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Aust. J. Rural Health (2014) 22, 146–155
Original Research Falls in rural and remote community dwelling older adults: A review of the literature Jackie Boehm, MPH, Richard C. Franklin, PhD and Jemma C. King, MPH School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, Queensland, Australia
Abstract Objective: Falls in older adults represent a significant challenge in Australia; however, the focus is often on urban-dwelling older adults. The aim of this review was to explore the literature on falls epidemiology and falls prevention interventions (FPI). Design: A literature review was conducted searching Medline, Scopus, Social Sciences Citation Index, Google Scholar, Google and the Australian Institute of Health and Welfare publication catalogue. Setting: Rural and remote Australia. Participants: Rural and remote community dwelling Australians aged 50 years and older. Intervention: Literature review. Main outcome measures: Falls epidemiology and effective falls prevention interventions. Results: Twenty references were identified: 14 related to falls epidemiology and 7 to FPI. No significant differences were found between rural, remote and major cities residents in relation to falls hospitalisation, falls mortality or fall-related injuries sustained. There are a wide assortment of health professionals and non-health professionals who are involved in providing FPI in rural and remote Australia. However, there was limited information on the effectiveness of these interventions in influencing falls outcomes. Conclusion: Few studies explored falls and their prevention in rural and remote Australia. The limited literature on the topic suggests that a change in focus to one that utilises existing services and resources will be required to create sustainable outcomes. Four areas are proposed for concentrated effort to reduce the impact of fall-related injury in rural and remote Australia: integration and collaboration among health professionals, promotion of physical activity across the lifespan,
community involvement and ownership of interventions, and evaluation and publication of findings. KEY WORDS: community programme, elderly, falls prevention, intervention, safety, senior.
Introduction
Accepted for publication 27 March 2014.
The relationship between place of residence and health is complex.1 There is a higher proportion of older adults in rural and remote Australia who have poorer health than their urban counterparts.2 Challenges stemming from an ageing population are extensive and have the potential to overwhelm already stretched health services, communities and individuals.2,3 Approximately one third of adults aged 65 years and older sustain a fall each year.4 Falls outcomes range from minor discomfort to death and place a significant burden on the health system.5 Falls represent a significant injury for older adults but are amendable to prevention by addressing the risk factors.6 Risk factors include impairments in balance, gait, strength, reaction time and vision; using multiple medications; depression; concern about falling; inappropriate footwear; and environmental hazards.4,5 Besides physical injury from a fall, outcomes include decreased confidence, quality of life, independence and physical activity.7 Some older women view death as preferable to the loss of independence, specifically entry into a nursing home following an injurious fall.8 This feeling is exaggerated in rural and remote older adults as entering a nursing home means, potentially leaving their community due to the absence of local services.2,9 The needs of the ageing rural and remote population are not being adequately addressed.10 This requires an improved research system that provides evidence-based policy and care10 and an understanding of the current breadth and depth of falls research. The aim of this review was to explore the literature on falls epidemiology and falls prevention interventions (FPI) relevant to rural and remote community-dwelling Australians aged 50 years and older.
© 2014 National Rural Health Alliance Inc.
doi: 10.1111/ajr.12114
Correspondence: Associate Professor Richard Franklin, James Cook University, Townsville, Queensland, 4811, Australia. Email: [email protected]
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What is already known on this subject: • The likelihood of having a fall requiring hospitalisation increases with age. • Older people represent a higher proportion of the population in rural and remote areas compared with urban areas and have poorer health. • Falls prevention interventions can assist in reducing the severity and frequency of falls.
What this study adds: • A review of falls epidemiology reveals that falls’ rates in rural and remote older Australians are similar to elsewhere in Australia. • There are few falls prevention interventions evaluated that have targeted rural and remote older Australians. • The sustainability of falls prevention work, particularly in the resource poor rural and remote environment, necessitates concentrated and collaborative ventures.
Methods Articles on falls in rural and remote Australia were identified searching the following databases: Medline, Scopus, Social Sciences Citation Index, Google Scholar, Google and the Australian Institute of Health and Welfare (AIHW) publications catalogue. Searches were conducted for publications pre-2013 and were undertaken in March 2013. Search strategies used differed based on the database functionality (Table 1). While the number of results obtained from Google was extensive, only the first 30 pages were reviewed as no new relevant publications were being found at this point. Literature from the searches was included if it met the following criteria: individuals were aged 50 years or older, were community dwelling, had sustained a fall or were involved in a FPI, place of residence was identified as being rural or remote and the article or report was published prior to 2013 (Table 2). The initial search identified 3702 publications. The exclusion criteria applied were: non-Australian sample, rural or remote populations were not specifically discussed, participants were younger than 50 years of age,
TABLE 1:
the sample included individuals with a specific condition (e.g. fall risks for individuals with Alzheimer’s) and the focus of the research was not specific to falling. Following application of the exclusion criteria, 20 references remained and were used for this review (Fig. 1).
Results There were 20 references which met the inclusion criteria: 14 related to falls epidemiology (Table 3) and 7 related to FPI (Table 4).
Falls epidemiology Rates of falls resulting in hospitalisation, injury or medical attention AIHW have published six reports examining the rate of falls hospitalisations in older adults from 2001 to 2009.4,21–25 Rates of older adults presenting to hospitals with fall-related injuries were similar for all remoteness zones, except very remote which were below the
Searches conducted and terms used
Database
Terms
Medline
1.
Scopus
1.
Social Sciences Citation Index
1.
Google and Google Scholar
1.
AIHW Publication Catalogue
1. 2. 3.
(fall OR falls) AND (rural OR remote) AND (elderly OR elder OR senior OR old OR older) AND community AND (Australia OR Australian) fall* AND (rural OR remote) AND (elder* OR senior* OR old*) AND community AND Australia* fall* AND (rural OR remote) AND (elder* OR senior* OR old*) AND community AND Australia* fall* AND (rural OR remote) AND (elder* OR senior* OR old*) AND community AND Australia* Rural Health Publications Injury Ageing and Aged Care
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148 TABLE 2:
J. BOEHM ET AL.
Terminology used: definitions and justifications of their use
Term
Definition and justification
Older people/person
An individual aged 50 years or older. The classification of an older adult commonly includes anyone aged 65 years and older. However, it is known physiological deterioration occurs from 40 years of age11,12 and physical inactivity increases with age (which are related to falls risk factors).11,12 Therefore this lowered inclusion age enables examination of a more relevant audience for falls prevention activities. This approach has previously been used in research.13 Also this enables any FPI targeting Aboriginal and Torres Strait Islanders to be included, who on average have a shorter life expectancy and experience falls related morbidity and mortality at a younger age.14–16 People living in their home and not an aged care facility. ‘. . . an event which results in a person coming to rest inadvertently on the ground or floor or other lower level’.17 Activity/programmes to assist in reducing falls and effects from falls.
Community dwelling Fall Falls prevention interventions (FPI) Rural and remote
By the article self-identifying (i.e. using one or both of the terms ‘rural’ or ‘remote’ either directly (in the article title, abstract, key words or journal title and then identify their study was in a rural or remote location) or indirectly (if another article linked to the article had self-identified as rural and remote). After reviewing the literature it was deemed applying a geographical classification system would be difficult as: (i) literature identified in the search did not provide sufficient information in their methods about the location; and (ii) might not capture relevant literature due to changes in classification systems.18–20 This method of accepting definitions of rural and remote identified in the literature has previously been used by other researchers.20
FIGURE 1: Research rural and remote falls.
Articles Found (n = 3702)
flowchart
for
Exclusion of Articles through review of title and abstract and removal of duplicates (n = 3621) Potentially Eligible Articles after title and abstract screening (n = 81)
Exclusion of Articles through full text reading (n = 61)
Articles Reviewed Relevant to Falls in Rural and Remote Older Australians (n = 20)
Falls Epidemiology Literature (n = 14)
Falls Prevention Interventions Literature (n = 7)
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FALLS IN RURAL AND REMOTE OLDER AUSTRALIANS
national average.4 There was a significant increase in major city and inner regional rates and a non-statistical increase in remote area rates. Outer regional rates remained steady and very remote rates decreased (not statistically significant).4 A 6-year longitudinal study (1996–2002) of women aged 70–75 years found no significant differences between falls rates, injury rates and the need for medical attention between urban, rural and remote areas.27 However, another study found that fall-related female fatality rates in rural and remote older adults were double and hospitalisations rates were higher compared with urban areas.32 When fatalities were explored by age-specific falls death rates and remoteness classification, it was found older adults in remote and very remote areas had a mortality rate lower than expected (not statistically significant) when compared with the same age group in major cities.14 While most literature noted no difference in rates by rurality, some localised variance was observed. A study examining fall events over a 6-month period in urban and rural areas in Queensland and New South Wales for those aged 70 years and older found the highest prevalence of reported falls in rural New South Wales and the lowest in rural Queensland; however, these differences were not significant.30
Injury type There were no significant differences in the type of injury sustained from a fall for women in urban, rural and remote areas in relation to serious injuries, major personal injury and broken bones.29
Causes of falls Tripping was the most common cause of a fall in the community.26 Commonly identified home hazards, which increased falls risk in rural Victorian homes, were home access (slippery paths, uneven surfaces at gates and lack of rails near steps), movement around the home (poor lighting, cluttered walkways and loose mats) and the bathroom (slippery floors, no rails and high shower hobs).31 A higher number of home hazards were associated with those who had previously had a fall.31 Specific environmental home hazards relevant to the rural setting differ to those in regional or metropolitan settings and include having a raised veranda, larger houses, outdoor toilet and a greater variety of ground surfaces.31
Self-perceived risk of falling One study compared differences by region, Northern Rivers, New South Wales to Wide Bay, Queensland, in © 2014 National Rural Health Alliance Inc.
relation to self-perceived risk of falling.28 People from Northern Rivers reported falls prevention was a high priority and they were more likely to believe falls are preventable.28 Overall, most of the sample perceived their falls risk as low (60%); however, men and young participants were more likely than women and older participants to perceive their risk of falling as low.28
Falls prevention intervention literature Health professionals (e.g. pharmacists, nurses, general practitioners (GP), occupational therapists, physiotherapists and health promotion officers) and non-health professionals (e.g. council employees) play a role in falls prevention in rural and remote areas33–35,38 (Table 5). Articles which evaluated the Stay on Your Feet (SOYF) programme33,34,38 found that common FPI in rural settings included: medication checks by GP (75%), assessment and referral by community health staff (75%) and pharmacist advice to dispose of out dated medication (72%).33 Less common FPI were: pharmacist advice on preventing falls, referrals from pharmacists and GP to allied health professionals and training of pharmacy staff on providing falls-related advice34,38 (Table 5). In rural and remote settings, nurses play a role in the identification and management of risks related to their clients sustaining a fall.35 Lack of resources and models of service delivery were identified as impeding their ability to implement FPI.35
Outcome of FPI Four studies described outcomes from FPI specifically for older adults.28,33,36,37 Of these, three studies found changes in awareness and knowledge in relation to falls risk factors and prevention;28,36,37 two studies found behaviour changes relating to identified falls risk factors including walking daily (although the size of this change is not articulated),33 and footwear worn;37 and one study reported unintended changes of increased medication use and decreases in physical activity.36 Only one article reported on changes in falls incidence with significant differences in fall-related hospital admissions and a non-significant but lower incidence in self-reported falls among the intervention group.37
Discussion Falls in community-dwelling older people in rural and remote Australia is an important but understudied issue. There was a paucity of literature (20 references), particularly in relation to fall fatalities by remoteness.14,32 This review found no statistically significant differences in falls injury rates between urban, rural and
Bradley4
Bradley25
Report – Hospitalised fall injury cases Report – Hospitalised fall injury cases Report – Hospitalised fall injury cases
Bradley24
78 606
83 490
80 364
Report – Hospital separations due to injury
Bradley and Harrison22
Report – Hospitalised fall injury cases
Age Standardised rate for 65+: 2295.9 per 100 000 population 74 748
Report – Hospitalised fall injury cases
Bradley and Harrison21
Bradley and Pointer23
132 322 deaths annually (between 2002–2004) 60 497
Report – Mortality in Rural, Remote and Regional Australia
Australia Institute of Health and Welfare14
Total Participants/ Cases
70%
70%
70%
71%
Women 75+ higher rates of falls than men
72%
46%
Female Participants/ Cases
65+
65+
65+
65+
65+
65+
All age groups
Age (years)
Older rural and remote participants
Study design
Falls epidemiology literature
Article and reference
TABLE 3:
Very remote: highest for 65–75 age group but lowest rates for people 80+ for all remoteness zones Major cities higher and very remote lower than national rate Rates higher in remote and major cities than the national rate Hospitalised falls and hip fractures for very remote locations were below national rates
Similar rates across remoteness zones with the exception of people, especially women living in very remote locations which were below average. Suggested this is due to very low rate of hospitalisations in 80+ category in very remote locations Rates of hospitalisations decrease with increasing remoteness – with major cities having the highest rate and very remote having the lowest
Reviews both Indigenous and non indigenous mortality
Other features/stakeholders
National (major cities, regional and remote)‡ National (major cities, regional and remote)‡ National (major cities, regional and remote)‡
National (major cities, regional and remote)‡
National (major cities, regional and remote)‡
National (major cities, regional and remote)‡
National (major cities, regional and remote)‡
Location(s) in Australia
150 J. BOEHM ET AL.
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Telephone surveys
Cross sectional (survey)
Prospective
Field Test
Report – Rates for falls in Highest fatality Women higher people 65+ rates in remote hospitalisation Death rates (1992–1996) & centres (for both rates due to Hospitalisations (1995–1996) genders) but not fall during significant the period of study
Hughes et al.28
Mackenzie et al.29
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Mackenzie et al.30
Mackenzie et al.31
Strong et al.32
32%
44.7%
Female
50%
100%
Mean age 75 years 65+
70+
70 to 75 years
60+
70 to 81
65+
South East of South Australia (rural) National (urban, rural and remote) Northern Rivers†, NSW (intervention) Wide Bay Qld (control group) National sample
Location(s) in Australia
Significantly higher rates of hospitalisations in remote zone Mortality rates resulting from a fall increases with age Uses RRMA classification
War veterans or widows
National (urban, rural and remote)
Rural Victoria§
Doesn’t specify number of rural and remote participants or type of area classification system used War veterans or widows Rural and Urban Communities in NSW and Qld
Nil specified
Uses RRMA classification
Stakeholder committee
Age (years) Other features/stakeholders
†Article uses the same region as the SOYF programme: North Coast, Northern Rivers which is defined in Kempton et al. 37 through the statement: ‘Briefly, the control area (Sunshine Coast, Queensland) was carefully selected to match the intervention area in terms of geography (coastal, rural region with urban centres), demography (high proportion of retirees) and climatic factors’ (bolding added), P28; ‡Uses Australian Standard Geographical Classification (ASGC) Classifications System to differentiate between major cities, regional and remote; §Rural is defined as ‘all areas outside the metropolitan centres’, P261.
264 total, rural and remote % unknown 83
12900
5033 Rural [8387 Total] 3202
Longitudinal Survey
Byles et al.27
Nil specified
7553
Cohort
Brown26
Female Participants/ Cases
Older rural and remote participants
Article and reference Study design
Continued
Total Participants/ Cases
TABLE 3:
FALLS IN RURAL AND REMOTE OLDER AUSTRALIANS
151
1947 (intervention)
Cross sectional (survey) Cross sectional
2:1 women : men
N/A
60+
60+
139 GP, 53 pharmacists, 129 Northern Rivers Area Health community health staff (57% Service, NSW† nursing, 26% physiotherapy, 12% occupational therapy, 5% health promotion), 9 shire councils, 8 access committees 77% 70 years and older 139 GP Northern Rivers Areas Health Service, NSW (Rural) Nurses 6 health services in 5 States (Rural and Remote) Nil specified North Coast‡, NSW (intervention) Qld (control) Nil specified Northern Rivers‡, NSW (intervention) & Wide Bay Qld (control group) Nil specified Northern Rivers‡, NSW (intervention) Nil specified Coastal rural‡ region with urban centres: North Coast, NSW (intervention) Sunshine Coast, Qld (control) Nil specified North Coast, NSW‡ (intervention) Nil specified North Coast, NSW‡ (intervention) & Sunshine Coast, Qld‡ (control) 53 community pharmacists Northern Rivers area‡, NSW
Location(s) in Australia
†Sample was ‘largely rural’; ‡Article uses the same region as the SOYF programme: North Coast, Northern Rivers which is defined in Kempton et al. 37 through the statement: ‘Briefly, the control area (Sunshine Coast, Queensland) was carefully selected to match the intervention area in terms of geography (coastal, rural region with urban centres), demography (high proportion of retirees) and climatic factors’ (bolding added). P28.
All residents hospitalised Not specified with fall related injuries N/A N/A
1992 (intervention baseline) 1665 (control baseline)
Cohort
70+
60+
60+
N/A
60+ N/A
N/A
Age (years) Other features/stakeholders
69% (intervention follow 60+ up) 66% (control follow up)
54 (74%) female
8 focus groups
73
66% intervention baseline & 65% control baseline 50%
N/A
74% N/A
N/A
Female participants
Survey and focus N/A groups Prospective cohort 2002 (intervention –Telephone survey baseline) 1666 (control baseline) Telephone surveys 3202
73 N/A
8 focus groups Survey
Van Beurden et al.38 Survey
Kempton et al.37
Hughes et al.28
Hahn et al.36
Butt35
Barnett et al.34
N/A
Total participants
Survey- mail or telephone
Study design
Older rural and remote participants
Falls prevention interventions literature
Barnett et al.33
Article and reference
TABLE 4:
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TABLE 5:
Frequency of falls prevention interventions in identified Australian FPI studies by key stakeholders
Types of falls prevention interventions
Stakeholder providing intervention (% of time provided)
Medication checks Assessment and referral Providing advice to bring in out of date medication for disposal Home safety Promotional material Checking footpaths Providing advice on reducing falls Checking roads Referral to allied health providers Check stairs Checking shops
GP (75%)23; Pharmacist (53%)33,38 Community health staff (75%)33 Pharmacist (72%)33,38 Community health staff (71%)33 Community health staff (67%)23; Pharmacist (10%)38 Shire Council (67%)33 GP (46.7%)22; Pharmacist (40% gave advice ‘sometimes’ and 26% ‘often’)38 Shire Council (44%)33 GP (22.6%)34 Shire Council (22%)33 Shire Council (11%)33
remote areas.4,23–25 Whether this is a function of reality or illustrative of differences in health seeking or reporting discrepancies is unknown. There can be local differences between groups in the same remoteness category and this needs further elucidation.28 Hospitalisation fall rates were below the national average in very remote areas.4 This can be due to lack of access to or proximity of health care thus only the most seriously injured are hospitalised; less severe injuries occurring; only healthy older adults remain in very remote locations (the ‘survivor effect’); or residents die before reaching hospital (the ‘non-survivor effect’).4 The aim of falls prevention work is to reduce (and hopefully eliminate) the occurrence of and severity of injury sustained from falls.5 For rural and remote locations, four areas are proposed in which to concentrate efforts based on this review and current FPI best practice.13,39–41
An integrated approach across health services GP and pharmacists play a key role in falls prevention in rural and remote communities as older people seek their advice.33,34,38 However, many services should be involved in FPI (e.g. vision assessment).37 Expanding providers’ knowledge of available FPI and involving other professions, where present, via referrals is also required. Exploring multi-purpose services or other aged care services (e.g. Medicare Locals, Transition Aged Care Programs, and Home and Community Care) for FPI in rural and remote locations is also required.
Physical activity engagement Although physical activity was not highlighted in the results, it is beneficial across the lifespan and exercise© 2014 National Rural Health Alliance Inc.
based interventions (focusing on strength, balance and flexibility) can reduce falls risk.13,39,40,42 Local councils should be involved in supporting exercise including those aimed at addressing falls risk factors. Utilising (or modifying) existing community programmes, resources and services should boost support for interventions and foster capacity building with little capital investment.
Community involvement and ownership of FPI Numerous challenges face rural and remote communities41,43 which help foster and necessitate a culture of self-reliance.32,44 In acknowledgement of these factors, it is important to not just involve the community but foster ownership from the onset among the community and older adult residents so that sustainable and meaningful results occur.45
Evaluation and publication of results The lack of literature on FPI in rural and remote Australia is illustrative of the absence of work in this area and of difficulties in obtaining meaningful results which are publishable. Research quantity and quality would be strengthened by supporting research which benefits rural and remote Australia, is evidence-based, community-driven, ensures appropriate evaluation and supports publication of programme delivery (including outcomes).10 Published results should also provide a concise description of the location as well as the characteristics of the population involved. Further research exploring population groups such as Aboriginal and Torres Strait Islander people, farmers and graziers, and those from non-English speaking backgrounds is required.
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Limitations
References
Using self-identified literature can have resulted in the inclusion of articles that might not be classed as rural or remote via a classification system or not finding articles that did not use the words ‘rural’ or ‘remote’.32 Information on FPI predominantly came from one programme (SOYF). This limited the ability to provide a variety of sources of information to confirm the existence of FPI in rural and remote Australia but does highlight that at least one programme is available for modification. This review only focused on Australian rural and remote literature. While the authors acknowledge that there is likely to be literature which is applicable to fall prevention in rural and remote areas in Australia from international sources, the aim of this paper was to explore the Australian experience. This review demonstrates the paucity of Australian literature, and the authors recommend caution when using the recommendation from this paper and advocate further research be undertaken to build an evidence base. The reliability of information available on the health status and hospitalisation of residents within rural and remote regions can vary between and within regions. Such data quality issues relevant to hospitalisations and fatalities need to be considered when interpreting the results including the exploration of falls in Aboriginal and Torres Strait Islander people.46
1 Dixon J, Welch N. Researching the rural–metropolitan health differential using the ‘social determinants of health’. Australian Journal of Rural Health 2000; 8: 254– 260. 2 Aged & Community Services Australia, National Rural Health Alliance. Older People and Aged Care in Rural, Regional and Remote Australia: A Discussion Paper. Deakin West, ACT: National Rural Health Alliance, 2004; 1–25. 3 Britt H, Valenti L, Miller GC. ‘It’s Different in the Bush’: A Comparison of General Practice Activity in Metropolitan and Rural Areas of Australia 1998–2000. Canberra: Australian Institute of Health and Welfare, 2001. 4 Bradley C. Hospitalisations due to falls by older people, Australia 2008–09. Canberra: AIHW, 2012. 5 Queensland Health. Queensland Stay on Your Feet®. 2010; [Cited 19 Mar 2013]. Available from URL: http:// www.health.qld.gov.au/stayonyourfeet/default.asp 6 Australia Institute of Health and Welfare, Commonwealth Department of Health and Family Services. First report on the national health priority areas. Canberra: AIHW, 1997. 7 Skelton DA, Beyer N. Exercise and injury prevention in older people. Scandinavian Journal of Medicine and Science in Sports 2003; 13: 77–85. 8 Salkeld G, Ameratunga SN, Cameron ID et al. Quality of life related to fear of falling and hip fracture in older women: a time trade off study Commentary: older people’s perspectives on life after hip fractures. British Medical Journal 2000; 320: 341–346. 9 Bernoth M, Dietsch E, Davies C. Forced Into Exile: The Traumatising Impact of Rural Aged Care Service Inaccessibility. Rural and Remote Health [Internet]. 2012; 12. [Cited 5 Jul 2013]. Available from URL: http://www.rrh.org.au/ 10 Perkins D. Rural residents need research. Australian Journal of Rural Health 2012; 20: 101–102. 11 The George Institute of Global Health. Effects of physical activity on fall risk factors in adults aged 40–65: report to Queensland Health Department. 2010. 12 Australian Government Department of Veterans’ Affairs and Department of Health and Ageing. Choose health: Be active – a physical activity guide for older Australians. 2005; [Cited 19 Mar 2013]. Available from URL: http:// www.health.gov.au/internet/main/publishing.nsf/Content/ 3244D38BBBEBD284CA257BF0001FA1A7/$File/ choosehealth-brochure.pdf 13 Boehm J, Franklin RC, Newitt R et al. Barriers and motivators to exercise for older adults: a focus on those living in rural and remote areas of Australia. Australian Journal of Rural Health 2013; 21: 141–149. 14 Australia Institute of Health and Welfare. Rural, regional and remote health: a study on mortality. Canberra: AIHW, 2007. 15 Brady M. Health care in remote Australian Indigenous communities. The Lancet 2003; 362: s36–s37. 16 LoGiudice D, Smith K, Atkinson D et al. Preliminary evaluation of the prevalence of falls, pain and urinary
Conclusion There is limited information available about falls in rural and remote older Australians and FPI. While population-based FPI can have positive impacts on fall awareness and behaviour change, the transferability of these interventions across rural and remote Australia is unknown. Four areas are recommended for concentrated and sustainable effort to improve falls outcomes in rural and remote Australia: integration and collaboration among health professionals; promotion of physical activity across the lifespan; community involvement and ownership of interventions; and evaluation and publication of findings.
Acknowledgements Special thanks to Rose Newitt, Kathryn MacFarlane, Tonya Grant, Barbra Kurkowski, Bindee Johnston and Jacqui Lloyd for their support in undertaking this review. Associate Professor Richard Franklin is funded via a Queensland Injury Prevention Council (QIPC) capacity building grant from Queensland Health.
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20
21 22
23 24 25 26
27
28
29
30
31
32
incontinence in remote living Indigenous Australians over the age of 45 years. Internal Medicine Journal 2012; 42: e102–e107. World Health Organisation. Falls. 2011; [Cited 21 Dec 2011]. Available from URL: http://www.who.int/ violence_injury_prevention/other_injury/falls/en/ Wakerman J. Defining remote health. Australian Journal of Rural Health 2004; 12: 210–214. McGrail MR, Humphreys JS. Geographical classifications to guide rural health policy in Australia. Australia and New Zealand Health Policy 2009; 6: 28–34. Wilson N, Couper I, De Vries E et al. A Critical Review of Interventions to Redress the Inequitable Distribution of Healthcare Professionals to Rural and Remote Areas. Rural Remote Health [Internet]. 2009; 9. [Cited 5 Jul 2013]. Available from URL: http://www.rrh.org.au/ Bradley C, Harrison JE. Hospitalisations due to falls in older people, Australia, 2003–04. Adelaide: AIHW, 2007. Bradley C, Harrison JE. Hospital separations due to injury and poisoning, Australia 2004–05. Adelaide: AIHW, 2008. Bradley C, Pointer S. Hospitalisations due to falls by older people, Australia 2005–06. Adelaide: AIHW, 2009. Bradley C. Hospitalisations due to falls by older people, Australia 2006–07. Canberra: AIHW, 2012. Bradley C. Hospitalisations due to falls by older people, Australia 2007–08. Canberra: AIHW, 2012. Brown D. Do Leaves Have to Fall in Their Autum? A Falls Prevention Strategy in Action in the South East of South Australia. Rural and Remote Health [Internet]. 2004; 4. [Cited 30 Jun 2011]. Available from URL: http:// www.rrh.org.au/ Byles J, Powers J, Chojenta C et al. Older women in Australia: ageing in urban, rural and remote environments. Australasian Journal on Ageing 2006; 25: 151–157. Hughes K, Van Beurden E, Eakin EG et al. Older persons’ perception of risk of falling: implications for fallprevention campaigns. American Journal of Public Health 2008; 98: 351–357. Mackenzie L, Byles J, Mishra G. An occupational focus on falls with serious injury among older women in Australia. Australian Occupational Therapy Journal. 2004; 51: 144– 154. Mackenzie L, Byles J, Higginbotham N. A prospective community-based study of falls among older people in Australia: frequency, circumstances, and consequences. OTJR-Occupation Participation and Health 2002; 22: 143–152. Mackenzie L, Byles J, Higginbotham N. Designing the Home Falls and Accidents Screening Tool (HOME FAST): selecting the items. British Journal of Occupational Therapy 2000; 63: 260–269. Strong K, Trickett P, Titulaer I et al. Health in Rural and Remote Australia: the First Report of the Australian Institute of Health and Welfare on Rural Health. Canberra: AIHW. 1998; [Cited 4 Oct 2011]. Available from URL:
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45
46
www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id= 6442459024 Barnett LM, van Beurden E, Eakin EG et al. Program sustainability of a community-based intervention to prevent falls among older Australians. Health Promotion International 2004; 19: 281–288. Barnett L, van Beurden E, Eakin E et al. Falls prevention in rural general practice: what stands the test of time and where to from here? Australian and New Zealand Journal of Public Health 2003; 27: 481–485. Butt C. Developing everyone’s capacity: a resource kit supporting workforce capacity in reducing falls risk in the older person. Australian Journal of Rural Health. 2005; 13: 8–9. Hahn A, van Beurden E, Kempton A et al. Meeting the challenge of falls prevention at the population level: a community-based intervention with older people in Australia. Health Promotion International 1996; 11: 203–211. Kempton A, Van Beurden E, Sladden T et al. Older people can stay on their feet: final results of a community-based falls prevention programme. Health Promotion International 2000; 15: 27–33. Van Beurden E, Barnett LM, Molyneux M et al. Preventing falls among older people – current practice and attitudes among community pharmacists. Journal of Pharmacy Practice and Research. 2003; 33: 51–54. Gillespie L, Robertson M, Gillespie W et al. Interventions for preventing falls in older people living in the community (review). The Cochrane Collaboration. 2009; 2: 1–48. Rose DJ. Preventing falls among older adults: no ‘one size suits all’ intervention strategy. Journal of Rehabilitation Research and Development 2008; 45: 1153–1166. Aged & Community Services Australia, National Rural Health Alliance. Older People and Aged Care in Rural, Regional and Remote Australia: National Policy Position. 2005; [Cited 21 Dec 2011]. Available from URL: http:// www.agedcare.org.au/what-we-do/policies-and-position/ policies-pdfs/Rural_remote_policy05.pdf Franklin RC, Boehm J, King J et al. A framework for the assessment of community exercise programmes: a tool to assist in modifying programmes to help reduce falls risk factors. Age and Ageing 2013; 42: 536–540. Epub June 5, 2013. Larson A. Rural health’s demographic destiny. Rural and Remote Health 2006; 6: 1–8. Fuller J, Edwards J, Procter N et al. How definition of mental health problems can influence help seeking in rural and remote communities. Australian Journal of Rural Health 2000; 8: 148–153. Kilpatrick S. Multi-level rural community engagement in health. Australian Journal of Rural Health 2009; 17: 39–44. Australia Institute of Health and Welfare. Impact of Rurality on Health Status. Canberra: AIHW. 2012; [Cited 19 Mar 2013]. Available from URL: http://www.aihw .gov.au/rural-health-impact-of-rurality/
Aust. J. Rural Health (2014) 22, 146–155
Original Research Falls in rural and remote community dwelling older adults: A review of the literature Jackie Boehm, MPH, Richard C. Franklin, PhD and Jemma C. King, MPH School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, Queensland, Australia
Abstract Objective: Falls in older adults represent a significant challenge in Australia; however, the focus is often on urban-dwelling older adults. The aim of this review was to explore the literature on falls epidemiology and falls prevention interventions (FPI). Design: A literature review was conducted searching Medline, Scopus, Social Sciences Citation Index, Google Scholar, Google and the Australian Institute of Health and Welfare publication catalogue. Setting: Rural and remote Australia. Participants: Rural and remote community dwelling Australians aged 50 years and older. Intervention: Literature review. Main outcome measures: Falls epidemiology and effective falls prevention interventions. Results: Twenty references were identified: 14 related to falls epidemiology and 7 to FPI. No significant differences were found between rural, remote and major cities residents in relation to falls hospitalisation, falls mortality or fall-related injuries sustained. There are a wide assortment of health professionals and non-health professionals who are involved in providing FPI in rural and remote Australia. However, there was limited information on the effectiveness of these interventions in influencing falls outcomes. Conclusion: Few studies explored falls and their prevention in rural and remote Australia. The limited literature on the topic suggests that a change in focus to one that utilises existing services and resources will be required to create sustainable outcomes. Four areas are proposed for concentrated effort to reduce the impact of fall-related injury in rural and remote Australia: integration and collaboration among health professionals, promotion of physical activity across the lifespan,
community involvement and ownership of interventions, and evaluation and publication of findings. KEY WORDS: community programme, elderly, falls prevention, intervention, safety, senior.
Introduction
Accepted for publication 27 March 2014.
The relationship between place of residence and health is complex.1 There is a higher proportion of older adults in rural and remote Australia who have poorer health than their urban counterparts.2 Challenges stemming from an ageing population are extensive and have the potential to overwhelm already stretched health services, communities and individuals.2,3 Approximately one third of adults aged 65 years and older sustain a fall each year.4 Falls outcomes range from minor discomfort to death and place a significant burden on the health system.5 Falls represent a significant injury for older adults but are amendable to prevention by addressing the risk factors.6 Risk factors include impairments in balance, gait, strength, reaction time and vision; using multiple medications; depression; concern about falling; inappropriate footwear; and environmental hazards.4,5 Besides physical injury from a fall, outcomes include decreased confidence, quality of life, independence and physical activity.7 Some older women view death as preferable to the loss of independence, specifically entry into a nursing home following an injurious fall.8 This feeling is exaggerated in rural and remote older adults as entering a nursing home means, potentially leaving their community due to the absence of local services.2,9 The needs of the ageing rural and remote population are not being adequately addressed.10 This requires an improved research system that provides evidence-based policy and care10 and an understanding of the current breadth and depth of falls research. The aim of this review was to explore the literature on falls epidemiology and falls prevention interventions (FPI) relevant to rural and remote community-dwelling Australians aged 50 years and older.
© 2014 National Rural Health Alliance Inc.
doi: 10.1111/ajr.12114
Correspondence: Associate Professor Richard Franklin, James Cook University, Townsville, Queensland, 4811, Australia. Email: [email protected]
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What is already known on this subject: • The likelihood of having a fall requiring hospitalisation increases with age. • Older people represent a higher proportion of the population in rural and remote areas compared with urban areas and have poorer health. • Falls prevention interventions can assist in reducing the severity and frequency of falls.
What this study adds: • A review of falls epidemiology reveals that falls’ rates in rural and remote older Australians are similar to elsewhere in Australia. • There are few falls prevention interventions evaluated that have targeted rural and remote older Australians. • The sustainability of falls prevention work, particularly in the resource poor rural and remote environment, necessitates concentrated and collaborative ventures.
Methods Articles on falls in rural and remote Australia were identified searching the following databases: Medline, Scopus, Social Sciences Citation Index, Google Scholar, Google and the Australian Institute of Health and Welfare (AIHW) publications catalogue. Searches were conducted for publications pre-2013 and were undertaken in March 2013. Search strategies used differed based on the database functionality (Table 1). While the number of results obtained from Google was extensive, only the first 30 pages were reviewed as no new relevant publications were being found at this point. Literature from the searches was included if it met the following criteria: individuals were aged 50 years or older, were community dwelling, had sustained a fall or were involved in a FPI, place of residence was identified as being rural or remote and the article or report was published prior to 2013 (Table 2). The initial search identified 3702 publications. The exclusion criteria applied were: non-Australian sample, rural or remote populations were not specifically discussed, participants were younger than 50 years of age,
TABLE 1:
the sample included individuals with a specific condition (e.g. fall risks for individuals with Alzheimer’s) and the focus of the research was not specific to falling. Following application of the exclusion criteria, 20 references remained and were used for this review (Fig. 1).
Results There were 20 references which met the inclusion criteria: 14 related to falls epidemiology (Table 3) and 7 related to FPI (Table 4).
Falls epidemiology Rates of falls resulting in hospitalisation, injury or medical attention AIHW have published six reports examining the rate of falls hospitalisations in older adults from 2001 to 2009.4,21–25 Rates of older adults presenting to hospitals with fall-related injuries were similar for all remoteness zones, except very remote which were below the
Searches conducted and terms used
Database
Terms
Medline
1.
Scopus
1.
Social Sciences Citation Index
1.
Google and Google Scholar
1.
AIHW Publication Catalogue
1. 2. 3.
(fall OR falls) AND (rural OR remote) AND (elderly OR elder OR senior OR old OR older) AND community AND (Australia OR Australian) fall* AND (rural OR remote) AND (elder* OR senior* OR old*) AND community AND Australia* fall* AND (rural OR remote) AND (elder* OR senior* OR old*) AND community AND Australia* fall* AND (rural OR remote) AND (elder* OR senior* OR old*) AND community AND Australia* Rural Health Publications Injury Ageing and Aged Care
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148 TABLE 2:
J. BOEHM ET AL.
Terminology used: definitions and justifications of their use
Term
Definition and justification
Older people/person
An individual aged 50 years or older. The classification of an older adult commonly includes anyone aged 65 years and older. However, it is known physiological deterioration occurs from 40 years of age11,12 and physical inactivity increases with age (which are related to falls risk factors).11,12 Therefore this lowered inclusion age enables examination of a more relevant audience for falls prevention activities. This approach has previously been used in research.13 Also this enables any FPI targeting Aboriginal and Torres Strait Islanders to be included, who on average have a shorter life expectancy and experience falls related morbidity and mortality at a younger age.14–16 People living in their home and not an aged care facility. ‘. . . an event which results in a person coming to rest inadvertently on the ground or floor or other lower level’.17 Activity/programmes to assist in reducing falls and effects from falls.
Community dwelling Fall Falls prevention interventions (FPI) Rural and remote
By the article self-identifying (i.e. using one or both of the terms ‘rural’ or ‘remote’ either directly (in the article title, abstract, key words or journal title and then identify their study was in a rural or remote location) or indirectly (if another article linked to the article had self-identified as rural and remote). After reviewing the literature it was deemed applying a geographical classification system would be difficult as: (i) literature identified in the search did not provide sufficient information in their methods about the location; and (ii) might not capture relevant literature due to changes in classification systems.18–20 This method of accepting definitions of rural and remote identified in the literature has previously been used by other researchers.20
FIGURE 1: Research rural and remote falls.
Articles Found (n = 3702)
flowchart
for
Exclusion of Articles through review of title and abstract and removal of duplicates (n = 3621) Potentially Eligible Articles after title and abstract screening (n = 81)
Exclusion of Articles through full text reading (n = 61)
Articles Reviewed Relevant to Falls in Rural and Remote Older Australians (n = 20)
Falls Epidemiology Literature (n = 14)
Falls Prevention Interventions Literature (n = 7)
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national average.4 There was a significant increase in major city and inner regional rates and a non-statistical increase in remote area rates. Outer regional rates remained steady and very remote rates decreased (not statistically significant).4 A 6-year longitudinal study (1996–2002) of women aged 70–75 years found no significant differences between falls rates, injury rates and the need for medical attention between urban, rural and remote areas.27 However, another study found that fall-related female fatality rates in rural and remote older adults were double and hospitalisations rates were higher compared with urban areas.32 When fatalities were explored by age-specific falls death rates and remoteness classification, it was found older adults in remote and very remote areas had a mortality rate lower than expected (not statistically significant) when compared with the same age group in major cities.14 While most literature noted no difference in rates by rurality, some localised variance was observed. A study examining fall events over a 6-month period in urban and rural areas in Queensland and New South Wales for those aged 70 years and older found the highest prevalence of reported falls in rural New South Wales and the lowest in rural Queensland; however, these differences were not significant.30
Injury type There were no significant differences in the type of injury sustained from a fall for women in urban, rural and remote areas in relation to serious injuries, major personal injury and broken bones.29
Causes of falls Tripping was the most common cause of a fall in the community.26 Commonly identified home hazards, which increased falls risk in rural Victorian homes, were home access (slippery paths, uneven surfaces at gates and lack of rails near steps), movement around the home (poor lighting, cluttered walkways and loose mats) and the bathroom (slippery floors, no rails and high shower hobs).31 A higher number of home hazards were associated with those who had previously had a fall.31 Specific environmental home hazards relevant to the rural setting differ to those in regional or metropolitan settings and include having a raised veranda, larger houses, outdoor toilet and a greater variety of ground surfaces.31
Self-perceived risk of falling One study compared differences by region, Northern Rivers, New South Wales to Wide Bay, Queensland, in © 2014 National Rural Health Alliance Inc.
relation to self-perceived risk of falling.28 People from Northern Rivers reported falls prevention was a high priority and they were more likely to believe falls are preventable.28 Overall, most of the sample perceived their falls risk as low (60%); however, men and young participants were more likely than women and older participants to perceive their risk of falling as low.28
Falls prevention intervention literature Health professionals (e.g. pharmacists, nurses, general practitioners (GP), occupational therapists, physiotherapists and health promotion officers) and non-health professionals (e.g. council employees) play a role in falls prevention in rural and remote areas33–35,38 (Table 5). Articles which evaluated the Stay on Your Feet (SOYF) programme33,34,38 found that common FPI in rural settings included: medication checks by GP (75%), assessment and referral by community health staff (75%) and pharmacist advice to dispose of out dated medication (72%).33 Less common FPI were: pharmacist advice on preventing falls, referrals from pharmacists and GP to allied health professionals and training of pharmacy staff on providing falls-related advice34,38 (Table 5). In rural and remote settings, nurses play a role in the identification and management of risks related to their clients sustaining a fall.35 Lack of resources and models of service delivery were identified as impeding their ability to implement FPI.35
Outcome of FPI Four studies described outcomes from FPI specifically for older adults.28,33,36,37 Of these, three studies found changes in awareness and knowledge in relation to falls risk factors and prevention;28,36,37 two studies found behaviour changes relating to identified falls risk factors including walking daily (although the size of this change is not articulated),33 and footwear worn;37 and one study reported unintended changes of increased medication use and decreases in physical activity.36 Only one article reported on changes in falls incidence with significant differences in fall-related hospital admissions and a non-significant but lower incidence in self-reported falls among the intervention group.37
Discussion Falls in community-dwelling older people in rural and remote Australia is an important but understudied issue. There was a paucity of literature (20 references), particularly in relation to fall fatalities by remoteness.14,32 This review found no statistically significant differences in falls injury rates between urban, rural and
Bradley4
Bradley25
Report – Hospitalised fall injury cases Report – Hospitalised fall injury cases Report – Hospitalised fall injury cases
Bradley24
78 606
83 490
80 364
Report – Hospital separations due to injury
Bradley and Harrison22
Report – Hospitalised fall injury cases
Age Standardised rate for 65+: 2295.9 per 100 000 population 74 748
Report – Hospitalised fall injury cases
Bradley and Harrison21
Bradley and Pointer23
132 322 deaths annually (between 2002–2004) 60 497
Report – Mortality in Rural, Remote and Regional Australia
Australia Institute of Health and Welfare14
Total Participants/ Cases
70%
70%
70%
71%
Women 75+ higher rates of falls than men
72%
46%
Female Participants/ Cases
65+
65+
65+
65+
65+
65+
All age groups
Age (years)
Older rural and remote participants
Study design
Falls epidemiology literature
Article and reference
TABLE 3:
Very remote: highest for 65–75 age group but lowest rates for people 80+ for all remoteness zones Major cities higher and very remote lower than national rate Rates higher in remote and major cities than the national rate Hospitalised falls and hip fractures for very remote locations were below national rates
Similar rates across remoteness zones with the exception of people, especially women living in very remote locations which were below average. Suggested this is due to very low rate of hospitalisations in 80+ category in very remote locations Rates of hospitalisations decrease with increasing remoteness – with major cities having the highest rate and very remote having the lowest
Reviews both Indigenous and non indigenous mortality
Other features/stakeholders
National (major cities, regional and remote)‡ National (major cities, regional and remote)‡ National (major cities, regional and remote)‡
National (major cities, regional and remote)‡
National (major cities, regional and remote)‡
National (major cities, regional and remote)‡
National (major cities, regional and remote)‡
Location(s) in Australia
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Telephone surveys
Cross sectional (survey)
Prospective
Field Test
Report – Rates for falls in Highest fatality Women higher people 65+ rates in remote hospitalisation Death rates (1992–1996) & centres (for both rates due to Hospitalisations (1995–1996) genders) but not fall during significant the period of study
Hughes et al.28
Mackenzie et al.29
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Mackenzie et al.30
Mackenzie et al.31
Strong et al.32
32%
44.7%
Female
50%
100%
Mean age 75 years 65+
70+
70 to 75 years
60+
70 to 81
65+
South East of South Australia (rural) National (urban, rural and remote) Northern Rivers†, NSW (intervention) Wide Bay Qld (control group) National sample
Location(s) in Australia
Significantly higher rates of hospitalisations in remote zone Mortality rates resulting from a fall increases with age Uses RRMA classification
War veterans or widows
National (urban, rural and remote)
Rural Victoria§
Doesn’t specify number of rural and remote participants or type of area classification system used War veterans or widows Rural and Urban Communities in NSW and Qld
Nil specified
Uses RRMA classification
Stakeholder committee
Age (years) Other features/stakeholders
†Article uses the same region as the SOYF programme: North Coast, Northern Rivers which is defined in Kempton et al. 37 through the statement: ‘Briefly, the control area (Sunshine Coast, Queensland) was carefully selected to match the intervention area in terms of geography (coastal, rural region with urban centres), demography (high proportion of retirees) and climatic factors’ (bolding added), P28; ‡Uses Australian Standard Geographical Classification (ASGC) Classifications System to differentiate between major cities, regional and remote; §Rural is defined as ‘all areas outside the metropolitan centres’, P261.
264 total, rural and remote % unknown 83
12900
5033 Rural [8387 Total] 3202
Longitudinal Survey
Byles et al.27
Nil specified
7553
Cohort
Brown26
Female Participants/ Cases
Older rural and remote participants
Article and reference Study design
Continued
Total Participants/ Cases
TABLE 3:
FALLS IN RURAL AND REMOTE OLDER AUSTRALIANS
151
1947 (intervention)
Cross sectional (survey) Cross sectional
2:1 women : men
N/A
60+
60+
139 GP, 53 pharmacists, 129 Northern Rivers Area Health community health staff (57% Service, NSW† nursing, 26% physiotherapy, 12% occupational therapy, 5% health promotion), 9 shire councils, 8 access committees 77% 70 years and older 139 GP Northern Rivers Areas Health Service, NSW (Rural) Nurses 6 health services in 5 States (Rural and Remote) Nil specified North Coast‡, NSW (intervention) Qld (control) Nil specified Northern Rivers‡, NSW (intervention) & Wide Bay Qld (control group) Nil specified Northern Rivers‡, NSW (intervention) Nil specified Coastal rural‡ region with urban centres: North Coast, NSW (intervention) Sunshine Coast, Qld (control) Nil specified North Coast, NSW‡ (intervention) Nil specified North Coast, NSW‡ (intervention) & Sunshine Coast, Qld‡ (control) 53 community pharmacists Northern Rivers area‡, NSW
Location(s) in Australia
†Sample was ‘largely rural’; ‡Article uses the same region as the SOYF programme: North Coast, Northern Rivers which is defined in Kempton et al. 37 through the statement: ‘Briefly, the control area (Sunshine Coast, Queensland) was carefully selected to match the intervention area in terms of geography (coastal, rural region with urban centres), demography (high proportion of retirees) and climatic factors’ (bolding added). P28.
All residents hospitalised Not specified with fall related injuries N/A N/A
1992 (intervention baseline) 1665 (control baseline)
Cohort
70+
60+
60+
N/A
60+ N/A
N/A
Age (years) Other features/stakeholders
69% (intervention follow 60+ up) 66% (control follow up)
54 (74%) female
8 focus groups
73
66% intervention baseline & 65% control baseline 50%
N/A
74% N/A
N/A
Female participants
Survey and focus N/A groups Prospective cohort 2002 (intervention –Telephone survey baseline) 1666 (control baseline) Telephone surveys 3202
73 N/A
8 focus groups Survey
Van Beurden et al.38 Survey
Kempton et al.37
Hughes et al.28
Hahn et al.36
Butt35
Barnett et al.34
N/A
Total participants
Survey- mail or telephone
Study design
Older rural and remote participants
Falls prevention interventions literature
Barnett et al.33
Article and reference
TABLE 4:
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TABLE 5:
Frequency of falls prevention interventions in identified Australian FPI studies by key stakeholders
Types of falls prevention interventions
Stakeholder providing intervention (% of time provided)
Medication checks Assessment and referral Providing advice to bring in out of date medication for disposal Home safety Promotional material Checking footpaths Providing advice on reducing falls Checking roads Referral to allied health providers Check stairs Checking shops
GP (75%)23; Pharmacist (53%)33,38 Community health staff (75%)33 Pharmacist (72%)33,38 Community health staff (71%)33 Community health staff (67%)23; Pharmacist (10%)38 Shire Council (67%)33 GP (46.7%)22; Pharmacist (40% gave advice ‘sometimes’ and 26% ‘often’)38 Shire Council (44%)33 GP (22.6%)34 Shire Council (22%)33 Shire Council (11%)33
remote areas.4,23–25 Whether this is a function of reality or illustrative of differences in health seeking or reporting discrepancies is unknown. There can be local differences between groups in the same remoteness category and this needs further elucidation.28 Hospitalisation fall rates were below the national average in very remote areas.4 This can be due to lack of access to or proximity of health care thus only the most seriously injured are hospitalised; less severe injuries occurring; only healthy older adults remain in very remote locations (the ‘survivor effect’); or residents die before reaching hospital (the ‘non-survivor effect’).4 The aim of falls prevention work is to reduce (and hopefully eliminate) the occurrence of and severity of injury sustained from falls.5 For rural and remote locations, four areas are proposed in which to concentrate efforts based on this review and current FPI best practice.13,39–41
An integrated approach across health services GP and pharmacists play a key role in falls prevention in rural and remote communities as older people seek their advice.33,34,38 However, many services should be involved in FPI (e.g. vision assessment).37 Expanding providers’ knowledge of available FPI and involving other professions, where present, via referrals is also required. Exploring multi-purpose services or other aged care services (e.g. Medicare Locals, Transition Aged Care Programs, and Home and Community Care) for FPI in rural and remote locations is also required.
Physical activity engagement Although physical activity was not highlighted in the results, it is beneficial across the lifespan and exercise© 2014 National Rural Health Alliance Inc.
based interventions (focusing on strength, balance and flexibility) can reduce falls risk.13,39,40,42 Local councils should be involved in supporting exercise including those aimed at addressing falls risk factors. Utilising (or modifying) existing community programmes, resources and services should boost support for interventions and foster capacity building with little capital investment.
Community involvement and ownership of FPI Numerous challenges face rural and remote communities41,43 which help foster and necessitate a culture of self-reliance.32,44 In acknowledgement of these factors, it is important to not just involve the community but foster ownership from the onset among the community and older adult residents so that sustainable and meaningful results occur.45
Evaluation and publication of results The lack of literature on FPI in rural and remote Australia is illustrative of the absence of work in this area and of difficulties in obtaining meaningful results which are publishable. Research quantity and quality would be strengthened by supporting research which benefits rural and remote Australia, is evidence-based, community-driven, ensures appropriate evaluation and supports publication of programme delivery (including outcomes).10 Published results should also provide a concise description of the location as well as the characteristics of the population involved. Further research exploring population groups such as Aboriginal and Torres Strait Islander people, farmers and graziers, and those from non-English speaking backgrounds is required.
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Limitations
References
Using self-identified literature can have resulted in the inclusion of articles that might not be classed as rural or remote via a classification system or not finding articles that did not use the words ‘rural’ or ‘remote’.32 Information on FPI predominantly came from one programme (SOYF). This limited the ability to provide a variety of sources of information to confirm the existence of FPI in rural and remote Australia but does highlight that at least one programme is available for modification. This review only focused on Australian rural and remote literature. While the authors acknowledge that there is likely to be literature which is applicable to fall prevention in rural and remote areas in Australia from international sources, the aim of this paper was to explore the Australian experience. This review demonstrates the paucity of Australian literature, and the authors recommend caution when using the recommendation from this paper and advocate further research be undertaken to build an evidence base. The reliability of information available on the health status and hospitalisation of residents within rural and remote regions can vary between and within regions. Such data quality issues relevant to hospitalisations and fatalities need to be considered when interpreting the results including the exploration of falls in Aboriginal and Torres Strait Islander people.46
1 Dixon J, Welch N. Researching the rural–metropolitan health differential using the ‘social determinants of health’. Australian Journal of Rural Health 2000; 8: 254– 260. 2 Aged & Community Services Australia, National Rural Health Alliance. Older People and Aged Care in Rural, Regional and Remote Australia: A Discussion Paper. Deakin West, ACT: National Rural Health Alliance, 2004; 1–25. 3 Britt H, Valenti L, Miller GC. ‘It’s Different in the Bush’: A Comparison of General Practice Activity in Metropolitan and Rural Areas of Australia 1998–2000. Canberra: Australian Institute of Health and Welfare, 2001. 4 Bradley C. Hospitalisations due to falls by older people, Australia 2008–09. Canberra: AIHW, 2012. 5 Queensland Health. Queensland Stay on Your Feet®. 2010; [Cited 19 Mar 2013]. Available from URL: http:// www.health.qld.gov.au/stayonyourfeet/default.asp 6 Australia Institute of Health and Welfare, Commonwealth Department of Health and Family Services. First report on the national health priority areas. Canberra: AIHW, 1997. 7 Skelton DA, Beyer N. Exercise and injury prevention in older people. Scandinavian Journal of Medicine and Science in Sports 2003; 13: 77–85. 8 Salkeld G, Ameratunga SN, Cameron ID et al. Quality of life related to fear of falling and hip fracture in older women: a time trade off study Commentary: older people’s perspectives on life after hip fractures. British Medical Journal 2000; 320: 341–346. 9 Bernoth M, Dietsch E, Davies C. Forced Into Exile: The Traumatising Impact of Rural Aged Care Service Inaccessibility. Rural and Remote Health [Internet]. 2012; 12. [Cited 5 Jul 2013]. Available from URL: http://www.rrh.org.au/ 10 Perkins D. Rural residents need research. Australian Journal of Rural Health 2012; 20: 101–102. 11 The George Institute of Global Health. Effects of physical activity on fall risk factors in adults aged 40–65: report to Queensland Health Department. 2010. 12 Australian Government Department of Veterans’ Affairs and Department of Health and Ageing. Choose health: Be active – a physical activity guide for older Australians. 2005; [Cited 19 Mar 2013]. Available from URL: http:// www.health.gov.au/internet/main/publishing.nsf/Content/ 3244D38BBBEBD284CA257BF0001FA1A7/$File/ choosehealth-brochure.pdf 13 Boehm J, Franklin RC, Newitt R et al. Barriers and motivators to exercise for older adults: a focus on those living in rural and remote areas of Australia. Australian Journal of Rural Health 2013; 21: 141–149. 14 Australia Institute of Health and Welfare. Rural, regional and remote health: a study on mortality. Canberra: AIHW, 2007. 15 Brady M. Health care in remote Australian Indigenous communities. The Lancet 2003; 362: s36–s37. 16 LoGiudice D, Smith K, Atkinson D et al. Preliminary evaluation of the prevalence of falls, pain and urinary
Conclusion There is limited information available about falls in rural and remote older Australians and FPI. While population-based FPI can have positive impacts on fall awareness and behaviour change, the transferability of these interventions across rural and remote Australia is unknown. Four areas are recommended for concentrated and sustainable effort to improve falls outcomes in rural and remote Australia: integration and collaboration among health professionals; promotion of physical activity across the lifespan; community involvement and ownership of interventions; and evaluation and publication of findings.
Acknowledgements Special thanks to Rose Newitt, Kathryn MacFarlane, Tonya Grant, Barbra Kurkowski, Bindee Johnston and Jacqui Lloyd for their support in undertaking this review. Associate Professor Richard Franklin is funded via a Queensland Injury Prevention Council (QIPC) capacity building grant from Queensland Health.
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17
18 19
20
21 22
23 24 25 26
27
28
29
30
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