Archives of Gerontology and Geriatrics 58 (2014) 283–292

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Twelve month follow up of a falls prevention program in older adults from diverse populations in Australia: A qualitative study Romi Haas a,*, Terry P. Haines a,b a b

Allied Health Research Unit, Southern Health, Victoria, 3192, Australia Physiotherapy Department, Monash University, Victoria, 3199, Australia

A R T I C L E I N F O

A B S T R A C T

Article history: Received 19 February 2013 Received in revised form 25 October 2013 Accepted 26 October 2013 Available online 2 November 2013

Several randomised trials demonstrate that multi dimensional falls prevention programs are effective in reducing falls in older adults. There is a need to examine the impact of these programs in real life settings where diverse populations exist. The aim of this study was to examine the acceptability and impact on sustained participation in falls prevention activities of a combined exercise and education falls prevention program. A semi structured telephone interview was conducted with 23 participants 12 months following the completion of a 15 week falls prevention program tailored to diverse communities in Victoria, Australia and provided in both a group and home based format. Reported benefits of the falls prevention program included physical improvements in joint flexibility, mobility and balance and enjoyment derived from both the exercises and socialisation. Recall of the educational component was minimal as were ongoing behavioral changes to reduce the risk of falling other than exercise. Participation in sustained exercise for falls prevention following the completion of the program was also inconsistent. Future improvements of such programs could focus upon ensuring the exercises prescribed are sufficiently challenging for each individual in order to be of physical benefit, altering the educational style to be goal directed and more enjoyable, and integrating further strategies to support sustained participation in falls prevention behavioral changes. Linking participants with alternate ongoing exercise opportunities or potential sources of ongoing support may be advantageous in enhancing long term participation in exercise for falls prevention following cessation of the program. Crown Copyright ß 2013 Published by Elsevier Ireland Ltd. All rights reserved.

Keywords: Fall prevention Older adult Exercise Education

1. Introduction Fall-related injury in older adults is a major and growing public health issue. In Australia an estimated one in three older persons living at home experiences a fall annually (Centre for Health Advancement and Centre for Epidemiology and Research, 2010; Gill, Taylor, & Pengelly, 2005) with falls accounting for $648.2 million per year in hospital care (Bradley, 2012a) and exceeding $1 billion per year in indirect costs (Moller, 2003). It has been estimated that there were nearly 11,000 more people aged 65 years and older admitted to hospital due to a fall in 2008–2009 than the age-standardised rate in 1999–2000 (Bradley, 2012b). Unless current trends in fall injuries can be reduced, these figures can be expected to increase disproportionately in comparison to the aging population.

* Corresponding author at: Allied Health Research Unit, Monash Health, Kingston Centre, Warrigal Road, Cheltenham, Victoria, 3192, Australia. Tel.: +61 3 9265 1815; fax: +61 3 9265 1590. E-mail address: [email protected] (R. Haas).

Various interventions have been identified as effective means of reducing fall rates and/or risk of falling. These include group exercise, home based exercise, home safety assessment and modification interventions and multifactorial interventions (Gillespie et al., 2012). Although the evidence relating to the provision of educational materials alone for preventing falls is inconclusive (Gillespie et al., 2012), patient education to reduce known falls risk factors has frequently been included as a component of effective multi component interventions (Clemson et al., 2004; Huang, Liu, Huang, & Kernohan, 2010; Robson, Edwards, Gallagher, & Baker, 2003). It is also widely held that ongoing participation in health behaviors to prevent falls, such as exercise, is necessary in order to sustain the beneficial effects of these strategies in the long term (Sherrington, Tiedemann, Fairhall, Close, & Lord, 2011). Previous research regarding the effectiveness, acceptability, and sustained participation in falls prevention programs have resulted predominantly from studies stipulating rigid inclusion criteria and enforcing strict conditions of participation that may not reflect the practical conditions of real life falls prevention programs. In particular, the ability to speak English is often a requirement of such trials with 22 randomized trials investigating the efficacy of falls prevention interventions in a recent Cochrane

0167-4943/$ – see front matter . Crown Copyright ß 2013 Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.archger.2013.10.010

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review excluding participants who did not speak English (Gillespie et al., 2012). Similarly, another systematic review of 24 studies investigating older people’s perceptions of facilitators and barriers to participation in falls prevention interventions identified that only three studies examined the health promotion needs of non English speaking groups (Bunn, Dickinson, Barnett-Page, Mcinnes, & Horton, 2008). Culturally and linguistically diverse populations (CALD) are an important component of communities in many developed countries and especially amongst older adults. In Australia, in 2006, 21% of those over the age of 65 were born in non English speaking countries (AIHW, 2007). It is recognised that the health care needs and responses of these populations are likely to differ from the remainder of the population due to intrinsic medical differences, higher life expectancies, varying cultural preferences and reduced English language proficiencies (AIHW, 2002; Omeri & Raymond, 2009). Consequently, there is a need to evaluate the effectiveness, acceptability, and sustained participation in falls prevention programs in real life settings where diverse populations exist. 1.1. Purpose This study examines the acceptability and impact on sustained participation in falls prevention activities of a mixed exercise and education falls prevention program, referred to as the Making a Move program, that was offered to a diverse community population in Victoria, Australia. This study investigates why people participated in the Making a Move program, how they felt about it, and how they perceive it affected them and their health behaviors since they completed this program. It further investigates the impact of CALD status and how the Making a Move program was offered (group based versus home based) on these outcomes. 2. Materials and methods 2.1. Design This investigation was a qualitative study that employed a semi structured, telephone based interview format. A semi structured interview technique was chosen in order to allow interviewers to tailor their questions to different participants and contexts and to allow for exploration of themes that were introduced.

Community Care program supports frail aged people whose capacity for independent living is at risk, or who are at risk of premature or inappropriate admission to long term residential care (Home & Community Care (HACC), 1985). The exercise component of the group based program was based upon the Well For Life/No Falls program (Day et al., 2002) while the home based program was based upon the New Zealand Otago Exercise Program (University of Otago School of Medicine, 2003). Each session included exercises designed to increase flexibility, leg strength and balance. An exercise physiologist who had received training in how to deliver the No-Falls program led the group sessions. Exercises could be modified or replaced by less demanding ones, depending on the ability of each participant. Each group contained a maximum of 15 participants who had the same language and/or cultural background. A community worker who spoke the language of the participants was present to assist with translation and provide encouragement. Where possible the program was held in a location of choice by the participants (for example, a local church) and transport was provided. The home based sessions were led by a care worker who followed an exercise program that was individually prescribed by a physical therapist who had assessed each participant at the commencement of the Making a Move program. Each care worker had received training in the implementation of the Otago Exercise Program and could speak the language of the participant they were assisting. Additional education elements were provided in the areas of feet and footwear, nutrition, and vision to both group and home based participants. The education component was delivered with a didactic approach, which allowed for questions and discussion following the provision of information. All education sessions were provided by a relevant health professional and interpreted by a qualified interpreter as required. A previous evaluation of this program (Pausenberger & Haines, 2011) revealed that participants improved in their perception of what they thought would be effective for falls prevention (changing from general activities such as ‘‘being careful’’ to nominating specific, evidence based activities such as exercise) as a result of the program. However, until now, it has not been investigated whether health behaviors identified at the post intervention assessment have been pursued or sustained by individual participants following the program completion. 2.4. Measurements

2.2. Participants Participants in this study were individuals who participated in the group (n = 11) and home based (n = 12) Making a Move program in 2009. A purposive sampling strategy was used to ensure equal representation from people in the group and home based programs and those with and without CALD backgrounds.

Each telephone interview followed a semi structured schedule (Appendix 1). Interview topics were designed to reveal the participant’s reasons for participating in the Making a Move program; their feelings about the program; the effects of the program; and whether they participated in relevant health behaviors since the program finished and why. 2.5. Procedure

2.3. Intervention The intervention investigated was the Making a Move program (2009), a falls prevention initiative that involves the provision of a 15 week exercise and educational program held once per week for approximately one hour and designed to prevent falls amongst older adults from diverse populations in both a group and home based setting. This was funded and implemented by the South East Healthy Communities Partnership, Victoria, Australia. The group based programs were offered to Home and Community Care eligible, community dwelling people aged >65 years and the home based programs were offered to similar individuals aged >80 years. The Home and

Prior approval to conduct this study was obtained from the Monash Health Human Research Ethics Committee (Reference Number 11187B). From a coded list of program participants currently involved with their service provider (as requested by agencies), one investigator (TH) randomly selected potential participants for the telephone interview using computer generated random numbers. A list stratified according to program setting and participant background was given to the service providers to make initial contact. CALD participants were identified according to: Country of birth, language other than English spoken at home and English language proficiency (McLennan, 1999).

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Service providers contacted potential participants via telephone. Once a participant gave verbal consent, telephone numbers were provided to the investigators. When potential participants could not be contacted or did not consent to participate, the service provider notified the investigators, who then provided further randomly selected participants to the service provider to contact. All interviews were conducted by an investigator (RH) or one of two research assistants (AL or EP). A qualified interpreter was utilised for the interviews with CALD participants as required. The interviewers used the same interview schedule and crosschecked 3 interviews at the project commencement to ensure consistent interview techniques were being utilised. The aims of each set of questions were clarified and discussion regarding the use of prompts and clarification techniques was conducted. 2.6. Data analysis All interviews were digitally recorded and analysed according to content and themes. Content analysis was applied to classifying responses to questions regarding the participant effects of the program and activities following program completion. Analysis of the themes underpinning why participants chose to participate in the Making a Move program, to undertake a particular activity or why participants felt they did or did not receive a particular benefit from the program was undertaken using a framework approach. This approach incorporated five stages; (i) familiarisation with the data, (ii) identifying a thematic framework in order to separate data, (iii) indexing by applying codes to text according to themes, (iv) charting themes to the appropriate part of the thematic framework, and (v) mapping data to define concepts and identify associations between categories (Pope, Ziebland, & Mays, 2000). The initial thematic framework was devised using a combination of a priori knowledge from the interview questions and inductive analysis as the themes emerged from the data. Codes were initially identified and labeled. Themes that linked together these codes were then established. An iterative process of testing and retesting the thematic framework using the data followed. Data was analysed both as a whole (that is, amongst all interviews) and separately within both the group and home based and CALD and non-CALD particiipants. Hyphenate non-CALD to ensure consistency throughout the manuscript. NVivo computer software (version 9, QSR International Pty Ltd, Doncaster, Victoria, Australia) was used to facilitate the coding, charting and mapping of data. Data codes were developed according to themes and mapped by one researcher (RH). Data codes were validated using peer review by another additional researcher (TH). Discussions between these two researchers were then used to modify the thematic framework originally developed. The modified thematic framework was used to identify and describe the reasons for participation in the Making a Move program, the effects of the program and the reasons for continued or lack of participation in health behaviors to prevent falls since program completion. 2.7. Trustworthiness Techniques and strategies used to ensure the accuracy and credibility of this study’s findings included member checking, peer debriefings and reflexivity (Cohen & Crabtree, 2006). 2.7.1. Member checking Two participants (one from each program setting) were given transcripts and codes from their interview along with the emergent themes. Both participants agreed the codes and themes reflected the key issues from their perspective.

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2.7.2. Peer debriefing Peer debriefing of the findings was conducted by members of the Allied Health Research Unit who were not involved in the research process. An investigator presented the research design and preliminary findings, including the data codes devised, examples of quotes and emergent themes. Co researchers were invited to discuss the methodology and comment on whether or not the coding and themes adequately represented the data. These comments were then incorporated into the final analysis. 2.7.3. Reflexivity The use of multiple investigators, a reflexive diary specifying when new codes and themes were identified and the documentation of investigator background and pre study expectations were used to foster reflexivity. Both investigators possessed background training in physiotherapy and entered this study with clinical backgrounds and research experience in falls prevention of older adults in both home and group based settings. One investigator (TH) had been involved in the development of the Making a Move program but neither were involved in its implementation. Prior to the study commencement, the investigators anticipated the Making a Move program had been well received by its recipients but that not many had continued participating in health behaviors to reduce falls since its completion due to a lack of reinforcement and support. 2.8. Sample size determination The participating service providers identified a total of 72 potential participants for this study. Data collection and analysis occurred in an iterative manner and the process of random purposive sampling continued until either saturation of themes and content had occurred or all consenting participants had been interviewed. 3. Results Of the 72 potential participants identified, 44 could not be contacted or declined participation, 23 actually participated and 5 were not contacted since data saturation had been achieved. Of the 44 who could not be contacted or declined participation: the service providers were unable to contact 13, 5 were deceased, 3 had been transferred to high level residential aged care, 12 gave no reason, 3 cited ill health and 8 could not recall the Making a Move program following detailed description. In total, n = 23 participants (32% of total potential participants) were recruited, of which n = 11 participated in group programs (n = 6 CALD, n = 5 non-CALD) and n = 12 participated in home programs (n = 5 CALD, n = 7 non-CALD). Interviews varied in duration from 7 to 42 min (mean 29 min). The characteristics of the participants who were interviewed are depicted in Table 1. Several themes emerged from the analysis of the semi structured interviews conducted with participants from the 2009 Make a Move program. These have been summarised under three topic areas: 1. Reasons for participation in the program, 2. Benefits reported from participating in the program, and 3. Ongoing participation in exercise to reduce the risk of falls. The themes within these topic areas are now presented. 3.1. Reasons for participation Fig. 1 depicts key factors influencing why participants chose or agreed to participate in the 2009 Making a Move program. These were grouped into motivators that were extrinsic and intrinsic to

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286 Table 1 Characteristics of participants interviewed.

Participants

Group CALD

Group non-CALD

Home based CALD

Home based non-CALD

Total Gender: female – n (%) Age: years – median (range)

23 16 (70) 84 (71, 92)

6 4 (67) 75.5 (71, 81)

5 5 (100) 82 (77, 82)

5 4 (80) 87 (85, 90)

7 3 (43%) 86 (84, 92)

Place of birth

Australia (n = 8) England (n = 3) India (n = 3) Vietnam (n = 1) Iraq (n = 1) China (n = 4) Lebanon (n = 1) Sri Lanka (n = 1) Holland (n = 1)

Iraq (n = 1) Vietnam (n = 1) China (n = 4)

Australia (n = 4) England (n = 1)

Lebanon (n = 1) Sri Lanka (n = 1) India (n = 3)

Australia (n = 4) England (n = 2) Holland (n = 1)

Language spoken

English (n = 12) Mandarin (n = 4) Cantonese (n = 1) Arabic (n = 2) Hindi (n = 3)

Mandarin (n = 4)

English (n = 5)

Arabic (n = 1)

English (n = 7)

Cantonese (n = 1) Arabic (n = 1)

the participant. Extrinsic motivators included encouragement from a doctor, family or council member who suggested participation in the program. ‘‘Any exercises that the doctors tell me to do, I do.’’ (Participant number–p. 9) Logistical factors such as location and convenience also assisted some participants to participate. ‘‘Just happy that someone was here and we didn’t have to go far.’’ (p. 14)

[(Fig._1)TD$IG]

These and other similar statements indicated that these practical considerations may also influence the decision to commence in a program of this nature. Intrinsic motivators predominantly revolved around the notion held by participants that exercise in general was good for them. They anticipated that the exercise would be beneficial to them for ‘keeping fit’ (p. 9), and ‘keeping young’ (p. 4). ‘‘Anything to get me out of a chair and get me moving would be a good thing.’’ (p. 6)

Sri Lankan (n = 1) Hindi (n = 3)

Some participants gave more specific reasons such as improving strength and balance while a few participants cited preventing falls as the rationale behind their participation in the Making a Move program. ‘‘Because of the exercise. I wanted just to strengthen my legs and my body. At my age, everything gets weaker and I have a balance problem.’’ (p. 10) One participant’s desire to participate and prevent falls stemmed from their previous experience in caring for their wife. ‘‘Because I had the experience of having to nurse my late wife. Toward the end of her life, she had a series of falls most of which were inside our apartment. From that I learnt a lesson and I thought well I don’t really want that to happen to me if I can avoid it.’’ (p. 1) 3.2. Benefits reported from participating in the Making a Move program Most of the participants interviewed believed that their participation in the Making a Move program was beneficial to

External Factors

Doctor

Council member

Internal Factors Internal belief in benefits

Family member

Enabling factors: • Location • Convenience

General health

Fall related

Encouragement or suggestion

Improve balance

Improve strength

Previous experience Fig. 1. Reasons for participation in the Making a Move program.

[(Fig._2)TD$IG]

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287

No, the program did not benefit me

Yes, the program benefitted me

Enjoyment

Educational benefit (minimal recall)

Physical improvement

No perceived risk of falling

Physically fit

Exercises too easy

Already exercising Performing the exercise

Participant / Staff

Social interaction

Flexibility

Mobility

Balance

Participant / Participant

Fig. 2. Benefits reported from participating in the Making a Move program.

some extent. Fig. 2 maps these reported benefits and also the reasons why some participants did not believe they benefited. The benefits reported from program participation were grouped into themes of enjoyment, physical improvement and educational benefit. Many of the participants interviewed enjoyed their participation in the Make a Move program. They enjoyed participating in the exercises, the social aspect of the program and the fact that it was beneficial to their health. The social benefits were enjoyed by both the group and home based participants alike, and the participants from both a CALD and nonCALD background. ‘‘It was good for me because when we gather there, we all communicate, we have entertainment, it’s much better for me. What’s good about it is that because everyone there is old, we do like a team altogether, so we enjoy it together. The people who are in charge, they are very kind people and looking after us.’’ (p. 18) Particular gratitude and recognition was given to the dedication and personalities of the staff involved in the Make a Move program and to the council and government for funding the program. ‘‘I just want to thank the Australian government for looking after their senior citizens.’’ (p. 22) Twelve of the twenty-three participants interviewed reported physical benefits such as improved joint flexibility, mobility and balance from their participation in the Make a Move program. ‘‘I think that it helps your balance a bit because you’re doing the exercises on your feet and your legs and that’s where you get your balance from. But I haven’t had any falls oh for years now and I think the exercises help with that.’’ (p. 5)

Another theme of benefit was improved knowledge from the educational components of the program. However, only five participants (all from group based programs) were able to recall any details of the education provided and of these, three gave specific examples of things they changed in response to the education. These included changing footwear, removing a mat in the lounge room so as not to trip and ensuring well lit areas around the house. ‘‘They gave me an idea to make sure about your shoes and not to wear (which I try to do) sandals, or try to make sure that you’ve got proper shoes on your feet, you know lace up, so that you’ve got support.’’ (p. 16) Not all participants felt the Making a Move program was of benefit to them. One of the reasons given for this was that they were already participating in other forms of physical activity, such as carpet bowls. Related to this was the perception that the participant was already fit, strong and healthy and that their existing physical activities were sufficient to maintain this. Also related to this was the perception that the participant was not at risk of falls, possibly in part due to their level of health and fitness, and also in part due to their participation in alternate forms of physical activity. ‘‘They probably weren’t for me because I didn’t feel that I was up to the stage where I required that sort of participation. I don’t use a walker, I don’t use a stick, I’m sort of active. I don’t attend exercise classes or anything but I am very mobile. And I felt that passing around rubber balls and doing that sort of thing just wasn’t for me at the point in time.’’ (p. 13) Another theme of reasons given for why the program was not of benefit was that some participants felt the exercises prescribed

[(Fig._3)TD$IG]

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288

Did you try to keep exercising after Making a Move?

Yes

No

If so, what did you do?

Exercises on T.V.

If not, why not?

Group program

Independent home exercise program

Walking

Exercises too easy No longer need to exercise

Same

Preference for other activity

Mood

Lazy

Lack of enjoyment

New

Were you able to keep doing it consistently?

Yes

No

What helped you continue?

T.V.

Convenience

Why did you stop?

Group setting

Reminders to exercise

Cost

Lack of enjoyment

No longer need to exercise

Forget

Fig. 3. Factors influencing decision of whether to continue exercising.

were ‘too easy to be of benefit’ (p. 11) to them considering their level of fitness at the time. ‘‘At the moment I am doing something that is far more demanding (physiotherapy group class) and which fulfills my needs more.’’ (p. 11) 3.3. Ongoing participation in elements of the Making a Move program Continued participation in exercise elements was most commonly discussed. Other elements of the Making a Move program, such as environmental modifications, were also continued. However, these non exercise elements were often activities that were completed once and did not require continued effort to perform. Examples of ongoing behaviors such as having regular vision checks, improving daily nutrition and hydration, or ensuring regular sun light exposure to promote vitamin D levels (all explained within the educational component of the program) were not described. Fig. 3 conceptualises the factors influencing the decision of whether to continue exercising to reduce the risk of falls after the completion of the Making a Move program. It was noted in these discussions that some had initially attempted to continue, but had met with barriers that meant they were no longer continuing. Thus we identified three themes of responses; i) those describing why some participants chose not to continue exercising at all following completion of the Making a Move program, ii) those describing why some participants initially tried to continue but eventually ceased, iii) and those describing facilitators to continued participation. Those participants who were no longer exercising reported that they were too lazy, not in the right mood, no longer needed

to exercise, did not enjoy exercising on their own or preferred another activity such as walking. Participants seemed more likely to walk as a regular form of ongoing exercise than performing exercises specific to falls prevention. This was perhaps because walking was seen as functional and necessary (for example, to get to/from the shops). There also seemed to be a belief that the exercises were supposed to help with walking and that once the walking had improved, the exercises were no longer needed. ‘‘She has stopped doing the exercise because she can walk so now she is only doing strolling or slow walking. Those exercises were group exercises, without the group she doesn’t do it. . .. . .those exercises are for those that need it and she doesn’t need it anymore.’’ (p. 22) Some participants from both the group and home based programs reported that they continued to do some of the exercises at home after the completion of the Make a Move program. It was interesting to note that group program participants broadly ceased participation in group based programs, instead performing similar exercises at home alone. Continuing to do exercises at home independently was often discussed as being less enjoyable. ‘‘When you have to do it at home it’s not as much fun.’’ (p. 21) Two groups however did continue to operate following completion of the Making a Move program. It was not clear who was funding these exercise groups or whether the focus of the program continued to be falls prevention. A separate group of Chinese speaking participants had an option to continue participation in some type of exercise group. However, this didn’t eventuate because of the potential fees involved.

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‘‘They tried to run it a second time. The first time there were no fees, the second time they tried to collect $1 each and because the senior citizens can’t be certain they can attend every time and sometimes they can’t come because of other things, we didn’t want to pay.’’ (p. 22) Some of these members joined a Tai Chi program in the community to which they or other members of their group had previously been involved. Other participants reported following an exercise program on television (Channel 31) indicating that education entertainment programs in mass media are accepted by some who have been exposed to supervised exercise programs. 4. Discussion This research has identified that sustained participation in exercise for falls prevention following program completion was inconsistent despite being of benefit to those who participated in the short term. Other behaviors encouraged through the program that required ongoing input from the participant were not undertaken. This indicates that multi dimensional falls prevention programs such as the Making a Move program require further adaptation to bring about longer-term health behavior change, particularly for non-exercise behaviors. This study identified a number of key areas that might be useful in enhancing the success of similar falls prevention initiatives in future. Potential improvements to such programs regarding participant recruitment, exercise prescription, participant education and strategies to support sustained participation in behavioral changes to prevent falls are now suggested. The results of this study support the role of the health professional in promoting participation in falls prevention programs. Encouragement from a doctor or council member was cited as a reason for participation in the Making a Move program. This is consistent with previous research suggesting an invitation from a health professional, particularly a doctor, to participate in physical activity (Grossman & Stewart, 2003) and falls prevention interventions (Yardley et al., 2006) is influential. Recently a metaanalysis also reported higher levels of adherence to home exercise falls prevention programs utilising a participant health service approach to recruitment (Simek, McPhate, & Haines, 2012). In terms of successfully recruiting participants into falls prevention programs, these results suggest program providers should link with local health care providers and care giver networks. In doing so, there is a risk however that individuals who are highly connected to health and support services will be involved, thus other avenues for recruiting less connected participants (for example, emergency department presentations and general media advertising) should also be considered. The difficulty of the exercises prescribed was of concern to some of the participants of the Making a Move program. For exercises to be of physical benefit, they need to be challenging enough to stimulate adaptation processes (Bird, Smith, & James, 1998) but not so difficult that they pose a safety risk or cause negative effects such as increasing pain. Balance training in particular needs to be highly challenging in order to be effective in preventing falls (Sherrington et al., 2008). While no participants described any negative effects or safety issues associated with the exercises they were prescribed, some participants felt that the exercises were too easy to be of benefit. Easy exercises were also associated with a lack of enjoyment thereby affecting the likelihood of continued exercise participation in the long term and perhaps influencing the tendency for participants to feel like they no longer needed to participate in such exercises after the completion of the program. This raises an important issue in the prescription of exercises associated with falls prevention

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programs, being that the difficulty of exercises need to be tailored to the physical capacity of each individual client. This is logistically difficult to achieve in a group environment where the staff to client ratio is significantly lower than in a home based program and where there is likely to be variation in the physical abilities of the participants. In a study investigating the factors influencing the clinical decision making processes used by expert physical therapists working in specialist falls and balance clinics, therapists were observed to address this difficulty by prescribing the same exercise types to group program participants and modifying the dosage according to individual client ability (Haas et al., 2012). Section 2.7.2 method of overcoming this difficulty may be to use an ‘exercise station’ approach whereby each participant in the group has the opportunity to perform some balance exercises appropriate to their individual physical ability under the close supervision of a trained staff member during each exercise group. Likewise care workers exercising with home based clients should perhaps be trained in the progression of exercises to address physical improvements made by the client throughout the program or reassessment by a physical therapist could be made available. A weakness of the 2009 Making a Move program identified in this study was that very few of the participants were able to recall the education component of this program. This differs to an investigation of another educational falls prevention program (Stepping On) where older adults were able to recall most aspects of the educational content (Ballinger & Clemson, 2006). However, this study used a cognitive-behavioral approach to increase knowledge and change attitudes and behaviors as opposed to the didactic approach used in the Making a Move program. It is possible that the didactic approach used did not engage participants sufficiently in order for them to retain the information let alone act on it. Goal setting, a technique involving the establishment of specific, measurable, achievable, realistic and time targeted goals, has been advocated as a useful strategy to establish and maintain motivation for behavioral change (Goodwin & Briggs, 2012; Locke, Shaw, Saari, & Latham, 1981; Yardley et al., 2007). Therefore, modifying the educational style of future programs to be goal directed could possibly enhance ongoing participation in health behaviors related to falls prevention. The use of goal setting has since been applied to a second iteration of the Making a Move program (2011), the benefits of which are currently being investigated. Another explanation for the difference in participant recollection of education content observed between the Stepping On program and the Making a Move program might be the greater time lag between program completion and participant interview in this study’s methodology. Participants of the Stepping On program were interviewed 3 months following program completion compared to after 12 months in our study. To eliminate this potential issue, future studies could focus on investigating the memory retention of participants educated immediately following program completion and the likelihood of continued participation in health behaviors related to falls prevention in addition to actual participation 12 months after. Although not necessarily an intentional effect, one of the integral components to the Making a Move program was the enjoyment experienced by its participants. Many of the program participants (in both group and home based settings) reported enjoyment derived from the exercises themselves and the social aspect of the program. Enjoyment was also seen to be a determinant in the likelihood of continued participation in exercise following program completion. The importance of continuing to integrate enjoyment into the exercises, education and social interactions associated with future falls prevention programs is supported theoretically and empirically. According to cognitive evaluation theory, enjoyment derived from a particular

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behavior may serve to maintain or increase a person’s intrinsic motivation for the particular behavior (Deci & Ryan, 1985). Enjoyment has also been demonstrated as an important predictor of exercise adherence (Resnick & Spellbring, 2000; Ryan, Frederick, Lepes, Rubio, & Sheldon, 1997; White, Randsdell, Vener, & Flohr, 2005). Publicising the enjoyment gained from older adults’ personal experience with falls prevention programs may therefore serve to enhance the uptake of future initiatives. Since some of the program participants had not participated in exercises for falls prevention before, this also highlights the importance of providing an enjoyable first time experience. Previous research suggests that cultural diversity affects the barriers and facilitators to older adults’ participation in falls prevention interventions (Horton & Dickinson, 2011). However, our study found little difference in the barriers and facilitators to ongoing participation in exercise for falls prevention following participation in the Making a Move program amongst CALD and non-CALD groups. These barriers and facilitators were similar to those identified in previous research (Bunn et al., 2008; Hill et al., 2011; Yardley et al., 2006). Specifically, encouragement by a carer, family member or health professional provided motivation to partake in the Making a Move program, along with program location and convenience, while barriers to continued participation in exercise included impediments to ongoing program delivery and attitudes such as insufficient motivation, performing other activities such as walking, and lack of enjoyment. One reason why our results may have differed from previous research is that the Making a Move program was delivered in a culturally specific manner. The use of language/cultural group specific programs utilising care workers from similar cultural backgrounds may have assisted participants to engage with the program initially, which may have been an issue that was not addressed in previous research. The effectiveness of long term therapies such as fall prevention programs may be compromised by older people’s reluctance to participate in or continue with recommendations (Sabate, 2003). In particular, ongoing exercise is necessary for a lasting falls prevention effect (Sherrington et al., 2011). However, in this study, sustained participation in exercise for falls prevention following completion of the Making a Move program was inconsistent and ongoing behavioral changes to reduce the risk of falling other than exercise were not reported. These results suggest that adherence to falls prevention recommendations in the long term may be problematic. Indeed, a recent systematic review has identified that after 12 months, it is possible that only half of communitydwelling older people are likely to be adhering to falls prevention interventions in clinical trials (Nyman & Victor, 2012). It therefore follows that future falls prevention initiatives should be intentional in how they support sustained participation in falls prevention recommendations. Regular monthly phone calls by support workers to provide ongoing encouragement have been found to be of assistance in enhancing long term participation in fall prevention home exercise programs (Simek et al., 2012) and could perhaps be applied to future programs. Similarly, training a community leader or facility worker to deliver a falls prevention exercise program to groups who are already meeting for other purposes may encourage long term participation in group based exercises. For such groups, participants would already have structures and supports in place to enable regular meetings but may need to be supported by intermittent consultation with an exercise professional in order to ensure the appropriateness of exercises for individual participants in terms of exercise type, dosage and progression. A number of difficulties were encountered in conducting this study. As previously mentioned, this study was limited by difficulties experienced in collecting data from older adults twelve

months after the program completion. Recruitment was hindered by agencies being unable to contact participants because they had moved to alternate accommodation during this time, by participant refusal to be interviewed and by potential participants developing cognitive decline during the follow up period. These difficulties may have led to a selection bias in that the participants interviewed were perhaps higher functioning and more likely to find the exercises too easy. Future studies could be improved by asking participants to consent to follow up interview at the completion of the program. Additionally assessing follow up knowledge of health behaviors relating to falls prevention separately from ongoing participation in such behaviors may help to differentiate between knowledge retention and behavioral change. Finally, the ultimate aim of any falls prevention program is to prevent falls. Therefore future studies should focus on assessing the impact of the Making a Move program on the number of falls experienced by participants. 5. Conclusions Participation in the 2009 Making a Move program was generally thought to be beneficial to those who participated. Reported benefits included physical benefits such as improved joint flexibility, mobility and balance; and enjoyment derived from the exercises themselves and the social environment. Recall of the educational component was minimal and ongoing behavioral changes to reduce the risk of falling other than exercise were not reported. Participation in ongoing exercise for falls prevention following the completion of the Making a Move program was inconsistent. Future improvements could focus upon ensuring the exercises prescribed are sufficiently challenging for each individual in order to be of physical benefit, altering the educational style to be goal directed and more enjoyable and integrating strategies to support sustained participation in behavioral changes to reduce the risk of falling. Linking participants with alternate ongoing exercise opportunities or potential sources of ongoing support may be advantageous in enhancing long term participation in exercise for falls prevention. Tailoring a program to the cultural needs of its participants may be helpful in facilitating participation of culturally diverse populations in falls prevention programs. Role of funding source The funds for the Making a Move falls prevention program and its evaluation were provided by the South East Healthy Communities Partnership, Victoria, Australia. Conflict of interest statement Terry Haines is the director of Hospital Falls Prevention Solutions Pty Ltd. This company provides consultative services to hospitals for the prevention of falls however this is not the subject matter of the present manuscript. He has provided expert witness testimony on the subject of the prevention of falls in hospitals and has received payment to speak at conferences on the same subject. Acknowledgments The authors thank Eva Pausenberger and Angel Lee for their assistance in conducting the semi-structured interviews for this project. The authors also wish to thank the following service providers (City of Greater Dandenong, Royal District Nursing Service, Southern Migrant and Refugee Center, Women’s Health in the South East and Move4Health) and participants of the 2009 Making a Move falls prevention program provided by South East

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Healthy Communities Partnership for their assistance in this project.

Appendix A. Semi structured interview questions used with participants Reason for Participation To start with, I would like to know why you took part in the Making a Move program in the first place? How did you first find out about this program? Did you discuss taking part in this program with anyone else, for example, a friend, family member, a doctor or other health professional? If yes: What did they say? Can you tell me why you took part in the Making a Move program? Feelings about the Making a Move program Now I would like to know about how you found taking part in the Making a Move program. Can you tell me how you felt about the Making a Move program overall? Prompt: Was it enjoyable–if so, what aspects? Prompt: Were there things about the program that you did not like–if so, what aspects? Can you recall if there were times that you did not want to do one of these sessions? If so: Why did you feel this way? Exercise Component The following questions are about the exercises that you did as a part of the Making a Move program. How did you feel when you were first told that you would be doing exercises as a part of Making a Move? Prompt: Had you done exercises like that before? Prompt: Were you confident that you would be able to do exercises like that? Prompt: Did you think the exercises would be beneficial to you at that time? If so: how? If not, why not? Did participating in the exercises change how you felt about doing exercises like that or being physically active in general? Prompt: Did performing the exercises affect how confident you were to exercise or be physically active? Prompt: Did you think that doing these exercises affected your health in any way (good or bad)? Prompt: Did you think that doing these exercises affected your mobility and independence to move around? Education Component The following questions are about discussions you may have had as a part of the Making a Move program. During the program, you may have had discussions about your feet and footwear, vision and diet. How did you find these discussions? Prompt: Did you feel comfortable to ask questions that were important to you? Do you think that you learned anything from these discussions? If so: what did you learn? If not: why not? Is there anything that you did at the time or after the Making a Move program finished because of what you discussed at these services? If so: describe what you have done. If not: why do you think you have not done anything? Exercise after the program finished The following questions are about exercise and physical activity that you may have done since the Making a Move program finished. Have you done any exercises like what you did as part of the Making a Move program since it finished? If so: Describe what you have done. Prompt: Did you do this as a part of a group or on your own? Prompt: How long have you been doing it for/when did you start/have you stopped? If not: Why have you not done any? Prompt: What would encourage you to start doing this sort of exercise again? Prompt: If you were to start doing this sort of exercise again, do you think it would be helpful to you? How/why not? Have you done other forms of physical activity or exercise since the Making a Move program finished that you were not doing before you did the Making a Move program? If so: Describe what you have done.

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Prompt: Are you doing this as a part of a group or on your own? Prompt: How long have you been doing it for/when did you start/have you stopped? Prompt: Why did (do) you do this exercise/why did you stop? Prompt: Do you think doing this physical activity is helping you? How/why not? If not: Why have you not done any? Prompt: If you were to start doing this sort of exercise again, do you think it would be helpful to you? How/why not? Have you had any falls since you finished the Making a Move program that you would like to tell me about? Finally: Is there anything else about the Making a Move program that you feel is important that we have not yet discussed?

References Australian Institute of Health and Welfare. (2002). Australia’s health 2002. Australia’s health no. 8. Cat. no. AUS 25. Canberra: AIHW. Australian Institute of Health and Welfare. (2007). Older Australia at a glance: 4th edition. Cat. no. AGE 52. Canberra: AIHW. Ballinger, C., & Clemson, L. (2006). Older people’s views about community falls prevention: an Australian perspective. The British Journal of Occupational Therapy, 69(6), 263–270. Bird, S. R., Smith, A., & James, K. (1998). The Principles of Exercise Prescription. Cheltenham: Nelson Thornes. Bradley, C. (2012a). Hospitalisations due to falls in older people, Australia 2007–2008. Injury research and statistics series no. 61. Cat. no. INJCAT 137. Canberra: AIHW. Bradley, C. (2012b). Hospitalisations due to falls by older people, Australia 2008–2009. Injury research and statistics series no. 62. Cat. no. INJCAT 138. Canberra: AIHW. Bunn, F., Dickinson, A., Barnett-Page, E., Mcinnes, E., & Horton, K. (2008). A systematic review of older people’s perceptions of facilitators and barriers to participation in falls-prevention interventions. Ageing and Society, 28(4), 449–472. Centre for Health Advancement, & Centre for Epidemiology and Research, (2010). New South Wales Falls Prevention Baseline Survey: 2009 Report. Sydney: NSW Department of Health. Clemson, L., Cumming, R. G., Kendig, H., Swann, M., Heard, R., & Taylor, K. (2004). The effectiveness of a community-based program for reducing the incidence of falls in the elderly: A randomized trial. Journal of the American Geriatrics Society, 52(9), 1487–1494. Cohen, D., & Crabtree, B. (2006). Qualitative research guidelines project. Retrieved from http://www.qualres.org/HomeGuid-3868.html. Day, L., Fildes, B., Gordon, I., Fitzharris, M., Flamer, H., & Lord, S. (2002). Randomised factorial trial of falls prevention among older people living in their own homes. BMJ (Clinical Research Ed.), 325(7356), 128. Deci, E. L., & Ryan, R. M. (1985). Intrinsic motivation and self-determination in human behavior. New York: Plenum Press. Gill, T., Taylor, A. W., & Pengelly, A. (2005). A population-based survey of factors relating to the prevalence of falls in older people. Gerontology, 51(5), 340–345. Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Sherrington, C., Gates, S., Clemson, L. M., et al. (2012). Interventions for preventing falls in older people living in the community. The Cochrane Library. Goodwin, V., & Briggs, L. (2012). Guidelines for the Physiotherapy management of older people at risk of falling. Chartered Physiotherapists working with Older People. Grossman, M. D., & Stewart, A. L. (2003). You aren’t going to get better by just sitting around: Physical activity perceptions, motivations, and barriers in adults 75 years of age or older. The American Journal of Geriatric Cardiology, 12(1), 33–37. Haas, R., Maloney, S., Pausenberger, E., Keating, J. L., Sims, J., Molloy, E., et al. (2012). Clinical decision making in exercise prescription for fall prevention. Physical Therapy, 92(5), 666–679. Hill, A. M., Hoffmann, T., McPhail, S., Beer, C., Hill, K. D., Brauer, S. G., et al. (2011). Factors associated with older patients’ engagement in exercise after hospital discharge. Archives of Physical Medicine and Rehabilitation, 92(9), 1395–1403. Home and Community Care (HACC). (1985). Funding & services. Retrieved from http:// www.health.vic.gov.au/hacc/hacc_victoria/funding.htm. Horton, K., & Dickinson, A. (2011). The role of culture and diversity in the prevention of falls among older Chinese people. Canadian Journal on Aging, 30(1), 57–66. Huang, H. C., Liu, C. Y., Huang, Y. T., & Kernohan, W. G. (2010). Community-based interventions to reduce falls among older adults in Taiwan – long time follow-up randomised controlled study. Journal of Clinical Nursing, 19(7-8), 959–968. Locke, E. A., Shaw, K. N., Saari, L. M., & Latham, G. P. (1981). Goal setting and task performance: 1969–1980. Psychological Bulletin, 90(1), 125. McLennan, W. (1999). Standards for Statistics on Cultural and Language Diversity. ABS Catalogue No. 1289.0. Canberra: Australian Bureau of Statistics, Commonwealth of Australia. Moller, J. (2003). Projected costs of fall related injury to older persons due to demographic change in Australia: Report to the Commonwealth Department of Health and Ageing. Canberra: New Directions in Health and Safety. Nyman, S. R., & Victor, C. R. (2012). Older people’s participation in and engagement with falls prevention interventions in community settings: An augment to the Cochrane systematic review. Age and Ageing, 41(1), 16–23.

292

R. Haas, T.P. Haines / Archives of Gerontology and Geriatrics 58 (2014) 283–292

Omeri, A., & Raymond, L. (2009). Diversity in the context of multicultural Australia: Implications for nursing practice. Contexts of nursing: An introduction, Churchill Livingstone, Australia: Elsevier. Pausenberger, E., & Haines, T. P. (2011). Application of evidence-based fall-prevention strategies to culturally and linguistically diverse older adult populations in Australia. Diversity in Health and Care, 8(4), 225–237. Pope, C., Ziebland, S., & Mays, N. (2000). Analysing qualitative data. British Medical Journal, 320, 114–116. Resnick, B., & Spellbring, A. M. (2000). Understanding what motivates older adults to exercise. Journal of Gerontological Nursing, 26(3), 34. Robson, E., Edwards, J., Gallagher, E., & Baker, D. (2003). Steady As You Go (SAYGO): A falls-prevention program for seniors living in the community. Canadian Journal on Aging, 22(2), 207–216. Ryan, R. M., Frederick, C. M., Lepes, D., Rubio, N., & Sheldon, K. M. (1997). Intrinsic motivation and exercise adherence. International Journal of Sport Psychology, 28, 335–354. Sabate, E. (2003). Adherence to long-term therapies: Evidence for action. Geneva: World Health Organization. Sherrington, C., Tiedemann, A., Fairhall, N., Close, J. C., & Lord, S. R. (2011). Exercise to prevent falls in older adults: An updated meta-analysis and best practice recommendations. New South Wales Public Health Bulletin, 22(4), 78–83.

Sherrington, C., Whitney, J., Lord, S., Herbert, R., Cumming, R., & Close, J. (2008). Effective exercise for the prevention of falls: A systematic review and metaanalysis. Journal of the American Geriatrics Society, 56(12), 2234–2243. Simek, E. M., McPhate, L., & Haines, T. P. (2012). Adherence to and efficacy of home exercise programs to prevent falls: A systematic review and meta-analysis of the impact of exercise program characteristics. Preventive Medicine, 55(4), 262–275. University of Otago School of Medicine. (2003). Otago exercise programme to prevent falls in older adults. Retrieved from http://www.acc.co.nz/PRD_EXT_CSMP/groups/ external_providers/documents/publications_promotion/prd_ctrb118334. pdf. White, D. J. L., Randsdell, L. B., Vener, J., & Flohr, J. A. (2005). Factors related to physical activity adherence in women: Review and suggestions for future research. Women and Health, 41(4), 123–148. Yardley, L., Beyer, N., Hauer, K., McKee, K., Ballinger, C., & Todd, C. (2007). Recommendations for promoting the engagement of older people in activities to prevent falls. Quality and Safety in Health Care, 16(3), 230. Yardley, L., Bishop, F. L., Beyer, N., Hauer, K., Kempen, G.I.J.M., Piot-Ziegler, C., et al. (2006). Older people’s views of falls-prevention interventions in six European countries. Gerontologist, 46(5), 650–660.