Understanding fall meaning and context in marketing balance classes to older adults.

Article

Understanding Fall Meaning and Context in Marketing Balance Classes to Older Adults

Journal of Applied Gerontology 32(1) 96–119 © The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464811399896 http://jag.sagepub.com

Lauren Clark1, Sallie Thoreson2, Cynthia W. Goss3, Lorena Marquez Zimmer4, Mark Marosits5, and Carolyn DiGuiseppi3 Abstract This study explored older, community-dwelling adults’ attitudes and values about proposed church-delivered balance classes for fall prevention. Community observation, group interviews with stakeholders, key informant interviews, and focus groups with church members ≥60 years of age were analyzed in two ways: first for inductive themes expressing community sentiment about fall prevention for older adults, then for content useful in creating locally tailored social marketing messages. Four themes expressed perceptions of fall-prevention programming: de-emphasizing fall risk and emphasizing strength and independence, moving older adults out of their “comfort zones” to join classes, identifying relationships to support fall-prevention activities, and considering gender-based differences in approaches to fall prevention. A content analysis of the same dataset yielded information about preferred places in the community, promotion through churches, a tolerable price, and the balance class product itself. The qualitative results will inform the social marketing program to increase intervention delivery success. Keywords qualitative methods, attitudes and perception toward aging/aged, falls Manuscript received: July 26, 2010; final revision received: November 30, 2010; accepted: January 6, 2011. 1

The University of Utah, Salt Lake City, UT, USA Colorado Department of Public Health & Environment, Denver, CO, USA 3 Colorado School of Public Health, Aurora, CO, USA 4 Private Consultant, Denver, CO, USA 5 Worldways Social Marketing, Denver, CO, USA 2

Corresponding Author: Lauren Clark, PhD, The University of Utah, 10 S 2000 E, Salt Lake City, UT 84112 Email: [email protected]

Downloaded from jag.sagepub.com at NORTHERN ARIZONA UNIVERSITY on May 31, 2015

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Introduction Falls are a leading cause of emergency room visits, hospitalizations, and deaths from injury among older adults in the United States (Centers for Disease Control and Prevention, 2009). Falls resulted in total lifetime costs of more than US$19 billion among Americans ages 65 and older injured in 2000. Of older adults who fall, 20% to 30% suffer moderate to severe injuries such as bruises, hip fractures, or head trauma. Among community-dwelling older adults who sustain hip fractures, 15% to 25% remain institutionalized at least a year (Magaziner, Simonsick, Kashner, Hebel, & Kenzora, 1990) and 20% to 90% require assistance with physical activities as long as 1 year afterward (Magaziner et al., 2000). Deficits in balance (the ability to maintain upright posture and adjust to both voluntary movements and external stimuli) and strength are two major components of fall risk in older adults (Lord & Sturnieks, 2005; Berg & Kairy, 20022003; Moreland, Richardson, Goldsmith, & Clase, 2004). Age-related changes in vision, muscle strength, joint flexibility, and central nervous system responsiveness contribute to fall risk with aging (Steinman, 2008). Multiple systematic reviews have shown that balance and strength training prevents fall-induced injuries among older adults (Gillespie et al., 2009; Kannus, Sievänen, Palvanen, Järvinen, & Parkkari, 2005; Province et al., 1995). Although balance training for fall prevention has proven effective in research settings and with high-risk individuals in their homes (Gillespie, 2009), such programs have rarely been translated into community-based programs. Furthermore, fall prevention research has seldom been evaluated for community acceptability and uptake in broader communitybased populations (Centers for Disease Control and Prevention, 2004; Robitaille et al., 2005; Yardley et al., 2007). Individually prescribed exercise programs delivered at home, arguably effective in reducing falls (Gillespie et al., 2009), lack the large-scale efficiencies of group-based balance and strength training classes delivered in the community. However, many recreational facilities do not offer exercise programs for older adults, usually because they perceive limited demand in this population (Hughes et al., 2005). Older adults may avoid group balance and strength training classes for a variety of reasons, including fear of trying something new (Yardley et al., 2006); fear of falling (Scheffer, Schuurmans, Van Dijk, Van Der Hooft, & De Rooij, 2008); a belief that nothing can be done to assuage age-related loss of function (Muse, 2005); unfamiliarity with organized exercise classes (Muse, 2005); and a negative association of exercise with physical work (Aronson & Oman, 2004). Social marketing aims to influence the voluntary behavior of target audiences through persuasion (Maibach, Rothschild, & Novelli, 2002), and is a promising means to increase uptake of fall-prevention classes by older adults. Incorporating


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Journal of Applied Gerontology 32(1)

Table 1. Four Essential Elements of Social Marketing (Maibach et al., 2002) Social marketing component Product Price

Placea Promotion

Definition Identification of desired benefits and creation or alteration of products so as to deliver as many desired benefits as possible Assessment of barriers or costs involved in adopting the product, whether psychological, economic, social, or environmental, and alteration of the product to reduce or eliminate as many of these as possible Understanding where target market members spend their time, and when and where they make their decisions, and use of resources to make the product accessible and convenient Creation of product or program awareness through communication or education

a. The study was designed to be a faith-based initiative, so the Place category focused solely on the Place aspect of use of resources to make the product accessible and convenient.

key aspects of behavioral change theory (Janz, Champion, & Strecher, 2002), social marketing offers benefits appealing to the target audience and reduces barriers that discourage participation (Maibach et al., 2002; see Table 1). Social marketing requires research to understand the target audience, the audience segments that will relate similarly to a given marketing offer, and program qualities suited to the unique needs and circumstances of each segment (Maibach, Ladin, Maxfield, & Slater, 1996; Slater, 2005). Social marketing has been used successfully to encourage preventive health behaviors in previously noncompliant older adults (Harrison et al., 2003; McCaul, Johnson, & Rothman, 2002; Reger et al., 2002). Existing qualitative studies provide a research base about barriers to older adults’ fall prevention and exercise class engagement (Yardley, Donovan-Hall, Francis, & Todd, 2006), yet it remains unclear how older adults in specific communities perceive and weigh different barriers to class participation and how a social marketing campaign could be formulated to increase uptake of such classes. Without innovative, community-tailored approaches, group programs to promote balance are unlikely to gain popularity. Churches might be particularly valuable settings for implementing a social marketing program targeted to older adults to increase their uptake of communitybased fall-prevention classes to build strength and balance. Church attendance increases with age, peaking at about 70 years of age, and 30% of regular participants in American religious congregations are aged 60 years and older (Chaves & Anderson, 2008; Firebaugh & Harley, 1991; Ploch & Hastings, 1994).


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Population-based interventions delivered through faith-based communities are recognized as effective for primary prevention and general health (DeHaven, Hunter, Wilder, Walton, & Berry, 2004), respond to the social isolation barriers of older adults (Sabir et al., 2009), have proven promising for recruiting hard-to-reach populations and effective in promotion of various health behaviors (Campbell et al., 1999; Dehaven et al., 2004; Resnicow et al., 2002), and address the documented need to develop novel approaches at the population level to increase the number of older adults who initiate and maintain a program of regular physical activity as one way to improve overall quality of life (Kelley, Kelley, Hootman, & Jones, 2009). The use of social marketing to promote church-based, community-centered balance training classes to prevent falls among older adults has great potential to reduce mortality and morbidity. We conducted a qualitative study to inform a social marketing campaign to increase the uptake of an established, group-delivered fall-prevention program among older adults (≥60 years of age) in a community that had limited success maintaining similar classes in the past. The grant program that funded this study required translation of an existing evidence-based program for fall prevention. Knowing that success of the community-based intervention to reduce falls depended on a research-based understanding of aging, falls, and fall prevention for older adults who are church members, the goal of this research was to specify the social marketing plan. The principles and processes used may be of value in other locations with similar conditions and to program planners preparing similar preintervention assessments. N’Balance, the fall-prevention program selected for dissemination in churches, was chosen for several reasons. N’Balance adapts the evidence-based FallProof! program (Rose, 2010; Rose, Jones, Dickin, Lemon, & Bories, 1999; Rose, Jones, & Lemon, 2001) as a balance and mobility training program delivered in a variety of community settings. N’Balance incorporates the key programmatic elements and lesson plans of the FallProof! program, and provides a training course appropriate for parks and recreation staff and others with experience working with older adult wellness programs. The N’Balance/FallProof! program uses specific exercises that enhance the balance system and lower body strength; such programs have been proven to reduce falls in older adults (Gillespie et al., 2009; Kannus et al., 2005; Province et al., 1995). N’Balance was also chosen because trained instructors already resided in the county, as these classes had been previously offered in the community. Furthermore, training for new instructors was available in-state. Finally, the local recreation department was willing to partner with the study and offer N’Balance classes. One caveat to selecting for community translation an existing intervention like N’Balance that was developed from an evidence-based program is that it is not modifiable without potentially reducing its efficacy. It was


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important for us to understand how this program—when implemented as designed— could be positioned in the community for maximal uptake.

Design and Method A qualitative research design following Thorne’s (2008) interpretive description method was used to guide the social marketing program’s development and respond to the target audience’s inherent motivation to participate in balance retraining classes, barriers to and facilitators of participation, and key program messages needed to elicit interest in participation. The Colorado Multiple Institutional Review Board approved the study.

Study Setting Mesa County, Colorado (estimated 2008 population 143,171) was chosen as the study area because it has a higher than average proportion of older adults (20% vs. 14% in Colorado) and because more than one quarter of its population regularly attends religious services (Churches and Church Membership, 2002). Mesa County includes one city (population 46,898), seven small communities (population 388-6,478), and remaining rural unincorporated areas. Most residents are White non-Hispanic (84%) or Hispanic (12%; U.S. Census Bureau, 2009).

Data Collection Qualitative fieldwork began with a focused but relatively unstructured community assessment and observation period by the research team. Through preliminary on-site observations we explored the past community efforts to offer balance retraining exercise classes to older adults, enumerated local churches and described their older adult membership, and sought details about current types of churchsponsored and community-sponsored programs promoting older adult health and wellness. During the initial fieldwork we also convened stakeholder data collection through two group discussions (n = 11) and individual interviews (n = 2) with health and human service agency and religious organization representatives interested in aging and older adult health and safety. Interviews explored older adults’ patterns of participation in churches, their views about falls, balance retraining exercise classes, and aging, and how we might explore these topics with older adults. The research team analyzed this first set of qualitative data by thematically integrating detailed notes and observations, and used those results to prepare semistructured interview guides for subsequent key informant interviews and focus group discussions. We learned that balance retraining exercise classes


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had been offered through a hospital-based wellness facility and parks and recreation programs at various points in the past, but that community interest was so low as to make these unsustainable. We also learned about high levels of engagement of older adults in faith communities and the prominent social positioning of churches in the community. The next steps were key informant interviews followed by focus group discussions conducted by an experienced, contracted facilitator. After obtaining informed consent, the facilitator administered a short demographic survey, described the balance retraining exercise program (N’Balance), and then initiated the interview using the key informant or focus group interview guide, as appropriate (Table 2). Key informants (n = 8) were knowledgeable about and influential in older adult activities within the community and included recreation center staff and church leaders. Individual 1-hr interviews were held at the participant’s workplace or place of worship. Six focus groups (n = 50 participants total) were comprised of older adults representing church members who were potential users of fall-prevention classes. Focus groups allowed for participants to share opinions and construct meaning about falls without being put “on the spot” as happens with individual interviews (Barbour, 2007). Participants were purposively recruited by a research team member residing in the county through personal visits to congregations and supplemental snowball sampling from recruits’ social networks (Bernard, 2006). Focus groups ranged in size from 5 to 13 participants. Inclusion criteria for attendees included residence in and attendance at religious services in Mesa County; age ≥60 years; capacity to hear and communicate verbally in a group discussion; and English or Spanish speaking ability. Focus group members represented major denomination groups as determined by Steensland et al. (2000): Catholic, Mainline Protestant, and Evangelical Protestant. A fourth denomination, The Church of Jesus Christ of Latter-day Saints (Mormon), was also included based on their high numbers in the community. One focus group was conducted in Spanish, one was recruited from the only known church-based exercise class in the area, and one represented rural Mesa County. Mixed-sex focus groups were purposefully constituted to mirror the daily cross-gender talk of older adults in the community. The focus groups and key informant interviews were audio taped, with participant consent, and transcribed verbatim by a professional transcription service. The Spanish language transcript was translated into English. Most focus group participants were English speaking (92%), female (76%), non-Hispanic White (91%), and lived in a city (84%). The six groups involved Mormons (n = 8), Evangelical Protestants (n = 8), Mainline Protestants (n = 13),


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Table 2. Interview Guides for Key Informants and Focus Groups Key informant interview guide In your opinion, what is most important to people about an exercise program (Like N’Balance)? What would make the way this exercise program is conducted appealing? (Product) What are the barriers standing in the way of participating? (Price) Where are good locations to hold the program, in terms of convenience and accessibility? (Place) Knowing what you do about local churches here, how do you think we can best partner with churches to get the word out to reach people above the age of 60? (Promotion) If your church was invited to take part in a study of older adult exercise classes for fall prevention, what do you think would happen? (asked of faith-based leaders only) Focus group interview guide Are you aware that exercise is a way for you, as an older adult, to prevent injury? If yes, how did you learn about this? As outlined earlier, we will be using the N’Balance program, with classes to be held twice a week, for 8 weeks, per session. What do you think would keep people from participating in a program like this? What would encourage people to participate in an exercise program like this? How could it best fit with your lifestyle and the lifestyles of other older adults in this community? How would you sell an exercise program like this to your neighbors? Knowing what you do about your local churches, how do you think we can best work with them to promote this program and get the word out? Right now, exercise programs for older adults are offered in two locations (specific locations listed). Do you think these are the best places to hold the program, in terms of convenience and accessibility? Do you feel like older adults in this community are ready to participate in a program like the one we’ve been talking about?

Catholics (n = 5), and mixed Catholics and Mainline Protestants (two groups; n = 16 participants). Respondent age varied as follows: 9% were under 65 years, 53% were 65 to 74 years, and 38% were 75 or older. Only two focus group participants reported ever participating in a balance retraining class, whereas 16 (33%) had no plans to do so in the future. Given a community history of sporadic offerings of balance retaining classes and low attendance, exposure of focus group participants to balance classes was predictably low.


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Data Analysis After cleaning the data, checking the accuracy of the translation of the Spanish transcript into English, and reviewing the audiotapes and transcripts as a whole, the process of interpretive description (Thorne, 2008) began with successive readings of the transcripts, followed by text coding using Atlas.Ti (Muhr, 2004) software. To determine the appropriateness of combining results from different data generation methods, the stakeholder, focus group, and interview data were initially reviewed to determine their similarities and differences. This was done by comparing coding frequencies and content by different data generation methods. Based on lack of systematic differences, all data were combined into one analytic unit to allow for constant comparisons across denomination, language, gender, and previous experience with exercise or fall-prevention classes. Similarly, differences in fall-prevention programming preferences by denomination were assessed across focus groups, and no systematic differences were apparent. The coding process consisted of inductively assigning short descriptive labels to segments of text, categorizing coded text segments using principles of similarity, and iteratively expanding the written interpretation of the text through constant comparison of similarities and differences across transcripts. Each codeword was defined for reliability of application across the dataset and listed in a qualitative codebook with associated properties. Two research team members coded a 20% subset of the data independently, discussed their interpretation and coding, arrived at consensus, and developed the codebook used for successive coding activities. Following coding, category development, and comparisons across categories, the data were examined for cultural themes and patterns (Thorne, 2008). In this inductive process, the most salient ideas were coded, compared, clustered into categories, and used to inform theme identification. Themes distilled the meaning of the entire dataset into a few unifying and densely supported abstractions that captured the experiences of research participants (DeSantis & Ugarriza, 2000). A second analytic process examined the predefined social marketing dimensions of product, place, price, and promotion (Table 1) across the entire dataset. Weekly review of this deductive analysis with the entire research team resulted in consensus about coding and category descriptions. The trustworthiness of study findings was heightened through prolonged engagement of one research team member in the community for the duration of the study, an audit trail of the data collection and analysis processes, and the involvement of two experienced qualitative researchers. The iterative analysis process, using multiple qualitative data collection methods, served to increase theoretical sensitivity and enhance the validity of the results.


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Findings The inductive analysis identified four themes. The deductive content analysis yielded information about the preferred positioning of the program relative to place, promotion, price, and product.

Inductively Identified Themes Let’s not emphasize falling. Stakeholders were the first to express the view that falls are an unappealing thought and discouraging topic. The theme was subtly woven into key informant and focus group discussions. Older adults fear that a “major fall could transform their next living arrangement” overnight, according to older adults in a focus group at the Catholic Church. With a fall, they might need to move from their own home to a nursing home, as one participant explained. There is stigma associated with a “fall prevention class,” said health and community leaders: “If you tell them they’re going to lose their independence because of fall risk, they’re going to respond negatively to it.” Far from motivating them to attend a class, emphasizing falls implies unpleasant associations. “Don’t use the term ‘fall prevention’ because it implies vulnerability,” said another stakeholder. To counteract the chain of association between falls and flagging strength, diminished independence, advancing frailty, nursing home placement, and death, a balance retraining exercise class should emphasize more positive messages. “Try to tie a package together about strength, independence, maintaining their ability to live like they want to live,” said one older adult in a focus group at the Catholic Church. Other words recommended across focus groups as a substitute for fall prevention included calling the class a “‘strength,’ ‘endurance,’ ‘flexibility,’ or ‘a balance’ [class] but not too much about falls” or a class about “wholeness” and “independence.” Choosing a “fall”-related title would set expectations for fall prevention that may not only be unrealistic, according to a stakeholder, but also would focus on a negative aspect of aging rather than the positive potential. Even with a positive message, a balance retraining exercise program may paradoxically miss those who could benefit because they will believe they are not the target of the intervention. Fit but aging baby boomers believe they “don’t need it,” according to stakeholders. Frail older adults who are aware of their fall-prone status believe fall prevention is not for them either since aging and falling are unavoidable and the time for prevention has passed. Emphasizing strength and independence, as opposed to fall prevention, expands the circle of interested community members to include those who believe they are either too old and frail or too young and healthy to benefit from balance retraining exercise classes.


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Resistance to fall-prevention messages can be overcome through piggybacking on popular interests like beauty, food, friendship, dating, and glamour. Focus groups engaged in lively discussion about the attraction offered by skimpy outfits on young, fit instructors, or the possibility of finding a date through mixing with other singles at the classes. Animated brainstorming among stakeholders led to suggestions for limousine rides to add glamour to the lives of older adults on a fixed income, concierge service while one exercises, and manicures as add-ons to the classes. Sex, socializing, and status summed up the playful innovations used to underscore the real message: reframing the program to be about strength and independence is attractive to older adults. Fall-prevention classes are outside our comfort zone. As a stakeholder said, “leaving home to attend a formal class is threatening. They don’t want to expose themselves to risk.” There is “an insecurity about trying something new,” explained a key informant. “If they’ve never exercised before they may be hesitant to try this.” To counteract this insecurity, the same key informant suggested that class organizers “make them feel comfortable and welcome, and [assure them] that they are able to do some of these exercises themselves. Give them some confidence in what they’re able to achieve.” The comfort zone theme references the newness of group exercise for some older adults, the hesitance, fear, or exposure experienced by pushing one’s physical performance in new directions, unfamiliarity with the equipment and movements involved in balance retraining exercises, and a degree of disruption to well-worn routines entailed by adding a twice-a-week trip to a destination that could be inconvenient or unfamiliar. Considering the frontier heritage of this Colorado setting, many older adults define exercise as work. Recreational exercise is unfamiliar. “We’re a hearty group. This is the West,” explained participants in one focus group. According to stakeholders, “doing exercise is a generational thing.” Most older adults were physically active when they were younger. Physical labor, dancing, and walking were normal activities of community life. As there was no conscious decision or advice to exercise for the sake of health in their younger years, it is a challenge for older residents to think of exercise as recreation and health promotion. “They don’t think they need it. It’s exercise, it’s work, they don’t need it, they would never want it,” stated a stakeholder. The comfort zone theme also explains the experience of Hispanic residents of the community who may view balance retraining exercise classes with skepticism. As a key informant of Hispanic descent explained, The older adults in the Hispanic group still have that syndrome that says “I don’t belong.” That’s the way it was in the past, and it will never change. A lot of them basically don’t want to get involved. They’re in a comfort


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zone. And to get into exercise, to losing weight, you have to change your way of living and get out of your comfort zone. What would it take for someone to get out of a comfort zone and participate in a program of balance retraining? For the Hispanic key informant, You have to be able to get out there and gamble. You’ve got to take a chance. And a lot of older people say, “I’m not willing. I’m comfortable here.” In other words, fences that we build up towards people keep us from controlling our own life, to get into a program. It’s hard to take charge of your own life. Focus groups developed the idea of the comfort zone in more detailed, situation-specific ways. Concerns about appearance, being compared with those “ballerina types,” fitting into a spandex outfit, and performance expressed embarrassment. A man who attended the focus group at the Catholic Church explained, “men and women can do [exercises] together with people they know, people they’re comfortable with and they won’t feel embarrassed.” The embarrassment, he explained, could be the result of “testosterone” and competition that pits participants against each other. A man at the Mormon focus group said, “Maybe we think if we are going to exercise with a bunch of guys they are going to outdo us. They will be able to do it better.” Perceptions about exercise as work in a semirural community, Hispanic perceptions of being outside the mainstream of community participation, competition in fitness levels, and the vulnerability of exposing oneself all contributed to the theme of fall prevention as an activity outside a personal and community comfort zone. Relationships support a good program. A key informant aptly summed up this theme when he was asked to describe a successful participatory, group-based intervention for older adults in churches like the balance retraining exercise program we proposed. “Speaking generally, I think it’s relationships.” “If you had your best friend go with you, then it works,” said one focus group attendee in a Protestant focus group. The challenge for program organizers is to build on the existing camaraderie and social support shared by congregants while still actively including those who are more isolated or have fewer friends at church. The relationship between a pastor and his older adult congregants initiates successful recruitment. A direct invitation from the priest was recommended by the Spanish-speaking focus group participants to spur recruitment. In a mainline Protestant group, a participant shared how important it is to “get the leaders involved and enthused, because so much of the enthusiasm comes from the top down.”


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Reinforcement for balance retraining exercise class attendance can come from family members, too. A member-checking interview with a woman who attended a class in the past mentioned that her son and husband urged her to follow through with the referral to attend. Relationships and support from others in the class will maintain participation. For example, finding key older adults who are natural lynchpins in the faith-based community was touted as the best kind of relationship-based retention. “What’s most important is the social aspect of catching up with people. That it’s among friends and so forth. You develop a friendship circle in that group.” Older adults at the focus groups believed that social events would spring up around the classes. Carpools to and from class, maybe a potluck lunch after class, some time to visit, and an additional kind of religious fellowship were possible relationship-building extensions to the class itself. As one focus group participant said, “we are at the point we realize that exercise is important. We all want to be in the best shape we can for our longevity. But I think I would look forward to a group with our church and the fact that a combined group of men and women is good for getting together, talking, sharing. It would be an uplifting thing to do.” In sum, relationships are important in recruiting older adults to a balance retraining exercise program, maintaining attendance, and building long-lasting ties that extend beyond the fall prevention initiative and enrich life. Women respond to a fall-prevention message more than men, and men rely on women for motivation. When probed on the topic of gender differences, a focus group discussant said, “Men are much more resistant to exercise. They’re self-conscious, whereas us girls go to spas and it doesn’t bother us.” One key informant said that “wives have to come with those husbands who are kind of bad.” A key informant told a story to illustrate the point: An older woman had to “bring in her husband to the physical therapy and exercise area. He was expected to work on the machines. She’d sit over on the wall and read a book,” presumably because she had no need for fall prevention and was there to motivate her husband. Similarly, a key informant said her husband went to an exercise class because she “worked on the doctors to tell him to go,” and she had to “push him.” Women’s responsibility in the community was to get men to take care of themselves. Women’s own participation in fall prevention or exercise classes was secondary. By telling stories of their heroism in getting cranky or difficult men to exercise, women disclosed their own positions of power in their households. By alluding to the need for a manly way to participate in exercise, men retained their decisiveness in directing their own health interventions and their independence from women’s control. The appeal of attending a balance retraining exercise class to be with one’s spouse or meet an interesting new person of the opposite sex was the reason given on the surface for hosting mixed-sex groups. Sometimes there


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are husband and wife teams who participate in groups like this, offering support to each other to attend, as one key informant observed. Having same-sex classes was suggested in the Catholic focus group to reach men since men-only groups work for “choir, Knights of Columbus, a men’s Bible Study group.” The same idea surfaced in a Protestant focus group when one participant said, “I think it would be better to have a man’s class and a woman’s class.” Another participant objected, stating, “We have a man in our class and he’s perfectly happy.” A third participant chimed in, “I’ve been in exercise classes that are coed. Never in a single sex one, though.” The same disagreements continued in several other focus groups, with men’s and women’s needs compared and their likelihood of attending same- or mixed-sex groups debated. Women’s gendered identities positioned them to be the primary motivators who could soften their “stubborn” men to enroll in health programs. Men’s gendered identities positioned them to protectively identify women as high-priority recipients of balance and fall-prevention messages. By reinforcing and reinscribing fall-prevention programming with sex and gender, older adults had a medium for reducing the desexing of fall-prone older adults. For program planning, making the messages about fall prevention specific to men and women will require building on accepted and preferred ways of seeing men’s and women’s roles and contributions to their own and each other’s health in this community.

Deductively Determined Dimensions of Social Marketing The deductive content analysis of the qualitative data enriched the description of the social marketing topics of product, place, price, and promotion in terms of the fall-prevention classes (Table 3). Data were reanalyzed through content analysis into these deductive categories. Product. Suggestions about the product (the balance retraining exercise classes) can be structured in three ways that will enhance its success. First, it should be primarily a social and interactive experience for attendees. Second, it should be fun and at the same time conducted in a professional way to make a difference in fall prevention and overall health. The fun aspect can come from some value-added prizes or through add-ons like blood pressure screening. “Doing things that are of interest, an activity for them” was seen as an appealing part of the product, according to a stakeholder. Third, the program should be do-able. Ease of attendance is boosted through the right kinds of music, clothing that is easy to wear to the class, no need for showers afterward, movements that are safe for different fitness levels, and instructors who meet group expectations. “The instructor will have to sit down with us and figure out what fits with the group that is there,” said one focus group participant, and tailor the product to the needs of participants.


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Make it doable and easy • Right kind of music • Clothing easy to wear • No need for showers • Movements safe for different fitness levels • Instructors meet group expectations

Price

Promotion

Avoid exclusivity of cliques and emphasize inclusivity so people feel warmly welcomed

Worries about frailty and safety risks

The place should have a comfortable atmosphere Not a hospital or clinical environment

Appeal to people and catch their interest by • Providing a sample or trial class • Getting ministerial or health care endorsements and internet publicity • Getting authoritative referrals • Offering freebies as incentives and enticements to offset program costs

Advertise the fall-prevention classes by sending a clear and accurate message of purpose and details of participation

Rely on people in the church and in large, active social networks to launch grassroots special invitations and coordinate attendance

Leaders blanket the general audience with an announcement about the program and word-of-mouth follow-up

Just don’t call it falls—it’s strength and independence

The fear and insecurity of leaving a comfort zone

Weather may prevent people from attending

Cost of the program and transportation to get there may require discounts, offset of price with “freebies” so participants believe they get something back Time of day as well as time competition for busy older adults • Not too early, too late • Not interrupting time with grandchildren, email, favorite TV programs

The place should be not too crowded or busy and should offer ample, accessible parking

Transportation will prove challenging for any location • Use carpool buddies • Clothing easy to wear • Arrange for vans • Spread groups across valley to reduce distance The place should have the space and equipment we need to do the exercises

Make it fun—but keep it professional

Place

Locate the class near where we live, work, worship, in areas we normally travel

Make it social and interactive

Product

Table 3. Social Marketing Elements Derived From Key Informant and Focus Group Interviews

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Place. As a faith-based fall-prevention intervention, places where marketing could be situated include church bulletins and newsletters, from the pulpit, and in Bible study classes. The place where the balance retraining exercise classes are offered is also considered since older adults stated that the classes should be conveniently located near where people live, work, worship, and normally travel. A comfortable place is important, as well, meaning an atmosphere where people like to spend time as opposed to a clinical-type of environment. “I’m talking about my mother because I deal with her a lot. If it had anything to do with a hospital, she’s not going to want to go,” said a Protestant focus group participant. Given the various transportation challenges (see Price for more detail), several ideas for getting to the place were forwarded, including using buddies, arranging for vans, and holding numerous small groups spread throughout the area to reduce the distance and cost of transportation. “People don’t like to ask other people to take them,” reminded one Catholic focus group participant, emphasizing the need for the place to be accessible to people who might independently be able to drive there in good conditions. Attributes of a successful place for the classes include a spacious room suitable for moving around, a safe and accessible building, and plenty of parking. Price. The costs of attending a fall-prevention class are linked to the addition of a new routine or scheduled activity into the lives of older adults. These costs include inconvenience in the form of transportation costs and other costs associated with the program, class times that may be too early or too late, competition for class time with other activities older adults enjoy (including time with grandchildren, time emailing friends, and time for favorite TV programs), and the fear of falling and exposure of frailty. “Are you going to embarrass yourself? This can keep a lot of people out of the class,” explained a Mormon focus group participant. A Protestant focus group member emphasized that people are “timid” especially if they “think they might fall.” The price of a balance retraining exercise class attendance is monetary as well as a perceived safety risk, and includes the discomfort of encountering various kinds of risks as well as rearranging one’s time. Jokingly referring to the perception among older adults that they should be entitled to health programming that is free or reduced in price, one church leader said, “[low] cost is definitely an incentive because they would describe themselves as living on a limited income—unlike the rest of us who have unlimited income—but yeah, they would see cost as a limitation.” Costs, in the case of a group balance retraining exercise program, encompassed perceived financial limitations, emotional costs of embarrassment, timidity, and fear of falling, as well as time. Promotion. The balance retraining classes may be promoted by reidentifying the program as strength and independence building classes instead of fall-prevention classes. “There’s a stigma of fall-prevention classes—you’re old and you’re at risk.


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It implies vulnerability” explained stakeholders. “Tie it in with strengthening your bones,” “being able to be independent,” or “maintaining your ability to live like you want to live” said participants across denominations in several focus groups. Leaders in churches identified themselves as the first layer of promotion since they can inform their congregations about the classes and identify particular individuals who may benefit. A second layer of promotion involves more grassroots connections between people within church congregations, particularly those with active social networks. Through these informal church-based networks invitations and offers for transportation assistance can be arranged. A clear and accurate message of the purpose of the group will minimize inappropriate expectations. Avoiding the appearance of exclusivity within the exercise groups will also promote attendance. Increasing the appeal and interest of these classes can be accomplished through several approaches recommended by the target audience, including a sample class, internet publicity and endorsements, a video and freebies, incentives, and enticements to offset the costs of attendance. Having a “real sharp leader,” as one key informant phrased it, makes a difference. If the leader can do a sample presentation at a women’s auxiliary church meeting, for example, people will join the class, and the leader’s personality, friendliness, and professionalism can keep them attending. Tools to address program promotion responded to the need for clear, accurate communication of the purpose of the program presented in positive terms through existing faith-based social networks.

Discussion Using an inductive qualitative analysis, we came to understand interpretations of aging and fall prevention as part of an integrated cultural context of independence and supportive relationships. By looking specifically for the social marketing elements in a deductive process we identified practical ways to enhance a fall-prevention program to appeal to older adults and fit with their expectations and lifestyles. The common emphases across the inductively and deductively derived results included the importance of social networks and relationships among older adults to launch and sustain an exercise program and the centrality of a personal “comfort zone.” Some older adults will desire an expanded social network or more cohesive social relationships, and some will be attracted to classes that reinforce their independence and health. The inductive analysis added a unique dimension of gendered talk to the results, whereas the social marketing analyses provided extensive, specific information about the kinds of incentives and demonstrations that would spark interest in the classes and the barriers that would limit enthusiasm. Researchers in other parts of the world have also reported identity and independence as central to fall-prevention messages (Yardley et al., 2006). An


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emphasis on relationships and social identity is characteristic of older Europeans. The chance to meet and visit with other people was viewed as a benefit of fall-prevention interventions in most European countries studied, even more so than the theme of increased independence (Yardley et al., 2006). Congruent with this U.S.-based study, older adults are attracted to relationship-centered and social environments and a message focused on independence and health (rather than falls and health decline with aging; Yardley et al., 2006). The diversity of this Colorado community meant that both distances for rural dwellers and traffic congestion for urban dwellers could be challenging barriers, congruent with accessibility and availability barriers identified in other studies (Yardley et al., 2006). Barriers may be offset by the high interest levels of faith-based leaders in disseminating health-related programs through faith-based communities (Hale & Bennett, 2003). The faith-based connection was identified as an asset by older adults who participated in the current study. Other research has also emphasized the importance of referrals from those in authoritative positions to motivate older adults to overcome barriers to participation (Yardley et al., 2006). The uniquely valuable contribution of this research was the grounding of the social marketing plan in qualitatively rich data. Lacking an understanding of local attitudes about aging, independence, and falling, we may have embarked on a traditional campaign to notify older church attendees, en masse, of the availability of a program deemed beneficial for fall prevention. The qualitative approach shaped the characteristics of intervention marketing.

Study Strengths and Limitations Recognizing that qualitative data is expensive and time consuming to collect and requires substantial time and expertise to analyze, the novel approach used in this study of dual analysis with different analytic frames proved a worthwhile investment to maximize utility of the dataset. Subject burden was minimized through a planned and sequential data collection process that involved the community on several levels through parsimoniously generated interview and focus group data. A limitation of this dual approach to analysis is the possibility that divergent viewpoints held by those in smaller denominations may not have been shared in the focus group or individual interview settings, and would then be missed in both analytic pathways. Prospective participants with a history of falling who were too frail to attend interviews or focus groups may have been underrepresented in this study. As a fall prevention, rather than a fall-remediation program, this limitation was acknowledged as acceptable. The research purpose was limited to determining how to best increase uptake of this established program in faith-based venues through a rich understanding of


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the community and attention to place, promotion, price, and product specification. The goal was not to understand how to modify or invent a program responsive to older adults’ desires, but how to market an existing community-based exercise course that is based on an evidence-based program for fall prevention. Qualitative approaches could be used in other situations to elicit older adults’ preferences for tailoring fall-prevention programs or their ideal venue in the community.

Recommendations The following recommendations, grounded in the data from the stakeholders, focus groups, and key informants, summarize the key points for successfully marketing a balance retraining program intended for older adult church members. In this research, the fall-prevention program (N’Balance) was predetermined. Qualitative research was undertaken to inform the social marketing approach, not to elicit a wish list of alternative ways to address falls or to invent a new program. Knowing our purpose and the desired outcome—dissemination and uptake of a fall-prevention program—frames our recommendations. First, we recommend social marketing that carefully describes the fall-prevention program as increasing the capacity for strength and independence among older adults, emphasizing the social nature of the program and the relationships of older adults in faithbased organizations. Ideas about independence and strength are embedded in the cultural context and can be used to anchor the fall-prevention intervention in locally meaningful language and understandings of successful aging. A heavyhanded recounting of the dangers and risks of falling would be detrimental to successful marketing of the program. Carefully crafted referrals by prominent authorities are recommended, with messages emphasizing healthy, strong, and independent aging. Second, acknowledge the tangible and intangible costs of the program to older adults, and overcome those costs by creating a fun, professional, “comfortable” experience. The idea of “comfort” is central to palatability of a new program, so attention to what constitutes a “comfort zone” and a location, time, place, and group of people with whom one is comfortable is key to successfully linking with this cultural value. Initial hesitancy about participation can be overcome through providing a preview of the program through a video demonstration and offering free “trial” classes. Both of these strategies exemplify increasing older adults’ “comfort” with participation and decreasing anxiety, hesitancy, embarrassment, and other uncomfortable feelings. Identifying community resources to subsidize the price of the class would address the more tangible direct cost of participation. Third, use sex-linked role behaviors and gender-based ideologies to keep the classes grounded in real-life relationships among men and women. Making the


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intervention “clinical” in nature or eliminating space for safe joking about men, women, and sexuality would be counter to the linguistic practices and experiences of older adults in this community. As women want to be the fulcrum of health action in their relationships, rely on them to disseminate messages about participation and program import to the men in their lives. Men, as the protectors of women, can be mobilized to encourage their wives’ participation and to participate to maintain their own strength and vigor. For single participants, the opportunity to meet and socialize with other people was appealing, and providing social space for interaction with other participants may stimulate interest. Instructors with appealing personalities and characteristics was identified as important for the comfort of the mixed-sex groups. Finding instructors who are experienced teaching both men and women with variable physical abilities is a starting point. Encouraging those instructors to diminish competitiveness in class using reassurance and humor may minimize participant embarrassment and facilitate social interactions.

Conclusion In conclusion, the formative qualitative research undergirding the intervention has provided an understanding of the contextual environment and attitudes, beliefs, and preferences of older adults who are prospective participants in a fall-prevention program. The inductive and deductive approaches to data analysis combined to identify important aspects of the structure and marketing of a successful intervention suited to this community.

Declaration of Conflicting Interests Mark Marosits has a fiduciary interest in Worldways Social Marketing, an agency that provided social marketing services to the N’Balance program.

Funding The authors disclosed receipt of the following financial support for the research and/ or authorship of this article: This research was supported by Grant Number R49/CCR811509 from the Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.

References Aronson, R. E., & Oman, R. F. (2004). Views of exercise and physical activity among rural-dwelling senior citizens. Journal of Rural Health, 20(1), 76-79.


115

Clark

Barbour, R. (2007). Doing focus groups. Los Angeles, CA: SAGE. Berg, K. O., & Kairy, D. (2002-2003). Balance interventions to prevent falls. Generations, 26(4), 75-78. Bernard, H. R. (2006). Research methods in anthropology: Qualitative and quantitative approaches (4th ed.). New York, NY: Altamira Press. Campbell, M. K., Demark-Wahnefried, W., Symons, M., Kalsbeek, W. D., Dodds, J., Cowan, A., . . . McClelland, J. W. (1999). Fruit and vegetable consumption and prevention of cancer: The Black Churches United for Better Health project. American Journal of Public Health, 89, 1390-1396. Centers for Disease Control and Prevention. (2004). Dissemination research on fall prevention: Development and testing of an exercise program package to prevent older adult falls. Federal register online, 69, 64762-64769. Retrieved from http:// edocket.access.gpo.gov/2004/04-24715.htm Centers for Disease Control and Prevention. (2009). Falls among older adults: An overview. Retrieved from http://www.cdc.gov/HomeandRecreationalSafety/Falls/ adultfalls.html Chaves, M., & Anderson, S. (2008). National Congregations Study. Cumulative data file and codebook. Durham, NC: Duke University. Churches and church membership in the United States 1990 and religious congregations and membership in the United States 2000. (2002). Retrieved from http:// www.thearda.com/mapsReports/reports/counties/08077_2000.asp DeHaven, M. J., Hunter, I. B., Wilder, L., Walton, J. W., & Berry, J. (2004). Health programs in faith-based organizations: Are they effective? American Journal of Public Health, 94, 1030-1036. DeSantis, L., & Ugarriza, D. N. (2000). The concept of theme as used in qualitative nursing research. Western Journal of Nursing Research, 22, 351-372. Firebaugh, G., & Harley, B. (1991). Trends in U.S. church attendance: Secularization and revival, or merely lifecycle effects? Journal for the Scientific Study of Religion, 30, 487-500. Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Lamb, S. E., Gates, S., Cumming, R. G., & Rowe, B. H. (2009). Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 2, CD007146. doi:10.1002/14651858.CD007146.pub2 Hale, W. D., & Bennett, R. G. (2003). Addressing health needs of an aging society through medical-religious partnerships: What do clergy and laity think? The Gerontologist, 43, 925-930. Harrison, R. V., Janz, N. K., Wolfe, R. A., Tedeschi, P. J., Chernew, M., Stross, J. K., . . . McMahon, Jr., L. F. (2003). Personalized targeted mailing increases mammography among long-term noncompliant medicare beneficiaries: A randomized trial. Medical Care, 41, 375-385.


116


Hughes, S. L., Williams, B., Molina, L. C., Bayles, C., Bryant, L. L., Harris, J. R., . . . Watkins, K. (2005). Characteristics of physical activity programs for older adults: Results of a multisite survey. The Gerontologist, 45, 667-675. Janz, N. K., Champion, V. L., & Strecher, V. J. (2002). The health belief model. In K. Glanz, B. K. Rimer, & F. M. Lewis (Eds.), Health behavior and health education: Theory, research, and practice (3rd ed., pp. 45-66). San Francisco, CA: Jossey-Bass. Kannus, P., Sievänen, H., Palvanen, M., Järvinen, T., & Parkkari, J. (2005). Prevention of falls and consequent injuries in elderly people. Lancet, 366, 1885-1893. Kelley, G. A., Kelley, K. S., Hootman, J. M., & Jones, D. L. (2009). Exercise and health-related quality of life in older community-dwelling adults: A metaanalysis of randomized controlled trials. Journal of Applied Gerontology, 28, 369-394. Lord, S. R., & Sturnieks, D. L. (2005). The physiology of falling: Assessment and prevention strategies for older people. Journal of Science and Medicine in Sport, 8(1), 35-42. Magaziner, J., Hawkes, W., Hebel, J. R., Zimmerman, S. I., Fox, K. M., Dolan, M., . . . Kenzora, J. (2000). Recovery from hip fracture in eight areas of function. Journals of Gerontology, Series A Biological Sciences and Medical Sciences, 55A, M498-M507. Magaziner, J., Simonsick, E. M., Kashner, T. M., Hebel, J. R., & Kenzora, J. E. (1990). Predictors of functional recovery one year following hospital discharge for hip fracture: A prospective study. Journals of Gerontology, Series A Biological Sciences and Medical Sciences, 45, M101-M107. Maibach, E. W., Ladin, K., Maxfield, A., & Slater, M. (1996). Translating health psychology into effective health communication: The American Healthstyles Audience Segmentation project. Journal of Health Psychology, 3, 261-278. Maibach, E. W., Rothschild, M. L., & Novelli, W. D. (2002). Social marketing. In K. Glanz, B. K. Rimer, & F. M. Lewis (Eds.), Health behavior and health education: Theory, research, and practice (3rd ed., pp. 437-461). San Francisco, CA: Jossey-Bass. McCaul, K. D., Johnson, R. J., & Rothman, A. J. (2002). The effects of framing and action instructions on whether older adults obtain flu shots. Journal of Health Psychology, 21, 624-628. Moreland, J. D., Richardson, J. A., Goldsmith, C. H., & Clase, C. M. (2004). Muscle weakness and falls in older adults: A systematic review and meta-analysis. Journal of the American Geriatric Society, 52, 1121-1129. Muhr, T. (2004). User’s manual for ATLAS.ti 5.0. Berlin, Germany: Scientific Software Development. Muse, T. (2005). Motivation and adherence to exercise for older adults. Topics in Geriatric Rehabilitation, 21(2), 107-115.


117

Clark

Ploch, D. R., & Hastings, D. W. (1994). Graphic presentations of church attendance using General Social Survey data. Journal for the Scientific Study of Religion, 33(1), 16-33. Province, M. A., Hadley, E. C., Hornbrook, M. C., Lipsitz, L. A., Miller, J. P., Mulrow, C. D., . . . Wolf, S. L. (1995). The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. Frailty injuries: Cooperative studies of intervention techniques. Journal of the American Medical Association, 273, 1341-1347. Reger, B., Cooper, L., Booth-Butterfield, S., Smith, H., Bauman, A., Wootan, M., . . . Greer, F. (2002). Wheeling Walks: A community campaign using paid media to encourage walking among sedentary older adults. Preventive Medicine, 35, 285-292. Resnicow, K., Jackson, A., Braithwaite, R., DiIorio, C., Blisset, D., Rahotep, S., & Periasamy, S. (2002). Healthy body/healthy spirit: A church-based nutrition and physical activity intervention. Health Education Research, 17, 562-573. Robitaille, Y., Laforest, S., Fournier, M., Gauvin, L., Parisien, M., Corriveau, H., . . . Damestoy, N. (2005). Moving forward in fall prevention: An intervention to improve balance among older adults in real-world settings. American Journal of Public Health, 95, 2049-2056. Rose, D. J. (2010). FallProof! A comprehensive balance and mobility training program (2nd ed.). Champaign, IL: Human Kinetics. Rose, D. J., Jones, C. J., Dickin, C., Lemon, N., & Bories, T. (1999). The effect of a community-based balance and mobility training program on functional performance and balance-related self-confidence in older adults with a history of falls [abstract]. Journal of Aging and Physical Activity, 793, 265. Rose, D. J., Jones, C. J., & Lemon, N. (2001, March). Effectiveness of a fall risk reduction program for older adult women with arthritis. Paper presented at the first joint conference of the American Society on Aging and the National Council on Aging, New Orleans, LA. Sabir, M., Wethington, E., Breckman, R., Meador, R., Reid, M., & Pillemer, K. (2009). A community-based participatory critique of social isolation intervention research for community-dwelling older adults. Journal of Applied Gerontology, 28, 218-234. Scheffer, A. C., Schuurmans, M. J., Van Dijk, N., Van Der Hooft, T., & De Rooij, S. E. (2008). Fear of falling: Measurement strategy, prevalence, risk factors and consequences among older persons. Age and Ageing, 37(1), 19-24. Slater, M. D. (2005). Choosing audience segmentation strategies and methods for health communication. In E. W. Maibach & R. L. Parrott (Eds.), Designing health messages: Approaches from communication theory and public health practice (pp. 186-189). Thousand Oaks, CA: SAGE. Steensland, B., Park, J., Regnerus, M., Robinson, L. D., Wilcox, W. B., & Woodberry, R. D. (2000). The measure of American religion: Toward improving the state of the art. Social Forces, 79, 291-318.


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Steinman, B. A. (2008). Self-reported vision, upper/lower limb disability, and fall risk in older adults. Journal of Applied Gerontology, 27, 406-423. Thorne, S. (2008). Interpretive description. Walnut Creek, CA: Left Coast Press. U.S. Census Bureau. (2009). Quick facts. Retrieved from http://quickfacts.census .gov/qfd/states/08/08077.html 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 & Safety in Health Care, 16, 230-234. Yardley, L., Bishop, F. L., Beyer, N., Hauer, K., Kempen, G., Piot-Ziegler, C., . . . Holt, A. R. (2006). Older people’s views of falls-prevention interventions in six European countries. The Gerontologist, 46, 650-660. Yardley, L., Donovan-Hall, M., Francis, K., & Todd, C. (2006). Older people’s views of advice about falls prevention: A qualitative study. Health Education Research, 21, 508-517.

Bios Lauren Clark, RN, PhD, conducts qualitative research with diverse, communitybased populations. Her current research has explored health promotion and obesity prevention among Latino children and people with disabilities, as well as research with rural elders at risk for falls. She is a professor at The University of Utah College of Nursing. Sallie Thoreson, MS, is an injury prevention specialist with the Colorado Department of Public Health and Environment and an affiliate of the Colorado Injury Control Research Center. Her areas of interest are promoting and implementing communitybased injury prevention programs as well as research projects on evaluating programs to increase the use of booster seats and seat belts in rural populations. Cynthia W. Goss, MA, is a senior professional research assistant in the Department of Epidemiology at the Colorado School of Public Health and an affiliate of the Colorado Injury Control Research Center. Her research interests include fall prevention among older adults, suicide prevention, road injury prevention, alcohol-related injury prevention, home safety promotion, and systematic reviews in injury prevention. Lorena Marquez Zimmer, MA, is a bilingual (Spanish–English) medical anthropologist with expertise in focus group research. She is a health equity coordinator at the Colorado Department of Public Health where she addresses the social determinants of health through organizational change. She has worked with populations experiencing health disparities for nearly 15 years.


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Mark Marosits, MSHA, is cofounder and senior consultant with Worldways Social Marketing, a full service agency exclusively serving public-interest organizations. He has led numerous social marketing projects spanning prevention, promotion and protection, and is the coauthor of the people and places framework for public health. Carolyn DiGuiseppi, MD, MPH, PhD, is professor of epidemiology in the Colorado School of Public Health and deputy director of the Colorado Injury Control Research Center. A primary focus of her research is the development and evaluation of communitybased approaches to injury prevention. She has previously published research evaluating programs to promote use of bicycle helmets, car safety seats, smoke detectors, and seat belts in rural populations.


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