ORIGINAL RESEARCH
Usability testing of a fall prevention toolkit Kayla R. Keuter, PA-C, MPH, MA; Gina M. Berg, PhD; Ashley M. Hervey, MEd; Nicole Rogers, PhD
ABSTRACT Objectives: This study sought to evaluate a fall prevention toolkit, determine its ease of use and user satisfaction, and determine the preferred venue of distribution. Methods: Three forms of assessment were used: focus groups, usability testing, and surveys. Focus group participants were recruited from four locations: two rural health clinics and two urban centers. Usability testing participants were recruited from two rural health clinics. Survey questions included self-reported prior falls, current fall prevention habits, reaction to the toolkit, and demographics. Results: Participants reported the toolkit was attractive, well-organized, and easy to use, but may contain too much information. Most participants admitted they would not actively use the toolkit on their own, but prefer having it introduced by a healthcare provider or in a social setting. Conclusions: Healthcare focuses on customer satisfaction; therefore, providers benefit from knowing patient preferred methods of learning fall prevention strategies. Keywords: fall prevention, older adults, patient education, home safety, usability testing, polypharmacy
F ll are the Falls h lleading di cause off iinjury j among adults d l ages 65 years and older in the United States and the leading cause of injury-related death among this age group.1 Twenty percent to 30% of those who fall will suffer a moderate to severe injury.2 One-quarter of all falls restrict patient activity either due to the injury itself or patient fear of future falls.3 Moreover, older adults are often unable to return to independent living immediately after an injurious fall. Not Kayla R. Keuter is an assistant professor at Wichita (Kans.) State University and practices at Wesley Medical Center in Wichita. Gina M. Berg is director of trauma research at Wesley Medical Center and a research assistant professor at the University of Kansas School of Medicine-Wichita. Ashley M. Hervey is a research associate at the University of Kansas School of Medicine-Wichita. Nicole Rogers is an associate professor of aging studies and director of graduate programs in the Department of Public Health Sciences at Wichita State University. The authors have disclosed no potential conflicts of interest, financial or otherwise. Acknowledgements: The authors would like to thank LaDonna Hale, PharmD, and PA students Nicolas Holway and Cameron Snell for their assistance with this manuscript. DOI: 10.1097/01.JAA.0000464273.90751.68 Copyright © 2015 American Academy of Physician Assistants
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only do falls affect the quality and quantity of life of an older adult, they are costly.4 In the United States, about 2 million older adults are treated each year in the ED for injuries sustained from falls, with hip fractures alone costing $10 billion.1,5 Reducing fall risk factors can help reduce direct healthcare costs and the disabilities associated with a fall. Although numerous risk factors (intrinsic and extrinsic) are associated with falls, the CDC focuses on polypharmacy, poor vision, home safety hazards, and lack of strength and balance. Polypharmacy, along with specific drug classifications, increases fall risk.6,7 Adverse effects of medications that can contribute to falls include agitation, dysrhythmias, confusion, dizziness, gait abnormalities, sedation, syncope, and visual disturbances.6 Poor vision increases significantly in older adults. As people age, they have decreased depth perception and contrast sensitivity, preventing them from detecting obstacles and increasing fall risk. Home safety hazards such as tripping hazards are widespread throughout homes and may be more detrimental for frail older adults.8 Lack of strength and balance and slower reaction times due to lack of exercise also increase fall risk.9 A patient’s risk of falling escalates with the increasing number of risk factors. Numerous fall prevention strategies targeting healthcare providers and patients have been developed to educate older adults on fall prevention.7,10,11 Based on the strategies recommended by the CDC and National Council on Aging (NCOA), the Wichita State University Regional Institute on Aging designed a fall prevention toolkit to provide education and fall prevention strategies for older adults living in rural Kansas where access to healthcare resources is often limited.12 The toolkit was designed to help initiate low-cost fall prevention strategies without the assistance of a healthcare provider.13 The toolkit contains four sections addressing the risk factors identified by the CDC: medication review and modification, vision examination, home safety evaluation and modification, and regular physical activity and balance training. Medication review This section aims to help older adults understand unexpected reactions to medications and
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Usability testing of a fall prevention toolkit
encourages them to discuss their medication regimen with their healthcare provider. Vision examination This section includes a number of resources to help identify and screen for vision problems. Home safety evaluation The toolkit provides instructions on how to assess the home for safety hazards that may increase the risk of falling and how to modify each identified hazard. Regular physical activity and balance training The exercise section provides a progressive program containing the four components of fitness (aerobic, flexibility, strength, and balance). Fall prevention interventions can be recommended and presented in various forms but are only as effective as participants allow. Changing behavior to reduce fall risk factors requires people to believe they are at risk for falling, understand behavior that increases risk, and believe that changing behavior will reduce risk. Fall prevention interventions and strategies can be recommended, but widespread implementation has been less than optimal.14,15 Furthermore, people are more likely to use products (such as the fall prevention toolkit) that can be easily obtained and meet their satisfaction level.16
consent was obtained. Eight to 15 participants were recruited and scheduled for each focus group. About 2 weeks before each focus group, participants were provided the toolkit for review along with the survey. The focus groups were conducted at four facilities by a trained facilitator using previously specified open-ended questions about the importance of fall prevention and the appearance and ease of use of the toolkit. All sessions lasted about 60 minutes, were audiotaped and transcribed verbatim, with names of participants removed. Following independent analysis, the research team catalogued participant responses for themes.
PARTICIPANTS Focus group participants were recruited and survey data was collected from four locations: two separate rural health clinics and two urban centers (senior fitness class and a fall prevention class). Usability testing participants were recruited from two separate rural clinics.
USABILITY TESTING Following informed consent, participants were given 20 to 30 minutes to review the toolkit. Participants were individually tested for six independent tasks with the following steps: • turn over a task card • read the task • find the appropriate section in the toolkit • perform the task to the best of their ability. Each task was observed by an investigator and the time for each step was recorded. During and/or immediately following each task, participants reported their reactions in a think-aloud protocol. Finally participants completed the survey. The six tasks were: • General appearance: look at the cover of the toolkit and report what you think about the appearance. • Medication safety: locate medication sheet and complete using your own medication bottles. • Vision: locate the vision section and complete the vision screening by following the directions provided. • Home safety evaluation: locate the home safety section and read and complete the home safety plan. • Physical activity: locate the exercise section, choose three exercises in the difficulty level of the participant’s choice, and perform them. • Overall reaction: report your overall reaction to the toolkit and the tasks you were asked to complete.
MATERIALS The Falling Less in Kansas toolkit is a booklet developed for older adults with specific attention paid to appropriate readability and design (large, easy-to-read type; clear organization and section distinction; and photographs to illustrate the recommended exercises). Reactions to the toolkit were assessed by a survey. Questions included self-reported previous falls; current fall prevention habits; attractiveness of the toolkit; ease of use and desire to use the toolkit; overall impression of toolkit; and patient demographics.
DATA ANALYSIS AND INTERPRETATION Quantitative data regarding participant characteristics, survey data, and portions of the usability data are presented as means or percentages as appropriate. Descriptive statistics were used to analyze survey results. Categorical variables were compared by the chi-square or Fisher exact test. Focus group comments were analyzed using content analysis and categorized for themes. All statistical analyses were performed using SPSS for Windows, version 20.
FOCUS GROUPS Participants who were invited to the focus groups were given an explanation of the study purpose and informed
RESULTS Survey participant characteristics Thirty-four participants consented; of those, 32 completed the participant survey
PURPOSE The purpose of this study was to evaluate the usability, satisfaction, and preferred venues of distribution for a fall prevention toolkit designed for use by older adults. METHODS Three forms of assessment were used to evaluate the Falling Less in Kansas (Falling LinKS) toolkit: focus groups, usability testing, and surveys. Approval was obtained from all appropriate institutional review boards.
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and were included in the analysis. Of the total respondents, 56% were from rural communities and 44% from an urban area (Table 1). The majority were female (81%) with an average age of 75 years (SD=9.03) and had fallen at least once in the past year (63%). When asked about current “toolkit practices” (behaviors identified by the toolkit as important for fall prevention), almost all (94%) reported having discussed their medications with their primary care provider (PCP) in the past year, but only one (3%) reported changes had been made following a fall. Most (75%) had an eye examination in the past year, or had one scheduled (19%). Two (6%) participants have had a structured home safety evaluation and two (6%) planned to have one completed. Seventy-two percent of participants reported they routinely exercise (Table 2), with many (44%) exercising at least five days per week. Most participants (84%) read the toolkit before the session, but only four (13%) had written a fall prevention plan. More than half (59%) attempted the exercises in the toolkit, seven (22%) scheduled an appointment with their PCP (not necessarily to review medications), six (19%) scheduled a vision examination, and one (3%) scheduled a home safety evaluation (Table 3). Most participants reported the toolkit was easy to use (69%), easy to understand (75%), contained interesting information (66%), and was overall satisfying (66%).
TABLE 1.
Survey participant characteristics (n=32) Number (Percentage)
Age (mean, 74.79; SD=9.03)
55-64 years 65-79 years >80 years
3 (9.4) 16 (50.0) 10 (31.3)
Sex
Male Female
3 (9.4) 26 (81.3)
Education level
High school or less Some college College degree
12 (37.5) 8 (25.0) 6 (18.8)
Falls in past year
0 >1
10 (31.3) 21 (62.5)
Live with
Alone Spouse or other
11 (34.4) 19 (59.4)
Live in
House or apartment Other
29 (90.6) 1 (3.1)
Community
Urban Rural
14 (43.8) 18 (56.3)
Percentages may not equal 100 due to missing data.
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More than half (59%) thought they would use the toolkit in the future (Table 4) and many (69%) would recommend it to a friend (Table 3). Focus group participant characteristics Thirty volunteers participated in four focus groups and 28 completed the postsession survey. Most participants were female (82%), with an average age of 74 years (SD=9.2); 61% reported living with a spouse or another person. More than half (61%) of participants had fallen at least once in the past year. Older adults in the focus groups agreed that education on fall prevention is important for their age group: “very important, but age 65 is not early enough to start.” Although many participants admitted to falling in the past year, they did not think they needed information about fall prevention at all or at least until they suffered an injury due to a fall (“It’s [fall prevention education] for people who can’t do things.”) Participants suggested excuses for their own falls and did not think their own falls were preventable. Participants, especially rural, commented that although the medication section in the toolkit was good, it was unnecessary. They trust their PCP and pharmacist to oversee their medications (“My doctor and pharmacist keep very good track of all of my medications.”) Discussion about the vision section was minimal because most (75%) routinely have vision examinations by an ophthalmologist. Although some of the home safety suggestions, such as eliminating throw rugs, were considered to be well known, participants reported that they learned something new in this section and found it to be informative. Participants discussed the importance of exercise for overall health. All urban participants were involved in organized exercise classes but commented that the toolkit could “help those in smaller towns [who] are unable to make it to classes.” Rural participants reported that working on the farm qualified as exercising. Overall, the “title draws you in” and the font size is “appropriate.” Participants felt the information was interesting (75%) and many reported that they would use the toolkit in the future (68%). However, negative reactions to the toolkit included “it contains too much information and is overwhelming.” Rural participants reported they would likely pick up the toolkit on their own because they had already fallen at least once, but preferred that their healthcare provider initiate a discussion on fall prevention. Participants reported they would recommend this toolkit to others they felt needed it (“I would like to get a copy for my sister.”) Overall comments were positive (“I applaud whoever is trying. It is really needed, no matter the criticisms.”) Usability testing participant characteristics Six participants consented to participate in the usability testing; one participant discontinued participation during testing. The average age of the participants was 79 years (range, 71 to
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Usability testing of a fall prevention toolkit TABLE 2.
Self-reported fall prevention habits of survey participants Total (%)
Urban (%)
Rural (%)
32
14 (43.8)
18 (56.3)
23 (71.9) 2 (6.3) 4 (12.5) 2 (6.3)
14 (100.0) 0 0 0
9 (52.9) 2 (11.8) 4 (23.5) 2 (11.8)
30 (93.8) 1 (3.1)
13 (100) 0
17 (94.4) 1 (5.6)
1 (3.1) 22 (68.8) 1 (3.1) 5 (15.6)
1 (7.7) 7 (53.8) 1 (7.7) 4 (30.8)
0 15 (93.8) 0 1 (6.2)
24 (75.0) 6 (18.8) 1 (3.1) 1 (3.1)
12 (85.7) 1 (7.1) 1 (7.1) 0
12 (66.7) 5 (27.8) 0 1 (5.6)
2 (6.3) 2 (6.3) 18 (56.3) 4 (12.5)
1 (7.7) 1 (7.7) 11 (84.6) 0
1 (7.7) 1 (7.7) 7 (53.8) 4 (30.8)
Exercise habits (P=0.031) Routinely exercise Plan to start an exercise program, not yet started No plans to exercise Do not know how to start an exercise program Medication discussion with PCP (P=0.388) Within past year No plans PCP made changes to medications after fall (P=0.091) Yes No Unsure Not applicable Vision care (P=0.237) Vision examination within past year Plan to have a vision examination No plans to have a vision examination Do not have a vision doctor Home safety plans (P=0.180) Had a home safety evaluation within past year Plan to have a home safety evaluation Do not have plans to have a home safety evaluation Do not know how to schedule a home safety evaluation Percentages may not equal 100 due to missing data.
85 years) with an equal number of men and women. Half of the participants lived alone, and only one reported not falling at least once in the past year. • General appearance. Participants’ comments on the general appearance were positive: “toolkit looks nice, has good color and gets your attention.” A couple of negative comments were, “although the people on the cover looked like they were having fun, they looked too young to worry about falling.” • Medication safety. The average time to complete the task was 1 minute, 14 seconds (range 18 seconds to 2 minutes, 39 seconds), with one person having a difficult time finding the medication list. Another participant had a difficult time understanding the instructions. None of the participants had difficulty writing the medication names, but doses and frequency varied: some participants wrote “2 at a time” or “one tab” instead of actual milligrams.
• Vision. Participants took an average of 1 minute, 24 seconds (range, 56 seconds to 1 minute, 51 seconds) to find the Amsler grid, but all were able to complete it. • Home safety. Participants took an average of 1 minute, 10 seconds (range, 19 seconds to 3 minutes, 5 seconds) to find this section and had no difficulty completing part of the home safety plan. All had positive comments about the suggestions to make their homes safer. • Physical activity. Participants had no difficulty finding this section (30 seconds), nor did they have any difficulty performing the exercises. Their overall reactions to the exercises were positive and they said that the instructions were easy to follow. • Overall response. Participants reported the toolkit was attractive, interesting, easy to use, and would help older adults avoid falls. Overall, participants were very satisfied with the toolkit and would likely recommend it for use.
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DISCUSSION TABLE 3. Survey participant use of toolkit In this study, the goal was to Total (%) Urban (%) Rural (%) evaluate the usability (usefulness, effectiveness, and likability), sat32 14 (43.8) 18 (56.3) isfaction, and preferred venues of Read toolkit (P=0.136) distribution of a fall prevention toolkit. All usability participants Yes 27 (84.4) 12 (100.0) 15 (83.3) demonstrated their ability to use No 3 (9.4) 0 3 (16.7) the toolkit successfully. These data represent that the toolkit is a quick Write fall prevention plan (P=0.183) and relatively easy product to use Yes 4 (12.5) 3 (25.0) 1 (6.7) as well as demonstrated a quick No 23 (71.9) 9 (75.0) 14 (93.3) learning curve. Actual user task times will vary when older adults Try to perform exercises (P=0.637) complete the tasks at their leisure. Yes 19 (59.4) 9 (75.0) 10 (66.7) The ease of finding specific secNo 8 (25.0) 3 (25.0) 5 (33.3) tions increased as more sections were evaluated. Schedule appointment with PCP (P=0.079) Most participants (94%) reported Yes 7 (21.9) 1 (9.1) 6 (40.0) that they regularly discuss their No 19 (59.4) 10 (90.3) 9 (60.0) medications with their PCP. Although inaccuracy was observed Schedule vision examination (P=0.144) with transcribing correct dosages, Yes 6 (18.8) 1 (8.3) 5 (31.2) usability testing participants demonstrated they can easily list the No 22 (68.8) 11 (91.7) 11 (68.8) names of their medications. The Schedule home safety evaluation (P=0.359) medication list in the toolkit should be completed by patients and taken Yes 1 (3.1) 0 1 (6.2) to their PCP for review; PCPs No 28 (87.5) 13 (100.0) 15 (93.8) should consider eliminating medRecommend to a friend (P=0.244) ications that can increase patients’ fall risk. Yes 22 (68.8) 9 (90.0) 13 (100.0) No participant had difficulty No 1 (3.1) 1 (10.0) 0 following the Amsler grid instrucPercentages may not equal 100 due to missing data. tions, but several reported lack of understanding of what to do with the results. Most (94%) reported having regular eye examinations, and section received very positive reviews and none of consequently, did not think the vision section was very the participants had difficulty following the instructions. beneficial. In addition to the exercises being easy to perform, After reviewing the toolkit, most participants found the participants reported that the exercises were advantainformation in the home safety section useful. As demongeous for people who are unable to travel to organized strated by Whitehead and colleagues, most adults feel exercise classes. Rural participants mentioned barriers their home is already safe, and patients with limited funds to traveling to exercise classes, including cost of may not be able to make home revisions.17 Adults do not transportation, travel distance, parking, and seasonal agree to home hazard assessments and prefer not to make restraints on driving; these findings are similar to those changes to their homes.17 If a home safety evaluation of Hutton and colleagues.9 Home-based exercises are recommends hand rails in the bathtub; the financial bar- suitable for fall prevention and are well-used by older rier may outweigh the benefit. To change behavior, one adults. 18 Although the socialization during group must believe the barrier is worth overcoming.3 Only two exercise was considered a benefit, home exercises as (6%) participants reported they would schedule a home provided by this toolkit overcome previously identified safety evaluation. barriers to exercise, including pressure to keep up with Although most participants (72%) reported that they others, different levels of fitness, and self-consciousness regularly exercise and believe it is important, they do of exercising with gym equipment. 9 The clarity of not think many other older adults exercise. The exercise explanations of exercises in the toolkit addresses the 50
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Usability testing of a fall prevention toolkit TABLE 4.
Survey participant reaction to toolkit (n=32) Strongly agree (%)
Agree (%)
Neutral (%)
Disagree (%)
Strongly disagree (%)
Nice general appearance
9 (28.1)
14 (43.8)
2 (6.3)
0
0
Easy to use
8 (25.0)
14 (43.8)
2 (6.3)
0
1 (3.1)
Instructions easy to understand
8 (25.0)
16 (50.0)
2 (6.3)
0
0
Interesting
5 (15.6)
16 (50.0)
3 (9.4)
0
1 (3.1)
Size of wording made it easy to read
13 (40.6)
12 (37.5)
1 (3.1)
0
0
Information was helpful
5 (15.6)
13 (40.6)
6 (18.8)
2 (6.3)
0
Information was easy to find
4 (12.5)
12 (37.5)
9 (28.1)
1 (3.1)
0
Will use in future
7 (21.9)
12 (37.5)
4 (12.5)
1 (3.1)
2 (6.3)
Overall, was very satisfied
6 (18.8)
15 (46.9)
4 (12.5)
0
1 (3.1)
Percentages may not equal 100 due to missing data.
excuse of lack of desire to exercise secondary to lack of self-efficacy.9,17 Overall, participant reaction to the toolkit was positive; the toolkit was important, attractive, and easy to read with an appropriate font size. Participants expressed the importance of using fall prevention strategies, such as those demonstrated in the toolkit. Interestingly, as noted by the toolkit developers, the participants felt the toolkit was good for other older adults rather than themselves.13 Although most of our participants had fallen, they provided excuses for their falls and did not think they needed intervention themselves. A low self-perceived risk of falling is a predictor of participation in interventions such as exercise.18 Whitehead and colleagues evaluated the likelihood of older adults participating in a fall prevention program after suffering a fall and found only 52% would consider fall prevention interventions.17 Whitehead and colleagues also reported that older adults, when asked specifically, would consider exercising (63%), a home assessment (57%), and discontinuing implicated medications (59%) as fall prevention strategies.17 Of our rural participants (not recruited from fitness or fall prevention classes), 53% reported they already regularly exercise and another 12% would like to start. Only 6% of all participants considered having a home safety assessment. Participants perceived consequences of falls as serious, but lacked the feeling that they were susceptible to falling. The participants’ lack of perceived need for this toolkit for themselves may have contributed to them not completing a fall prevention plan. Based on successful completion of the assigned tasks and the positive remarks regarding aesthetics and design, major changes to the toolkit were not recommended.
FUTURE RESEARCH AND PARTICIPANT SUGGESTIONS Completion of a well-designed product does not ensure its use. Subject compliance is the most commonly reported barrier to successful fall prevention intervention.19 Although the toolkit was attractive and easy to use, most participants did not think they would ever use it. Focus group participants reported they would be more likely to use the toolkit if it was introduced to them by either their PCP or through the media. Proposed dissemination was simple distribution, but following the comments of the participants, social interaction may be necessary to stimulate interest and motivate toolkit adoption. Barriers to having a PCP introduce the toolkit include lack of appropriate fall prevention training, competing risks (such as medication benefits versus adverse drug reactions), and lack of time.14 The American Geriatrics Society recommends all adults age 65 years or older be assessed annually for falls.7 The US Preventive Services Task Force recently recommended that PCPs initiate relevant fall prevention interventions in communitydwelling older adults.20 Despite this recommendation, only 37% of older adults are asked by their PCP if they have fallen.21 The Patient Protection and Affordable Care Act encourages the maximization of value for patients and emphasizes care based on patient needs.22 These cumulating recommendations, along with participant requests for PCP involvement, should encourage PCPs to evaluate fall risk and promote fall risk reduction. Older adults gain knowledge of fall prevention programs from a variety of resources, including general practitioners (32%), family members (23%), community health nurses, and other healthcare workers (20%).3 In addition to discussion with PCPs, our participants
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encouraged dissemination of fall prevention strategies through media and community organizations. Future research could evaluate whether distribution of educational materials by these avenues leads to a higher use rate than when the toolkit is introduced by other means. Compliance with a fall prevention program determines its success. STUDY LIMITATIONS Limitations of this study include a small sample size (limiting true representation of the general population, but appropriate for usability testing); recall bias (self-report); social desirability bias; volunteer bias; and test situation (not in participant’s home or natural setting). Most of the study participants (81%) reported a high school or greater education, which possibly does not accurately represent the Kansas population. However, the US Census Bureau (2008-2012) estimates that 84.7% of Kansans (an average of men and women) ages 65 years and older have received at least a high school diploma.23 The urban focus group participants were all enrolled in exercise classes and therefore may have strong positive attitudes toward exercise, may be more motivated to learn fall prevention strategies, and more apt to change behavior. CONCLUSION Falls are prevalent and preventable in older, independent living adults. Despite guidelines and many fall prevention interventions, falls continue to increase. To be effective, fall prevention strategies (exercise and balance training, vision examinations, medication reviews, and home safety evaluations) must be accessible, easy to use, and satisfactory to the older adults who need to adopt them. Providing an independent resource, such as the Falling Less in Kansas fall prevention toolkit, would inform older adults of specific fall prevention strategies. However, like all intervention strategies, this tool must also appeal to the older adult user. Although participants would recommend it to friends, many also admitted that they were disinclined to use it themselves or to adopt the provided strategies. Fall prevention tools, such as this toolkit, may be most used if introduced to older adults by a healthcare provider or in a social setting such as a senior center or church. Without personal intent and professional encouragement, even fall risk reduction plans that are well-designed may not be used. By focusing on customer need, healthcare providers will benefit from knowing the best ways to promote fall prevention strategies. JAAPA REFERENCES 1. Centers for Disease Control and Prevention. Public health and aging: nonfatal injuries among older adults treated in hospital emergency departments—United States 2001. MMWR Morb Mortal Wkly Rep. 2003;52(42):1019-1022. 2. American Trauma Society. http://www.amtrauma.org. Accessed February 10, 2015.
3. Kempton A, Van Beurden E, Sladden T, et al. Older people can stay on their feet: final results of a community-based falls prevention programme. Health Promot Int. 2000;15(1):27-33. 4. Carroll NV, Slattum PW, Cox FM. The cost of falls among the community-dwelling elderly. J Manag Care Pharm. 2005;11(4): 307-316. 5. Carter ND, Kannus P, Khan KM. Exercise in the prevention of falls in older people: a systematic literature review examining the rationale and the evidence. Sports Med. 2001;31(6):427-438. 6. Ruddock B. Medications and falls in the elderly. CPJ/RPC. 2004;137(6):17-18. 7. American Geriatrics Society; British Geriatrics Society; American Academy of Orthopedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc. 2001;49(5):664-672. 8. Gill TM, Robison JT, Williams CS, Tinetti ME. Mismatches between the home environment and physical capabilities among community-living older persons. J Am Geriatr Soc. 1999;47(1): 88-92. 9. Hutton L, Frame R, Maggo H, et al. The perceptions of physical activity in an elderly population at risk of falling: a focus group study. J Physiother. 2009;37(2):85-92. 10. Mayo Clinic. Fall Prevention: 6 tips to prevent falls. http://www. mayoclinic.com/health/fall-prevention/HQ00657. Accessed February 2, 2015. 11. UK National Institute for Clinical Excellence. Clinical practice guideline for the assessment and prevention of falls in older people. http://www.nice.org.uk/nicemedia/pdf/CG021fullguide line.pdf. Accessed February 2, 2015. 12. Wichita State University Regional Institute on Aging Falling LinKS Research Team. The Falling LinKS Toolkit. http://www. wichita.edu/aging. Accessed February 2, 2015. 13. Radebaugh TS, Bahner CA, Ballard-Reisch D, et al. Falling less in Kansas: development of a fall risk reduction toolkit. J Aging Res. 2011;2011:532079. 14. Chou WC, Tinetti ME, King MB, et al. Perceptions of physicians on the barriers and facilitators to integrating fall risk evaluation and management into practice. J Gen Intern Med. 2006;21(2):117-122. 15. Tinetti ME, Baker DI, King M, et al. Effect of dissemination of evidence in reducing injuries from falls. N Engl J Med. 2008;359 (3):305-310. 16. Rubin J. Handbook of Usability Testing. New York, NY: John Wiley & Sons, Inc., 1994. 17. Whitehead CH, Wundke R, Crotty M. Attitudes to falls and injury prevention: what are the barriers to implementing falls prevention strategies? Clin Rehabil. 2006;20(6):536-542. 18. Sjosten NM, Salonoja M, Piirtola M, et al. A multifactorial fall prevention programme in the community-dwelling aged: predictors of adherence. Eur J Public Health. 2007;17(5):464-470. 19. Fortinsky RH, Iannuzzi-Sucich M, Baker DI, et al. Fallrisk assessment and management in clinical practice: views from healthcare providers. J Am Geriatr Soc. 2004;52(9): 1522-1526. 20. Moyer VA. US Preventive Services Task Force. Prevention of falls in community-dwelling older adults: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157 (3):197-204. 21. Wenger NS, Solomon DH, Roth CO, et al. The quality of medical care provided to vulnerable community-living older patients. Ann Intern Med. 2003;139(9):740-747. 22. Porter ME, Lee TH. The strategy that will fix health care. Harv Bus Rev. 2013;91(12):24. 23. US Census Bureau. Educational attainment 2008-2012 American community survey 5-year estimates. American FactFinder. http:// factfinder2.census.gov/faces/tableservices/jsf/pages/productview. xhtml?pid=ACS_12_5YR_S1501. Accessed February 2, 2015.
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Usability testing of a fall prevention toolkit Kayla R. Keuter, PA-C, MPH, MA; Gina M. Berg, PhD; Ashley M. Hervey, MEd; Nicole Rogers, PhD
ABSTRACT Objectives: This study sought to evaluate a fall prevention toolkit, determine its ease of use and user satisfaction, and determine the preferred venue of distribution. Methods: Three forms of assessment were used: focus groups, usability testing, and surveys. Focus group participants were recruited from four locations: two rural health clinics and two urban centers. Usability testing participants were recruited from two rural health clinics. Survey questions included self-reported prior falls, current fall prevention habits, reaction to the toolkit, and demographics. Results: Participants reported the toolkit was attractive, well-organized, and easy to use, but may contain too much information. Most participants admitted they would not actively use the toolkit on their own, but prefer having it introduced by a healthcare provider or in a social setting. Conclusions: Healthcare focuses on customer satisfaction; therefore, providers benefit from knowing patient preferred methods of learning fall prevention strategies. Keywords: fall prevention, older adults, patient education, home safety, usability testing, polypharmacy
F ll are the Falls h lleading di cause off iinjury j among adults d l ages 65 years and older in the United States and the leading cause of injury-related death among this age group.1 Twenty percent to 30% of those who fall will suffer a moderate to severe injury.2 One-quarter of all falls restrict patient activity either due to the injury itself or patient fear of future falls.3 Moreover, older adults are often unable to return to independent living immediately after an injurious fall. Not Kayla R. Keuter is an assistant professor at Wichita (Kans.) State University and practices at Wesley Medical Center in Wichita. Gina M. Berg is director of trauma research at Wesley Medical Center and a research assistant professor at the University of Kansas School of Medicine-Wichita. Ashley M. Hervey is a research associate at the University of Kansas School of Medicine-Wichita. Nicole Rogers is an associate professor of aging studies and director of graduate programs in the Department of Public Health Sciences at Wichita State University. The authors have disclosed no potential conflicts of interest, financial or otherwise. Acknowledgements: The authors would like to thank LaDonna Hale, PharmD, and PA students Nicolas Holway and Cameron Snell for their assistance with this manuscript. DOI: 10.1097/01.JAA.0000464273.90751.68 Copyright © 2015 American Academy of Physician Assistants
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only do falls affect the quality and quantity of life of an older adult, they are costly.4 In the United States, about 2 million older adults are treated each year in the ED for injuries sustained from falls, with hip fractures alone costing $10 billion.1,5 Reducing fall risk factors can help reduce direct healthcare costs and the disabilities associated with a fall. Although numerous risk factors (intrinsic and extrinsic) are associated with falls, the CDC focuses on polypharmacy, poor vision, home safety hazards, and lack of strength and balance. Polypharmacy, along with specific drug classifications, increases fall risk.6,7 Adverse effects of medications that can contribute to falls include agitation, dysrhythmias, confusion, dizziness, gait abnormalities, sedation, syncope, and visual disturbances.6 Poor vision increases significantly in older adults. As people age, they have decreased depth perception and contrast sensitivity, preventing them from detecting obstacles and increasing fall risk. Home safety hazards such as tripping hazards are widespread throughout homes and may be more detrimental for frail older adults.8 Lack of strength and balance and slower reaction times due to lack of exercise also increase fall risk.9 A patient’s risk of falling escalates with the increasing number of risk factors. Numerous fall prevention strategies targeting healthcare providers and patients have been developed to educate older adults on fall prevention.7,10,11 Based on the strategies recommended by the CDC and National Council on Aging (NCOA), the Wichita State University Regional Institute on Aging designed a fall prevention toolkit to provide education and fall prevention strategies for older adults living in rural Kansas where access to healthcare resources is often limited.12 The toolkit was designed to help initiate low-cost fall prevention strategies without the assistance of a healthcare provider.13 The toolkit contains four sections addressing the risk factors identified by the CDC: medication review and modification, vision examination, home safety evaluation and modification, and regular physical activity and balance training. Medication review This section aims to help older adults understand unexpected reactions to medications and
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Usability testing of a fall prevention toolkit
encourages them to discuss their medication regimen with their healthcare provider. Vision examination This section includes a number of resources to help identify and screen for vision problems. Home safety evaluation The toolkit provides instructions on how to assess the home for safety hazards that may increase the risk of falling and how to modify each identified hazard. Regular physical activity and balance training The exercise section provides a progressive program containing the four components of fitness (aerobic, flexibility, strength, and balance). Fall prevention interventions can be recommended and presented in various forms but are only as effective as participants allow. Changing behavior to reduce fall risk factors requires people to believe they are at risk for falling, understand behavior that increases risk, and believe that changing behavior will reduce risk. Fall prevention interventions and strategies can be recommended, but widespread implementation has been less than optimal.14,15 Furthermore, people are more likely to use products (such as the fall prevention toolkit) that can be easily obtained and meet their satisfaction level.16
consent was obtained. Eight to 15 participants were recruited and scheduled for each focus group. About 2 weeks before each focus group, participants were provided the toolkit for review along with the survey. The focus groups were conducted at four facilities by a trained facilitator using previously specified open-ended questions about the importance of fall prevention and the appearance and ease of use of the toolkit. All sessions lasted about 60 minutes, were audiotaped and transcribed verbatim, with names of participants removed. Following independent analysis, the research team catalogued participant responses for themes.
PARTICIPANTS Focus group participants were recruited and survey data was collected from four locations: two separate rural health clinics and two urban centers (senior fitness class and a fall prevention class). Usability testing participants were recruited from two separate rural clinics.
USABILITY TESTING Following informed consent, participants were given 20 to 30 minutes to review the toolkit. Participants were individually tested for six independent tasks with the following steps: • turn over a task card • read the task • find the appropriate section in the toolkit • perform the task to the best of their ability. Each task was observed by an investigator and the time for each step was recorded. During and/or immediately following each task, participants reported their reactions in a think-aloud protocol. Finally participants completed the survey. The six tasks were: • General appearance: look at the cover of the toolkit and report what you think about the appearance. • Medication safety: locate medication sheet and complete using your own medication bottles. • Vision: locate the vision section and complete the vision screening by following the directions provided. • Home safety evaluation: locate the home safety section and read and complete the home safety plan. • Physical activity: locate the exercise section, choose three exercises in the difficulty level of the participant’s choice, and perform them. • Overall reaction: report your overall reaction to the toolkit and the tasks you were asked to complete.
MATERIALS The Falling Less in Kansas toolkit is a booklet developed for older adults with specific attention paid to appropriate readability and design (large, easy-to-read type; clear organization and section distinction; and photographs to illustrate the recommended exercises). Reactions to the toolkit were assessed by a survey. Questions included self-reported previous falls; current fall prevention habits; attractiveness of the toolkit; ease of use and desire to use the toolkit; overall impression of toolkit; and patient demographics.
DATA ANALYSIS AND INTERPRETATION Quantitative data regarding participant characteristics, survey data, and portions of the usability data are presented as means or percentages as appropriate. Descriptive statistics were used to analyze survey results. Categorical variables were compared by the chi-square or Fisher exact test. Focus group comments were analyzed using content analysis and categorized for themes. All statistical analyses were performed using SPSS for Windows, version 20.
FOCUS GROUPS Participants who were invited to the focus groups were given an explanation of the study purpose and informed
RESULTS Survey participant characteristics Thirty-four participants consented; of those, 32 completed the participant survey
PURPOSE The purpose of this study was to evaluate the usability, satisfaction, and preferred venues of distribution for a fall prevention toolkit designed for use by older adults. METHODS Three forms of assessment were used to evaluate the Falling Less in Kansas (Falling LinKS) toolkit: focus groups, usability testing, and surveys. Approval was obtained from all appropriate institutional review boards.
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and were included in the analysis. Of the total respondents, 56% were from rural communities and 44% from an urban area (Table 1). The majority were female (81%) with an average age of 75 years (SD=9.03) and had fallen at least once in the past year (63%). When asked about current “toolkit practices” (behaviors identified by the toolkit as important for fall prevention), almost all (94%) reported having discussed their medications with their primary care provider (PCP) in the past year, but only one (3%) reported changes had been made following a fall. Most (75%) had an eye examination in the past year, or had one scheduled (19%). Two (6%) participants have had a structured home safety evaluation and two (6%) planned to have one completed. Seventy-two percent of participants reported they routinely exercise (Table 2), with many (44%) exercising at least five days per week. Most participants (84%) read the toolkit before the session, but only four (13%) had written a fall prevention plan. More than half (59%) attempted the exercises in the toolkit, seven (22%) scheduled an appointment with their PCP (not necessarily to review medications), six (19%) scheduled a vision examination, and one (3%) scheduled a home safety evaluation (Table 3). Most participants reported the toolkit was easy to use (69%), easy to understand (75%), contained interesting information (66%), and was overall satisfying (66%).
TABLE 1.
Survey participant characteristics (n=32) Number (Percentage)
Age (mean, 74.79; SD=9.03)
55-64 years 65-79 years >80 years
3 (9.4) 16 (50.0) 10 (31.3)
Sex
Male Female
3 (9.4) 26 (81.3)
Education level
High school or less Some college College degree
12 (37.5) 8 (25.0) 6 (18.8)
Falls in past year
0 >1
10 (31.3) 21 (62.5)
Live with
Alone Spouse or other
11 (34.4) 19 (59.4)
Live in
House or apartment Other
29 (90.6) 1 (3.1)
Community
Urban Rural
14 (43.8) 18 (56.3)
Percentages may not equal 100 due to missing data.
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More than half (59%) thought they would use the toolkit in the future (Table 4) and many (69%) would recommend it to a friend (Table 3). Focus group participant characteristics Thirty volunteers participated in four focus groups and 28 completed the postsession survey. Most participants were female (82%), with an average age of 74 years (SD=9.2); 61% reported living with a spouse or another person. More than half (61%) of participants had fallen at least once in the past year. Older adults in the focus groups agreed that education on fall prevention is important for their age group: “very important, but age 65 is not early enough to start.” Although many participants admitted to falling in the past year, they did not think they needed information about fall prevention at all or at least until they suffered an injury due to a fall (“It’s [fall prevention education] for people who can’t do things.”) Participants suggested excuses for their own falls and did not think their own falls were preventable. Participants, especially rural, commented that although the medication section in the toolkit was good, it was unnecessary. They trust their PCP and pharmacist to oversee their medications (“My doctor and pharmacist keep very good track of all of my medications.”) Discussion about the vision section was minimal because most (75%) routinely have vision examinations by an ophthalmologist. Although some of the home safety suggestions, such as eliminating throw rugs, were considered to be well known, participants reported that they learned something new in this section and found it to be informative. Participants discussed the importance of exercise for overall health. All urban participants were involved in organized exercise classes but commented that the toolkit could “help those in smaller towns [who] are unable to make it to classes.” Rural participants reported that working on the farm qualified as exercising. Overall, the “title draws you in” and the font size is “appropriate.” Participants felt the information was interesting (75%) and many reported that they would use the toolkit in the future (68%). However, negative reactions to the toolkit included “it contains too much information and is overwhelming.” Rural participants reported they would likely pick up the toolkit on their own because they had already fallen at least once, but preferred that their healthcare provider initiate a discussion on fall prevention. Participants reported they would recommend this toolkit to others they felt needed it (“I would like to get a copy for my sister.”) Overall comments were positive (“I applaud whoever is trying. It is really needed, no matter the criticisms.”) Usability testing participant characteristics Six participants consented to participate in the usability testing; one participant discontinued participation during testing. The average age of the participants was 79 years (range, 71 to
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Usability testing of a fall prevention toolkit TABLE 2.
Self-reported fall prevention habits of survey participants Total (%)
Urban (%)
Rural (%)
32
14 (43.8)
18 (56.3)
23 (71.9) 2 (6.3) 4 (12.5) 2 (6.3)
14 (100.0) 0 0 0
9 (52.9) 2 (11.8) 4 (23.5) 2 (11.8)
30 (93.8) 1 (3.1)
13 (100) 0
17 (94.4) 1 (5.6)
1 (3.1) 22 (68.8) 1 (3.1) 5 (15.6)
1 (7.7) 7 (53.8) 1 (7.7) 4 (30.8)
0 15 (93.8) 0 1 (6.2)
24 (75.0) 6 (18.8) 1 (3.1) 1 (3.1)
12 (85.7) 1 (7.1) 1 (7.1) 0
12 (66.7) 5 (27.8) 0 1 (5.6)
2 (6.3) 2 (6.3) 18 (56.3) 4 (12.5)
1 (7.7) 1 (7.7) 11 (84.6) 0
1 (7.7) 1 (7.7) 7 (53.8) 4 (30.8)
Exercise habits (P=0.031) Routinely exercise Plan to start an exercise program, not yet started No plans to exercise Do not know how to start an exercise program Medication discussion with PCP (P=0.388) Within past year No plans PCP made changes to medications after fall (P=0.091) Yes No Unsure Not applicable Vision care (P=0.237) Vision examination within past year Plan to have a vision examination No plans to have a vision examination Do not have a vision doctor Home safety plans (P=0.180) Had a home safety evaluation within past year Plan to have a home safety evaluation Do not have plans to have a home safety evaluation Do not know how to schedule a home safety evaluation Percentages may not equal 100 due to missing data.
85 years) with an equal number of men and women. Half of the participants lived alone, and only one reported not falling at least once in the past year. • General appearance. Participants’ comments on the general appearance were positive: “toolkit looks nice, has good color and gets your attention.” A couple of negative comments were, “although the people on the cover looked like they were having fun, they looked too young to worry about falling.” • Medication safety. The average time to complete the task was 1 minute, 14 seconds (range 18 seconds to 2 minutes, 39 seconds), with one person having a difficult time finding the medication list. Another participant had a difficult time understanding the instructions. None of the participants had difficulty writing the medication names, but doses and frequency varied: some participants wrote “2 at a time” or “one tab” instead of actual milligrams.
• Vision. Participants took an average of 1 minute, 24 seconds (range, 56 seconds to 1 minute, 51 seconds) to find the Amsler grid, but all were able to complete it. • Home safety. Participants took an average of 1 minute, 10 seconds (range, 19 seconds to 3 minutes, 5 seconds) to find this section and had no difficulty completing part of the home safety plan. All had positive comments about the suggestions to make their homes safer. • Physical activity. Participants had no difficulty finding this section (30 seconds), nor did they have any difficulty performing the exercises. Their overall reactions to the exercises were positive and they said that the instructions were easy to follow. • Overall response. Participants reported the toolkit was attractive, interesting, easy to use, and would help older adults avoid falls. Overall, participants were very satisfied with the toolkit and would likely recommend it for use.
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DISCUSSION TABLE 3. Survey participant use of toolkit In this study, the goal was to Total (%) Urban (%) Rural (%) evaluate the usability (usefulness, effectiveness, and likability), sat32 14 (43.8) 18 (56.3) isfaction, and preferred venues of Read toolkit (P=0.136) distribution of a fall prevention toolkit. All usability participants Yes 27 (84.4) 12 (100.0) 15 (83.3) demonstrated their ability to use No 3 (9.4) 0 3 (16.7) the toolkit successfully. These data represent that the toolkit is a quick Write fall prevention plan (P=0.183) and relatively easy product to use Yes 4 (12.5) 3 (25.0) 1 (6.7) as well as demonstrated a quick No 23 (71.9) 9 (75.0) 14 (93.3) learning curve. Actual user task times will vary when older adults Try to perform exercises (P=0.637) complete the tasks at their leisure. Yes 19 (59.4) 9 (75.0) 10 (66.7) The ease of finding specific secNo 8 (25.0) 3 (25.0) 5 (33.3) tions increased as more sections were evaluated. Schedule appointment with PCP (P=0.079) Most participants (94%) reported Yes 7 (21.9) 1 (9.1) 6 (40.0) that they regularly discuss their No 19 (59.4) 10 (90.3) 9 (60.0) medications with their PCP. Although inaccuracy was observed Schedule vision examination (P=0.144) with transcribing correct dosages, Yes 6 (18.8) 1 (8.3) 5 (31.2) usability testing participants demonstrated they can easily list the No 22 (68.8) 11 (91.7) 11 (68.8) names of their medications. The Schedule home safety evaluation (P=0.359) medication list in the toolkit should be completed by patients and taken Yes 1 (3.1) 0 1 (6.2) to their PCP for review; PCPs No 28 (87.5) 13 (100.0) 15 (93.8) should consider eliminating medRecommend to a friend (P=0.244) ications that can increase patients’ fall risk. Yes 22 (68.8) 9 (90.0) 13 (100.0) No participant had difficulty No 1 (3.1) 1 (10.0) 0 following the Amsler grid instrucPercentages may not equal 100 due to missing data. tions, but several reported lack of understanding of what to do with the results. Most (94%) reported having regular eye examinations, and section received very positive reviews and none of consequently, did not think the vision section was very the participants had difficulty following the instructions. beneficial. In addition to the exercises being easy to perform, After reviewing the toolkit, most participants found the participants reported that the exercises were advantainformation in the home safety section useful. As demongeous for people who are unable to travel to organized strated by Whitehead and colleagues, most adults feel exercise classes. Rural participants mentioned barriers their home is already safe, and patients with limited funds to traveling to exercise classes, including cost of may not be able to make home revisions.17 Adults do not transportation, travel distance, parking, and seasonal agree to home hazard assessments and prefer not to make restraints on driving; these findings are similar to those changes to their homes.17 If a home safety evaluation of Hutton and colleagues.9 Home-based exercises are recommends hand rails in the bathtub; the financial bar- suitable for fall prevention and are well-used by older rier may outweigh the benefit. To change behavior, one adults. 18 Although the socialization during group must believe the barrier is worth overcoming.3 Only two exercise was considered a benefit, home exercises as (6%) participants reported they would schedule a home provided by this toolkit overcome previously identified safety evaluation. barriers to exercise, including pressure to keep up with Although most participants (72%) reported that they others, different levels of fitness, and self-consciousness regularly exercise and believe it is important, they do of exercising with gym equipment. 9 The clarity of not think many other older adults exercise. The exercise explanations of exercises in the toolkit addresses the 50
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Usability testing of a fall prevention toolkit TABLE 4.
Survey participant reaction to toolkit (n=32) Strongly agree (%)
Agree (%)
Neutral (%)
Disagree (%)
Strongly disagree (%)
Nice general appearance
9 (28.1)
14 (43.8)
2 (6.3)
0
0
Easy to use
8 (25.0)
14 (43.8)
2 (6.3)
0
1 (3.1)
Instructions easy to understand
8 (25.0)
16 (50.0)
2 (6.3)
0
0
Interesting
5 (15.6)
16 (50.0)
3 (9.4)
0
1 (3.1)
Size of wording made it easy to read
13 (40.6)
12 (37.5)
1 (3.1)
0
0
Information was helpful
5 (15.6)
13 (40.6)
6 (18.8)
2 (6.3)
0
Information was easy to find
4 (12.5)
12 (37.5)
9 (28.1)
1 (3.1)
0
Will use in future
7 (21.9)
12 (37.5)
4 (12.5)
1 (3.1)
2 (6.3)
Overall, was very satisfied
6 (18.8)
15 (46.9)
4 (12.5)
0
1 (3.1)
Percentages may not equal 100 due to missing data.
excuse of lack of desire to exercise secondary to lack of self-efficacy.9,17 Overall, participant reaction to the toolkit was positive; the toolkit was important, attractive, and easy to read with an appropriate font size. Participants expressed the importance of using fall prevention strategies, such as those demonstrated in the toolkit. Interestingly, as noted by the toolkit developers, the participants felt the toolkit was good for other older adults rather than themselves.13 Although most of our participants had fallen, they provided excuses for their falls and did not think they needed intervention themselves. A low self-perceived risk of falling is a predictor of participation in interventions such as exercise.18 Whitehead and colleagues evaluated the likelihood of older adults participating in a fall prevention program after suffering a fall and found only 52% would consider fall prevention interventions.17 Whitehead and colleagues also reported that older adults, when asked specifically, would consider exercising (63%), a home assessment (57%), and discontinuing implicated medications (59%) as fall prevention strategies.17 Of our rural participants (not recruited from fitness or fall prevention classes), 53% reported they already regularly exercise and another 12% would like to start. Only 6% of all participants considered having a home safety assessment. Participants perceived consequences of falls as serious, but lacked the feeling that they were susceptible to falling. The participants’ lack of perceived need for this toolkit for themselves may have contributed to them not completing a fall prevention plan. Based on successful completion of the assigned tasks and the positive remarks regarding aesthetics and design, major changes to the toolkit were not recommended.
FUTURE RESEARCH AND PARTICIPANT SUGGESTIONS Completion of a well-designed product does not ensure its use. Subject compliance is the most commonly reported barrier to successful fall prevention intervention.19 Although the toolkit was attractive and easy to use, most participants did not think they would ever use it. Focus group participants reported they would be more likely to use the toolkit if it was introduced to them by either their PCP or through the media. Proposed dissemination was simple distribution, but following the comments of the participants, social interaction may be necessary to stimulate interest and motivate toolkit adoption. Barriers to having a PCP introduce the toolkit include lack of appropriate fall prevention training, competing risks (such as medication benefits versus adverse drug reactions), and lack of time.14 The American Geriatrics Society recommends all adults age 65 years or older be assessed annually for falls.7 The US Preventive Services Task Force recently recommended that PCPs initiate relevant fall prevention interventions in communitydwelling older adults.20 Despite this recommendation, only 37% of older adults are asked by their PCP if they have fallen.21 The Patient Protection and Affordable Care Act encourages the maximization of value for patients and emphasizes care based on patient needs.22 These cumulating recommendations, along with participant requests for PCP involvement, should encourage PCPs to evaluate fall risk and promote fall risk reduction. Older adults gain knowledge of fall prevention programs from a variety of resources, including general practitioners (32%), family members (23%), community health nurses, and other healthcare workers (20%).3 In addition to discussion with PCPs, our participants
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encouraged dissemination of fall prevention strategies through media and community organizations. Future research could evaluate whether distribution of educational materials by these avenues leads to a higher use rate than when the toolkit is introduced by other means. Compliance with a fall prevention program determines its success. STUDY LIMITATIONS Limitations of this study include a small sample size (limiting true representation of the general population, but appropriate for usability testing); recall bias (self-report); social desirability bias; volunteer bias; and test situation (not in participant’s home or natural setting). Most of the study participants (81%) reported a high school or greater education, which possibly does not accurately represent the Kansas population. However, the US Census Bureau (2008-2012) estimates that 84.7% of Kansans (an average of men and women) ages 65 years and older have received at least a high school diploma.23 The urban focus group participants were all enrolled in exercise classes and therefore may have strong positive attitudes toward exercise, may be more motivated to learn fall prevention strategies, and more apt to change behavior. CONCLUSION Falls are prevalent and preventable in older, independent living adults. Despite guidelines and many fall prevention interventions, falls continue to increase. To be effective, fall prevention strategies (exercise and balance training, vision examinations, medication reviews, and home safety evaluations) must be accessible, easy to use, and satisfactory to the older adults who need to adopt them. Providing an independent resource, such as the Falling Less in Kansas fall prevention toolkit, would inform older adults of specific fall prevention strategies. However, like all intervention strategies, this tool must also appeal to the older adult user. Although participants would recommend it to friends, many also admitted that they were disinclined to use it themselves or to adopt the provided strategies. Fall prevention tools, such as this toolkit, may be most used if introduced to older adults by a healthcare provider or in a social setting such as a senior center or church. Without personal intent and professional encouragement, even fall risk reduction plans that are well-designed may not be used. By focusing on customer need, healthcare providers will benefit from knowing the best ways to promote fall prevention strategies. JAAPA REFERENCES 1. Centers for Disease Control and Prevention. Public health and aging: nonfatal injuries among older adults treated in hospital emergency departments—United States 2001. MMWR Morb Mortal Wkly Rep. 2003;52(42):1019-1022. 2. American Trauma Society. http://www.amtrauma.org. Accessed February 10, 2015.
3. Kempton A, Van Beurden E, Sladden T, et al. Older people can stay on their feet: final results of a community-based falls prevention programme. Health Promot Int. 2000;15(1):27-33. 4. Carroll NV, Slattum PW, Cox FM. The cost of falls among the community-dwelling elderly. J Manag Care Pharm. 2005;11(4): 307-316. 5. Carter ND, Kannus P, Khan KM. Exercise in the prevention of falls in older people: a systematic literature review examining the rationale and the evidence. Sports Med. 2001;31(6):427-438. 6. Ruddock B. Medications and falls in the elderly. CPJ/RPC. 2004;137(6):17-18. 7. American Geriatrics Society; British Geriatrics Society; American Academy of Orthopedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc. 2001;49(5):664-672. 8. Gill TM, Robison JT, Williams CS, Tinetti ME. Mismatches between the home environment and physical capabilities among community-living older persons. J Am Geriatr Soc. 1999;47(1): 88-92. 9. Hutton L, Frame R, Maggo H, et al. The perceptions of physical activity in an elderly population at risk of falling: a focus group study. J Physiother. 2009;37(2):85-92. 10. Mayo Clinic. Fall Prevention: 6 tips to prevent falls. http://www. mayoclinic.com/health/fall-prevention/HQ00657. Accessed February 2, 2015. 11. UK National Institute for Clinical Excellence. Clinical practice guideline for the assessment and prevention of falls in older people. http://www.nice.org.uk/nicemedia/pdf/CG021fullguide line.pdf. Accessed February 2, 2015. 12. Wichita State University Regional Institute on Aging Falling LinKS Research Team. The Falling LinKS Toolkit. http://www. wichita.edu/aging. Accessed February 2, 2015. 13. Radebaugh TS, Bahner CA, Ballard-Reisch D, et al. Falling less in Kansas: development of a fall risk reduction toolkit. J Aging Res. 2011;2011:532079. 14. Chou WC, Tinetti ME, King MB, et al. Perceptions of physicians on the barriers and facilitators to integrating fall risk evaluation and management into practice. J Gen Intern Med. 2006;21(2):117-122. 15. Tinetti ME, Baker DI, King M, et al. Effect of dissemination of evidence in reducing injuries from falls. N Engl J Med. 2008;359 (3):305-310. 16. Rubin J. Handbook of Usability Testing. New York, NY: John Wiley & Sons, Inc., 1994. 17. Whitehead CH, Wundke R, Crotty M. Attitudes to falls and injury prevention: what are the barriers to implementing falls prevention strategies? Clin Rehabil. 2006;20(6):536-542. 18. Sjosten NM, Salonoja M, Piirtola M, et al. A multifactorial fall prevention programme in the community-dwelling aged: predictors of adherence. Eur J Public Health. 2007;17(5):464-470. 19. Fortinsky RH, Iannuzzi-Sucich M, Baker DI, et al. Fallrisk assessment and management in clinical practice: views from healthcare providers. J Am Geriatr Soc. 2004;52(9): 1522-1526. 20. Moyer VA. US Preventive Services Task Force. Prevention of falls in community-dwelling older adults: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157 (3):197-204. 21. Wenger NS, Solomon DH, Roth CO, et al. The quality of medical care provided to vulnerable community-living older patients. Ann Intern Med. 2003;139(9):740-747. 22. Porter ME, Lee TH. The strategy that will fix health care. Harv Bus Rev. 2013;91(12):24. 23. US Census Bureau. Educational attainment 2008-2012 American community survey 5-year estimates. American FactFinder. http:// factfinder2.census.gov/faces/tableservices/jsf/pages/productview. xhtml?pid=ACS_12_5YR_S1501. Accessed February 2, 2015.
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