INJURY

Determinants of uptake of home modifications and exercise to prevent falls in community-dwelling older people Lara A. Harvey,1 Rebecca J. Mitchell,1 Stephen R. Lord,2 Jacqueline C.T. Close3,1

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alls in older people are common; about one in three people aged 65 years and older living in the community in Australia are estimated to fall each year. This proportion increases with age.1 About 40% of older people who experience a fall, do so more than once. Estimates suggest that in New South Wales (NSW) one in 10 falls will require admission to hospital, and a further 20% will require some form of medical treatment.1 Falls are the single most common cause of injury-related hospitalisation among older people in Australia.2 Research has demonstrated that many falls can be prevented through occupational therapy home safety programs and exercise interventions.3 A meta-analysis of six randomised controlled trials has shown that conducting a home safety assessment and implementing the recommended safety modifications reduced fall risk in community-dwelling older people by around 21%.4 Similarly, meta-analysis of the impact of group-based or home-based exercise interventions confirmed that exercise was an effective strategy for preventing falls both in the general population and for high-fall-risk individuals.3 Exercise programs that include a balance component were found to be the most efficacious in terms of reducing fall risk.5 Despite the mounting evidence to support the efficacy of fall prevention interventions and the development of national guidelines6 and state level plans7 to support the implementation of evidence-based fall

Abstract Objective: To examine the age-specific population prevalence and predictors of uptake of home modifications and exercise to prevent falls in the NSW older population. Methods: A total of 5,681 respondents were asked questions on fall prevention activities as part of the 2009 NSW Falls Prevention Survey. Results were weighted to represent the NSW population. Regression analysis was used to determine factors associated with uptake of interventions. Results: Overall, 28.9% of the older population have modified their home, and 35.1% increased exercise to prevent falls. Main predictors of home modification were being aged 85+ (RR 2.04, 95% CI 1.76-2.35) and physiotherapy/occupational therapy intervention (RR 1.57, 95% CI 1.222.01). Main predictors of increasing exercise were physiotherapy/OT intervention (RR 2.12, 95% CI 1.86-2.42) and medical advice (RR 1.45, 95% CI1.32-1.60). Older respondents (RR 0.68, 95% CI 0.57-0.81) and those with fair/poor health (RR 0.86, 95% CI 0.77-0.96) were less likely to report increased exercise. Conclusion: More than one-quarter of the older population of NSW report having made modifications to their home and one-third increased exercise to prevent falls. There was a clear gradient of increased uptake of home modifications with increasing age, with the reverse trend for increased exercise. Implication: Although fall prevention initiatives are having an impact at the population level, targeted strategies for high-risk groups are still required. Key words: falls, falls prevention, injury prevention prevention initiatives, the number and rate of fall-related hospitalisations in Australia continues to increase.8 Studies have shown that the greatest increase in hospitalisation rate occurs in the oldest (85 years and older), and is predominantly driven by an increase in non-fracture injury, most notably traumatic brain and other head injuries.9,10 Research is needed at the population level to determine the extent to which older people in the community engage with fall injury prevention activities, and how this

engagement may vary for different sectors of the older population. This study aimed to determine at a population level the prevalence of uptake of home modifications and self-reported exercise, balance and strength training in the older population in NSW, and to explore the determinants of uptake of these fall prevention initiatives: demographic characteristics, fall experience, personal health characteristics and the influence of health professionals.

1. Falls and Injury Prevention Group, Neuroscience Research Australia, University of New South Wales 2. Falls and Balance Group, Neuroscience Research Australia, University of New South Wales 3. Prince of Wales Clinical School, University of New South Wales Correspondence to: Dr Lara Harvey, Falls and Injury Prevention Group, Neuroscience Research Australia, University of New South Wales, Sydney, NSW 2052; e-mail: [email protected] Submitted: October 2013; Revision requested: January 2014; Accepted: March 2014 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2014; 38:585-90; doi: 10.1111/1753-6405.12243

2014 vol. 38 no. 6

Australian and New Zealand Journal of Public Health © 2014 Public Health Association of Australia

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Harvey et al.

Article

Methods

spoken at home, educational level, type of accommodation, Socio-Economic Indexes for Areas (SEIFA) and Australia Remoteness Index for Area Plus (ARIA+). The SEIFA Index used was the Index of Relative SocioEconomic Disadvantage, which is derived from attributes including low income and educational attainment, high unemployment, unskilled occupations and other aspects that measure disadvantage.1 ARIA+ is a measure of remoteness, which is calculated using the road distances from populated localities to the nearest service centres across Australia.11

The survey Data were obtained from the 2009 NSW Falls Prevention Baseline Survey, conducted by the NSW Ministry of Health. The survey was administered using computer assisted telephone interviewing (CATI) between March and July 2009. The target population for the survey was all NSW residents aged 65 years and over living in households with private telephones; the survey sample comprised about 625 people in each of the (then) eight NSW Area Health Services (AHS). Households within each AHS were contacted using random digit dialling. One person from the household was randomly selected for inclusion in the survey. If the selected respondent did not speak English, the language of choice for conducting the interview was established; and the interview conducted in one of the five most common community languages: Arabic, Chinese (Mandarin/Cantonese), Greek, Italian or Vietnamese. The survey questionnaire and data collection methods are described in detail elsewhere.1 The overall response rate for the survey was 60.8%, with 4.9% of interviews conducted in a language other than English. Proxy respondents, such as family members, were required for 361 participants unable to answer on their own behalf. In total, 5,681 respondents answered questions on home modifications and exercise participation.

Respondents were asked if they had fallen in the past 12 months, how many times had they fallen and how many of these falls had resulted in an injury (anything from bruises to cuts or broken bones or concussion). Fall beliefs were ascertained by “Older people fall and there is nothing that can be done about it” (coded as strongly agree/agree, disagree/strongly disagree); “Are you afraid of falling?” (no, somewhat afraid, fairly/very afraid); and “In general, how would you rate your likelihood of falling?” (High, moderate, low/non-existent). General health was determined by self-reported health status, and doctor-diagnosed physical comorbidities. Measures of functionality assessed were selfreported problems with usual activities and problems with mobility. General health and functionality measures were dichotomised.

Outcome measures Two main outcomes of interest were defined. The outcome variable ‘Home modification/ relocation’ was defined as those respondents who answered either ‘yes’ or ‘relocated to a safer home’ to the question “Have you, or someone else made changes to your home to prevent falls?”. The variable ‘increased exercise’ included respondents who answered that they ‘Got more exercise’, ‘Started to do balance exercises’ or ‘Started to do muscle strengthening exercises’ to the question “Have you made any of the following changes in the last 12 months to prevent falls?”

Covariates Covariates relating to demographic characteristics, fall history, fall beliefs and attitudes, general health and exposure to fall injury prevention initiatives were explored. Demographic characteristics assessed were: sex, age group, living alone, language

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To determine whether respondents had received fall prevention advice from a health professional they were asked whether they had spoken to a health professional in the past 12 months about ways to prevent falls, exercises or physical activities they could do, side effects of medications, or if they had reported a fall. Exposure to information in the media was elicited by asking whether in the last twelve months they recalled hearing or seeing anything in the media about preventing falls in older people or encouraging older people to be more physically active. All survey questions were field tested for reliability and convergent validity prior to use.1

Statistical analysis Data were analysed using SAS version 9.3.12 To allow for calculation of prevalence estimates for the NSW population, the data were weighted to adjust for the probability of selection and for differing non-response rates among males and females and different age groups. The SURVEYFREQ procedure was used to calculate prevalence

estimates and 95% confidence intervals (CIs) for 10-year age groups: 65–74 years, 75–84 years and 85 years and older. Chisquared tests were used to test differences in proportions between groups. Univariate regression analysis was used to generate relative risks and confidence intervals (CIs) for the associations between the main outcome variables and the covariates. This was achieved using the GENMOD procedure, using generalised estimating equations (GEE) with a poisson error distribution and log link function.13 Cases with missing data were excluded. Covariates associated with the outcome variables were tested in the multivariate regression models. Backwards stepwise elimination was used to determine the final models and variables with statistical significance of p

Determinants of uptake of home modifications and exercise to prevent falls in community-dwelling older people.

To examine the age-specific population prevalence and predictors of uptake of home modifications and exercise to prevent falls in the NSW older popula...
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