social cognitive theory with construct validity and split into three stages focusing on frequency and duration of walks (12 weeks duration), walking intensity (12 weeks) and finally maintaining the level of walking achieved in the previous stages (24 weeks). Manuals for each stage of the program were mailed to participants, who also received telephone coaching at the beginning of and halfway through each stage.

Measurement:
Procedure
– Prior approval for the study was obtained from the University of Southampton School of Psychology Ethics Committee.

– Focus group sizes varied between three and six participants, and were carried out at the centres from where participants were recruited.

– During the focus groups, one researcher led the discussion, while another researcher attended to practical matters (e.g. completion of consent forms) and recorded the order of speakers to assist later transcription.
– During the focus groups, which lasted 60 to 90 minutes, the researchers explored previous experiences of communications regarding falling (e.g. in the media, from health professionals, among family and friends, other communications and interactions).
– In addition, in order to stimulate further discussion, examples of health promotion messages about falling prevention were summarized from existing materials and presented on cards in large print. It’s worth noting that the original materials were presented in the early focus groups, but caused reading difficulties that disrupted conversation and so were later replaced with larger-print examples in later interviews.

– Interviews were also carried out in participants’ homes. The format of both interviews and focus groups was that firstly the researcher reiterated the aims and ground rules of the study (e.g. confidentiality,

freedom of expression) and the participants completed consent forms.

-After the discussions, participants completed forms giving personal details and were offered a small gift as a token of appreciation for their participation.

– All focus groups and interviews were audiotaped and fully transcribed.

– Resulting interviews were thematically analyzed and coded using grounded theory-methodology’s constant comparison technique to examine the circumstances under which particular opinions were expressed.

– The researchers also explicitly searched for disconfirming data to overcome the tendency for confirmation bias (Yardley et al., 2006).

– Baseline assessment questionnaires were administered to participants as mentioned in “Tools used” above to assess participant histories prior to randomization.

– Participants were then randomised into the intervention group or control group by a research assistant using sequentially numbered sealed opaque envelopes.
– The randomization scheme used randomized permuted blocks of size 6 and 4 by the chief investigator, who had no contact with participants and was not involved with gathering data.
– Neither research assistants nor participants were blinded to group allocation.
– Falls were recorded through monthly fall calendars for both the control and intervention group participants; when participants reported a fall, they were contacted by telephone to confirm the fall and document any related injuries.
– Participants in the intervention group received three program manuals and telephone-based coaching to guide them through the three phases of the 48-week walking program (12 weeks, 12 weeks, and 24 weeks long respectively).
– Participants in the control group were mailed information about health issues (nutrition, sleeping habits and mental health) at the same time the intervention group received their walking manuals. Control group participants were contacted via telephone at the same points in the study as intervention group participants to discuss the health information sent. At the end of the study control group participants were sent the walking programme materials so that they did not miss out on any of what the intervention group learned.

– Both control group and intervention group participants were retested with the same Questionnaire used in the baseline phase at the end of the trial.

– Statistical analyses were conducted via binomial regression, relative risk statistics, and post hoc tests on fall data were conducted on sub-groups defined as: participants aged 65–74 years and those aged 75+ years. Secondary outcome variables with nominal data were analysed using chi-squared analysis. Continuous physical performance scores were compared by forced entry multiple linear regression analysis, with baseline scores and experimental group included as independent variables in the models. Finally, a Cohen’s D score was used to evaluate the standardized effect size for the impact of the walking programme by using responses to the exercise walking component of the IPEQ (Voukelatos et al., 2015).

Evaluation:
Strengths:
– The sample size of n = 66 is fairly high for a qualitative study, which allows for a greater diversity of opinions and for the themes coded by the researchers to be substantiated with reference to a larger number of interviews

– The design is congruent with other qualitative research done on the same topic and appropriate for the research question oriented to assessing older adults’ perceptions of fall-prevention literature.
– The researchers wisely controlled for differences in what participants tend to disclose in group settings versus in 1-on-1 settings and compensated for this tendency by testing people in both social contexts to collect a wider range of data unbiased by interviewing context.

– The researchers were able to gather a fascinating range of perceptions of older adults in relation to fall prevention materials due to the open-endedness of their questions combined with the depth of follow-up questions that the researchers asked to dive deeper into participant points of view. In addition, their use of existing fall prevention materials as a springboard for discussion helped ensure that the conversations did not remain mired in generalities and abstract opinions, but were also grounded in responses to specific and concrete examples of fall prevention media.
– The study uncovered a revealing combination of widespread acknowledgement of the potential usefulness of falls prevention advice in principle, together with frequent rejection of that advice by the participants as unnecessary, irrelevant or inappropriate for them, a revelatory finding that helps to combat health professionals’ ageist bias towards assuming that older adults predominantly reject fall prevention advice out of ignorance or cognitive impairment (Yardley et al., 2006).

– The fact that the researchers attempted to recruit participants from multiple living situations makes their sample more reflective of the larger population than it would have been if they drew all of their participants from the same living setting. Similarly, the manner in which the researchers attempted to sample as systematically as they could in order to take into account variations across multiple health conditions is also a strength of the study.
–  The way in which the researchers intentionally sought out disconfirming data (e.g. instances where receiving falls advice were mentioned or where unequivocally enthusiastic views of falls prevention advice were offered) was a strength. In so doing, they compensated for the natural human tendency towards confirmation bias.

– The sample size of n = 386 is high enough to have sufficient statistical power to draw meaningful conclusions although it was lower than what the researchers had planned to aim for (i.e. n = 464 in order to be able to aim for a fall rate of 33%, a significance level of 0.05 and 80% power).
– The parallel groups randomized controlled trial approach is appropriate for attempting to gather explanatory data in relation to the variables as defined by the researchers (see “Variables” section above).
– In addition, the fact that the researchers used multiple secondary variables as ways of evaluating and operationalized the “efficiency” of the program they used in reducing incidence of falls is a strength of their study since it captures more dimensions of the construct (Engel & Schutt, 2013).
– Moreover, the groups were balanced across demographic, socioeconomic and outcome measure variables, which is a strength for generalizability of findings.
– The researchers attempted to use some random sampling from the Australian Electoral Roll, which is a strength, although they had limited success in this way since participation of randomly selected individuals was contingent upon their interest, willingness, ability, and consent to participate.
– The Australian Quality of Life (aQoL) questionnaire has been shown to be sensitive and valid for measuring health-related quality of life in community-dwelling older adults, which was appropriate to the community-dwelling participants in the study (Richardson et al., 2004).
– The CRST assessment via the portable electronic dynamometer has been shown to have good reliability and external validity with respect to fall prediction (Voukelatos et al., 2015).
– The SPPB is a standardized measure of lower extremity physical performance that has been evaluated to have good reliability and validity (Voukelatos et al., 2015).
– Even though the researchers removed blinding after assessment to groups, the use of these objective measures helps to minimize the impact of potential experimenter bias.
– The walking program was tailored to an inactive starting level, which is relevant to the participants who were all coded as “inactive” as part of the inclusion criteria. In addition, the program was g effectively grounded in five constructs derived from social cognitive theory: knowledge, behavioural skills, goal-directed behaviour, outcome expectations and reinforcement.
– The Falls Efficacy Scale-International (FES-I) has been assessed as having excellent reliability and construct validity (Richardson et al., 2004).
– The Incidental and Planned Exercise Questionnaire (IPEQ) was specifically designed for older adults and has been evaluated to have good reliability and validity (Delbaere et al., 2010).
– The study offered helpful information on the effectiveness of one approach to a fall prevention walking program for older adults.
Evaluation:
Limitations:
– Because participants were generally sampled through availability or convenience sampling, the resulting sample cannot be expected to be representative of the larger population; therefore, its findings cannot be generalized to the larger population with any degree of confidence.
– The quasi-quotas from different settings that the researchers chose are not proportional to the larger structure of the overall population; for instance, most of the people included in the study lived in sheltered facilities and the independent living older adults who still live in their homes in the community was under-sampled. This fact creates additional constraints on representativeness and generalizability.
– While the study’s qualitative model is useful to reveal individuals’ views of health promotion messages, quantitative methods would be needed to assess the prevalence of these views and their relative influence on individuals’ behaviour (i.e. explanatory research).
– The researchers did not explain the rationale by which their constructed their questionnaire, nor share any details about the extent to which they diverged from their pre-chosen questions into extemporaneous lines of questioning in different focus group and intervention sessions. As a result, it is not possible to determine how standardized the sets of questions asked of different participants really were. If the interviews were quite different in some cases, this may have skewed the results and the ability of researchers to compare the findings across participants.
– The study did not use any validated or reliable questionnaires.
– As mentioned above, the sample size was not as high as the researchers had intended in order to reach their goals for statistical power for the study.
– Envelope-based assignment randomization is not a validated approach and is subject to inconsistency in the shuffling of the envelopes; researchers could have used a different system such as randomized number assignment done by a computer program.Neither research assistants nor participants were blinded to group allocation. This could have resulted in experimenter bias.
– There were differential attrition rates in the intervention vs. control group. Since three times as many intervention group participants (n=18) withdrew from the study for health reasons compared with the control group (n=6) remaining participants in the intervention group may have had better health than the control group. This difference may have led the researchers to overestimate the positive effects of the intervention.
– The age-group sub-group analysis was conducted post hoc, and the study did not have significant statistical power to conduct such an analysis, as the experimenters themselves admitted in the Discussion.
– Although the participants did include some attempt at random sampling from the Australian Electoral Roll, they had to mainly rely upon convenience / availability sampling for practical purposes, which does not allow for a confident assertion that the sample is entirely representative of the larger population and could, therefore, place some limitations on generalizability.
– Participants were selected for the physical performance testing on the basis of proximity to the study centre (i.e. they lived 50 km away from it and so could access it easily) – findings from these participants are not likely to be generalizable since people who live in the same are likely to have more similar characteristics to one another than they do to people from the same population who live farther away.
– Since only English-speakers were sampled, potential cultural differences in perceptions amongst non-English speaking populations were not taken into account.
– Since only inactive participants were tested for the purposes of the study, the results of the program intervention for older adults coded as “active” was not assessed. A parallel control and intervention group for this population could have been included to test the walking program intervention more extensively.
– In addition, the generalizability of the results of the study beyond the Australian context is questionable; the study would need to be replicated.
– Since the walking program was delivered through printed manuals and not through in-person instruction, there could have been differential rates of understanding and absorption of the materials. In addition, participants did not control for whether or not participants actually read the materials at all since they were not systematically quizzed on the material during the phone interviews. This is a flaw and potentially serious limitation of the study in terms of generalizability and validity. Great variance in reading rates and understanding rates of the intervention manuals is possible.

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  1. Falling Forward into Progress: Concluding Words on an Ongoing Issue

In conclusion, falls are an enduring challenge that older adults will continue to face.  However, with the advent of novel intervention methods and the ongoing development of scientific understanding, social workers will increasingly find themselves in a position to be of better service to their clients as they intervene with individuals and families around this significant issue. In so doing, both social workers and their clients may find themselves increasingly progressing towards preventing the occurrence of falls and rehabilitating their adverse effects when they do occur.

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