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Effect of Educational Health Program on Prevention
of Falling among Older Adults at Geriatric Homes
*MahboubaSobhyAbd El Aziz, ** AminaAbdElrazek Mahmoud and*** Farida Kamel
* Assist. Prof. of Community Health Nursing, Faculty of Nursing, Benha University.
**& ***Lecturer of Community Health Nursing, Faculty of Nursing, Benha University and
IsmaaliaUniversity.
*mahbobah.abdelaziz@fnur.bu.edu.eg **amina.osman@fnur.bu.edu.eg
ABSTRACT
Back ground: Falls are a major public health problem among older adults and the leading cause
of fatal and nonfatal injuries among them. The aim of this study was to evaluate the effect of
educational health program on prevention of falling among older adults. Research design: A
quasi-experimental design was used in this study. Setting: The study was conducted at Geriatric
Homes, Benha Geriatic Home in Benha City and Abo Negada Geriatic Home in Ismalia City.The
sample:A purposive sample was used in this study, the total number of older adults in the above
mentioned setting were 40 older adults; 24 from Benha City and 16 from Ismalia City. Tools:
Three tools were utilized in this study comprised 1- A structured interviewing questionnaire for;
the socio-demographic characteristics, the past medical history, falls risk factors assessment of
older adults, and for the assessment of knowledge of the older adults, 2- The Falls Efficacy Scale
International (FESI) to assess older adults fear of falling 3- An observation checklist was used to
A) assess practices of the older adults physical activities B) Assess geriatric safety homes
environments. Results of this study showed; 32.5% of the older adults aged from 65 to less than
70 years old. 55 % of them were female, 45% had secondary education, and 82.5% of them were
widow. As regard total knowledge of older adults regarding falls; before the program; 40 % of
them had good total knowledge scores, while after the program increased to 70 % of them.
Concerning to total falls efficacy scale-international; 55% of older adults were very concerned.
This study concluded that: Educational health program has showed a highly statistically
significant effect on knowledge and practices of the older adults post program and improving their
knowledge and practices regarding falling prevention. The study recommended that: Well-
designed educational health program are needed in Geriatric Homes to prevent falling include
intrinsic & extrinsic risk factors and further research is needed for the prevention of falls in older
adults.
Key words: Older adults, falls prevention, and health education program.
Introduction
Older adults are among the fastest increasing age groups; older adults are
defined as any age after 60 or 65 years and constitute a vulnerable group that needs
special care. Globally, the number of older adults (aged 60 years or over) is
expected to more than double, from 841 million people in 2013 to more than 2
billion in 2050(World Population Ageing, 2013).
A fall can be defined as a sudden, unintentional change in position causing
older adults to land at a lower level, on object, the floor, or the ground, other than
as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming
external force. Falls are a serious threat to the lives, health, and independence of
older adults. Falls are caused by complex interactions among multiple risk factors,
which are characterized as intrinsic (patient related) or extrinsic (external to the
patient).Between 30% and 40% of older adults fall at least once year. Falls were
leading cause of fatal and nonfatal injuries among older adults, death rate due to
falls is 10 100 000 persons for those aged 65 to 74 years and 147 100 000
persons for those aged 85 years or older (Al-Faisal, 2006; Michael, 2010).
Falls are the public health epidemic of this decade; falls are the leading cause
of traumatic brain injury and fractures in older adults. For individuals aged 65 and
older, falls outpace motor vehicle accidents as the leading cause of unintentional
death by several thousands. Falls are the leading cause of emergency department
visits by older adults, and hospital admissions due to trauma. Falls also threaten the
independence of older adults as institutionalization rates increase among those who
have had multiple falls, also lead to psychological disturbances such as social
withdrawal, increased anxiety, and fear of falling (Tiffany & Shubert, 2011;
Jennifer et al., 2012).
Older adults have the highest risk of death or serious injury arising from a
fall and the risk increases with age. In the United States of America, 20–30% of
older adults who fall suffer moderate to severe injuries such as bruises, hip
fractures, or head traumas. This risk level may be in part due to physical, sensory,
and cognitive changes associated with ageing, in combination with environments
that are not adapted for an aging population (World Health Organization (WHO),
2012).
The term falls prevention refers to the optimal management of falling risk to
prevent the falls. It is estimated that the maximum reduction in fall rates due to an
intervention is between 30% and 40%.Health education about risk factor of falling,
exercise and physical activity, medical assessment and management, medication
adjustment, environmental modification and education about vitamin D
supplementary have the strongest benefit for preventing falls among older adults. A
certain number of older adults will still fall, regardless of interventions, but every
effort must be taken to minimize risk (Campbell & Robertson, 2007; Tinetti&
Kumar, 2010).
Significant of the study
According to Centers for Disease Control and Prevention (CDC, 2015): each
year, millions of older people—those 65 Over 700,000 patients a year are
hospitalized because of a fall injury, most often because of a head injury or hip
fracture and older—fall. In fact, one out of three older people falls each year, also
2.5 million older people are treated in emergency departments for fall injuries, and
Over 700,000 patients a year are hospitalized because of a fall injury, most often
because of a head injury or hip fracture, each year at least 250,000 older people are
hospitalized for hip fractures.
Globally, falls are a major public health problem. An estimated 424 000 fatal
falls occur each year, making it the second leading cause of unintentional injury
death, after road traffic injuries. Over 80% of fall-related fatalities occur in low-
and middle-income countries, death rates are highest among adults over the age of
60 years. Though not fatal, approximately 37.3 million falls are severe enough to
require medical attention occur each year, such falls are responsible for over 17
million DALYs (disability-adjusted life years) lost. The largest morbidity occurs in
older adults 65 years or older. Age is one of the key risk factors for falls. In Egypt,
there is gradual increase in the absolute and relative numbers of older people over
the last few decades. The last country profile of Egypt shows that the percentage of
older adults (more than 65 years) is 3.7 % of the total population in 2009(Kamel et
al., 2013).
Community Health Nurses play an important role regarding reducing of falls
among older adults through identifying the hazards of falls at geriatric home, and
the way to minimize, also guiding older adults about factors that contribute to falls,
consequence of falls, and the way to prevent falls so this program is very
important .
Aim of the Study:
This study aimed to evaluate the effect of educational health program on
prevention of falling among older adults through:-1-Assessing the older adults'
knowledge, fear of falling and practices physical activities needs towards prevention
of falling, 2- Assessing risk factor of falling among older adults, 3-Assessing safety
environment at Geriatric homes,4-Developing and implementing an educational
health program based on the previously detected needs of older adults, and 5-
Evaluating the degree of improvement as an impact of the exposure to the
educational health program.
Research hypothesis
To fulfill the aim of this study the following research hypothesis formulated:
Older adults who received the educational health program would have improved
knowledge and practices related to risk factors to prevent them from falling.
Subjects and Methods
Study design and setting
A quasi experimental design was utilized to carry out this study, with pre-post
assessment to evaluate the effect of the educational health program. This study was
conducted at Geriatric Homes, Benha Geriatic Home in Benha City and Abo
Negada Geriatic Home in Ismalia City.
Sampling
A purposive sample used in this study, the total number of older adults in the
above mentioned setting were 44 older adults; 26 from Benha Geriatic Home in
Benha City and 18from Abo Negada Geriatic Home in Ismalia City.4 older adults
were excluded for pilot study. All older adults were taken according to certain
criteria their age above 60 years and independents.
Tools of data collection:
1) A structured interviewing questionnaire: It consisted of the following
four parts: Part one: Socio-demographic characteristics of the older adults
included five items as age, gender, residence, education, and marital status. Part
two: Concerned with the past medical history of older adults. Part three
included the falls risk factors of older adults as history of falling, medication,
vision, and nutrition. Part four: Assessed the knowledge of older adults about
falling, which included 28 items about meaning of falling, causes of falls, and
preventive measures of falling. Scoring system; for each question was given as
follows: 3 if good knowledge, 2 if average knowledge, and 1if poor
knowledge.The total knowledge scores were considered good if the score of the
total knowledge ≥ 75 % (≥ 21), considered average if it is equals 50- < 75% (14-
< 21), and considered poor if it is less than 50% (< 14).
2)The Falls Efficacy Scale International (FESI) adopted from (Yardley et al.,
2005),through asking questions; it included fifteen items used to assess older
adults' fear of falling e.g. cleaning the room, getting dressed or undressed,
preparing simple meals, taking a bath or shower, going to the shop, getting in or
out a chair, going up or down stairs, etc. Scoring system for each item was given
as follows: 4 if very concerned, 3 if fairly concerned, 2 if somewhat concerned,
and 1 if not at all concerned. The total scores of scale were considered very
concerned if equal 60, considered fairly concerned if equal 45, considered
somewhat concerned if equal 30, and considered not at all concerned if equal 15.
3) An Observation Checklist: It was concerned with two parts. Part one
designed to assess practices of the older adults' physical exercises; it included
nine physical exercises, which included 49 items about modified mountain pose,
heel raise, stand on one foot, side leg raise, back leg raise ,sit to stand, heel-toe
pose, backwards steps, and shift forward and back. Scoring system; the total
practices were considered satisfactory if the score of the total practices equals ≥
65 % (≥ 23), and considered unsatisfactory if it is < 65% (< 32).Part two to
assess Geriatric safety homes environments. Scoring system; each item was
assigned a score of 1 if present and 2 if absent.
Validity test
The tools were revised for content validity by 3 juries who were experts in the
Community Health Nursing Specialties, for clarity, relevance,
comprehensiveness, and applicability. According to their suggestions, the
modifications were applied.
Reliability test
Reliability of the tools was applied by the researcher for testing the internal
consistency of the tool, by administration of the same tools to the same subjects
under similar condition on one or more occasion. Answers from repeated testing
were compared (test- re –test reliability).
Operational Design:
Preparatory phase
Preparation of study design and data collection tools based on reviewing
current, past, local, and international related literature about various aspects of
falling among older adults by using journals, periodicals books and internet
search to construct the tools and prepare the health educational program.
Ethical considerations
Personal communication was done with older adults to explain the
purpose of the study, assure their best possible cooperation and ensuring
confidentiality of the data. The researchers emphasized to older adults that the
study was voluntary and anonymous. Older adults had the full right to refuse to
participate in the study or to withdraw at any time without giving any reason.
Administrative design
Official permission was obtained by submission of an official letter from the
Faculties of Nursing to the responsible authorities of the study settings to obtain
the permission for data collection.
Pilot study
After the development of the tools, a pilot study was carried out on 10%
of the sample (4 older adults) to ascertain the clarity, applicability, feasibility of
the tool, to estimate the exact time needed to fill in the questionnaire, and to
detect any problems that might face the researcher and interfere with data
collection. After conducting the pilot study, minor necessary changes were done,
the tool was then finalized. The pilot sample was not included in the main study
sample.
Field work
• Preparation of data collection tools was carried out over a period of six
months from the beginning of May 2015 to end of October 2015, including
experts' opinions, validity, and reliability test.
• Official permissions were obtained from the deans of the faculties (Benha
and El -Isamailia Faculties of Nursing), also from administrators of the Geriatric
home.
• A pilot study was carried out to test clarity and simplicity of questions.
Program construction:
The current study was carried out on four phases, preparatory phase,
development phase, implementation phase and evaluation phase.
1. Program assessment phase: The program was designed after extensive
review of related literature, by the researchers. Based on results obtained
from pre-assessment tools, it was revised and modified.
2. Program development phase: The program was developed based on the
actual results that were obtained from pre-program assessment using the
interviewing questionnaire, practices and observation checklist as well as,
literature review which aimed to enhance the older adults’ knowledge, and
practices regarding prevention of falling.
An objective of the program was to improve knowledge and practices
related to risk factors of older adults' to prevent them from falling.
Contents of program: The content of the program was designed to meet
older adults' needs and to fit into their interest and level of understanding. Its
contents were:
Meaning of falling.
Causes of falling included intrinsic and extrinsic risk factors:
a- Intrinsic risk factors as medical history of some diseases e.g., urinary
incontinence, osteoporosis, fracture, arthritis, anemia, vitamin D
deficiency diabetes mellitus, hypertension, stroke, cataract,
cardiovascular diseases, gastrointestinal tract diseases, and chest
diseases. Taking some medications as; antihypertensive drugs,
sedatives, cardiovascular medications …etc.
b- Extrinsic risk factors as poor lighting, stairs with
inadequate handrails, rugs/floor surfaces with low friction, lack of
equipment/aids such as walking sticks or walking frames ….etc.
Preventive measures of falling.
3. Program implementation phase: The program was implemented in a
period of six months, from the beginning of May 2015 to the end of October
2015.Implementation of the program was carried out at the Geriatric Homes
of Benha City and Ismaalia City. The subject material used has been
sequenced through the 5 sessions (2 sessions for theory and 3 sessions for
practices). The duration of each session ranged from 30 to 45 minutes
including times for discussion according to older adults’ achievement,
progress and feedback. The sessions contained knowledge about falling as
meaning, causes, intrinsic and extrinsic risk factors preventive measures,
and three practical sessions for physical activities to prevent risk of falling.
Older adults were divided into small groups; each group included about 6 or
5older adults. The five sessions were implemented for each group separately
for 2 weeks (2 days/week), in addition to one week for pre and posttest.
Sometimes the researcher worked with two groups in the same day. At the
beginning of the first session, an orientation to the program and its purpose
took place. After each session, a feedback about the previous session was
done as well as the objectives of the new topics were mentioned. Methods of
teaching included lectures, group discussions, demonstrations, re-
demonstration and role play. An instructional media was used including an
illustrated booklet and brochure.
4. Program evaluation phase: After the implementation of the program,
the post-test was done to the older adults to assess knowledge, and practice
physical exercises by the same format of the pre-test to evaluate the
effectiveness of the implemented program. This was done immediately
after the intervention of program implementation.
Statistical Design
The collected data were verified prior to computerized entry; statistical
analysis was done by using the Statistical Package for Social Science (SPSS)
version 20. Data were presented in tables by using mean, standard deviation,
number, percentage distribution, and Chi- Square. Statistical significance
was considered at:
P- Value > 0.05 insignificant
P- Value < 0.05 significant
P- Value < 0.001 highly significant.
Results
Table (1) Shows that, 32.5% of the older adults aged from 65 to < 70
years old. Regarding to gender 55 % of them was female, 60% live in separate
room, 45% had secondary education, and 82.5% of them were widow.
Table (2) Elaborated that all older adults had past medical history, 70 %
of them had arthritis, and osteoporosis, 80% of them had hypertension, while
47.5% of them had diabetes mellitus.
Table (3) Shows that the risk factor of falls among the older adults, around
45% of them had risk factor due to previous falling at last 12 month, and 80% of
them due to taking medication as antihypertensive drugs, 50% taking diuretic
medication, 25% of older adult liable to falling due to difficulty seeing across
the room with or without glasses. 30.0% liable to falling due to vitamin D
deficiency while 75% of them due to calcium deficiency.
Table (4) Explains that; the older adults' knowledge about falling
(meaning, causes, and preventive measures of falling) improved significantly
after the implementation of the program (P < 0.001).
Figure (1) Illustrates that, before the program implementation; 40 % of the
older adults had good total knowledge scores regarding falling, while after the
program implementation; total knowledge scores increased to70 %.
Table (5) Explains that; total practices of the older adults' physical
exercises (modified mountain pose ,heel raise, stand on one foot, side leg
raise ,back leg raise ,sit to stand, heel-toe pose, backwards steps, and shift
forward and back)improved significantly after the implementation of the
program (P < 0.001).
Figure (2) Illustrates that, the total scores of older adults' practices was
satisfactory for30%of them before the program implementation and increased to
80%after the program implementation
Table (6) Shows that; the highly percentage of older adults was 55%
related to total falls efficacy scale-international. As regards taking a bath or
shower and walking up or down a slope, very concerned was 55%. Also, 45% of
older adults were cleaning the room fairly concerned. As regards going up or
down stairs 42% of older adults were somewhat concerned. Meanwhile 37% of
subjects were not at all concerned related to going to the shop and walking on an
uneven surface.
Table (7) Shows that; 100% of geriatric safety homes environment had
lamp, extension & telephone cords are located outside of walking path, flooring is
free from rips &holes, older adults uses furniture for support while ambulating,
lighting is adequate, older adults easily opens/closes at least one window & all
blinds or shades, floors & tabletops are free of clutter.
Table (8) Shows that; there were high statistically significant differences
between the older adults' total knowledge scores and their gender, residence, and
educational levels (P < 0.001).
Table (9)Shows that; there were high statistically significant differences
between the older adults' total practices scores and their age, gender, residence,
educational levels, and their marital status (P < 0.001).
Table (1): Distribution of older adults according to their socio-demographic
characteristics (n= 40).
Socio-demographic characteristics
No.
%
Age / years
< 65
9
22.5
65-
13
32.5
70-
10
25.0
≥ 75
8
20.0
X±SD = 66.80 ± 5.09 Range =22.00
Gender
Male
18
45.0
Female
22
55.0
Residence
Separate
24
60.0
Conjoint
10
25.0
Triple
6
15.0
Education
Illiterate
11
27.5
Basic education
14
10.0
Secondary education
18
45.0
High education
7
17.0
Marital status
Single
2
5.0
Married
3
7.5
Divorced
2
5.0
Widow
33
82.5
Table (2): Distribution of older adults according to their past medical
history (n= 40).
%
No.
Past history
25.0
10
Urinary incontinence
70.0
28
Osteoporosis
5.0
2
Fracture
70.0
28
Arthritis
17.0
7
Anemia
47.5
19
Diabetes mellitus
80.0
32
Hypertension
2.5
1
Stroke
25.0
10
Cataract
47.5
19
Cardiovascular diseases
55.0
22
Gastrointestinal tract diseases
32.0
13
Chest diseases
N.B.: Answers were not mutually exclusive.
Table (3): Distribution of older adults according to their falls risk factors
(n= 40).
%
No.
Falls Risk Factors
N.B.: Answers were not mutually exclusive.
Table (4): Percentage distribution of the older adults' knowledge about falling
before& after the program implementation (n=40).
Knowledge
Before- program (%)
After- program (%)
X2
P-value
Good
Average
Poor
Good
Average
Poor
Meaning of falling
25.0
0.0
75.0
80.0
0.0
20.0
24.2
< 0.001
Causes of falling
12.5
25.0
52.5
50.0
32.5
17.5
19.5
< 0.001
Preventive measures of
falling
27.5
17.5
55.0
55.0
20.0
25.0
20.7
<0.001
** Highly statistically significant difference (P <0.001).
1-Falls history:
45.0
18
- Fear of falling due to previous falling the last 12 months
40.0
16
- Loss confidence and balanced since have fallen
2- Medication:
55.0
22
- Taken 4 or more medications
- Taken any of the following medication:
32.3
3
Sleeping pills
80.0
32
Antihypertensive drugs
50.0
20
Diuretics
2.5
1
Anesthetics
40.0
16
Antihistamine
45.0
18
Cathartics
2.5
1
Anti-seizure
32.5
13
Hypoglycemic
7.5
3
Psychotropic
25.0
10
Sedative/ hypnotics
3- Vision:
25.0
10
- Difficulty seeing across the room without glasses
17.5
7
- Recently started wearing bifocals ( last three months)
4- Nutrition:
55.0
22
- Vitamin D deficiency
57.5
23
- Calcium deficiency
Figure (1): Percentage distribution for total knowledge scores regarding falling
among the older adults before& after the program implementation
(n=40).
Table (5): Percentage distribution of older adults' physical exercises before& after the
program implementation (n=40).
Before-program
After-program
40%
70%
25%
20%
35%
10%
Good
Average
Poor
Physical exercises
Before- program (%)
After- program (%)
X2
P-value
** Highly statistically significant difference (P <0.001).
Done
completely
(%)
Done
incompletely
(%)
Done
completely
(%)
Done
incompletely
(%)
Modified mountain pose
55.0
45.0
87.5
12.5
10.9
<0.001**
Heel raise
42.5
57.5
60.0
40.0
10.2
<0.001**
Stand on one foot
37.5
62.5
72.5
27.5
15.0
<0.001**
Side leg raise
62.5
37.5
85.0
15.0
14.4
<0.001**
Back leg raise
55.0
45.0
82.5
17.5
16.8
<0.001**
Sit to stand
25.0
75.0
70.0
30.0
16.2
<0.001**
Heel-toe pose
30.0
70.0
57.5
42.5
14.5
<0.001**
Backwards steps
72.5
27.5
67.5
32.5
12.8
<0.001**
Shift forward and back
25.0
75.0
55.0
45.0
14.3
<0.001**
Figure (2): Percentage distribution for total scores of older adults' practices
before& after the program implementation (n=40).
After- program
Before-program
20%
70%
80%
30%
Unsatisfactory
Satisfactory
Table (6): Percentage distribution of the older adults' according to falls efficacy
scale-international. (n=40).
Falls Efficacy Scale
Not at all
concerned (%)
Somewhat
concerned (%)
Fairly
concerned
(%)
Very
concerned (%)
Cleaning the room (e.g. sweep, vacuum,
dust)
22.5
17.5
45.0
15.0
Getting dressed or undressed
5.0
20.0
25.0
50.0
Preparing simple meals
30.0
20.5
32.5
17.0
Taking a bath or shower
7.5
17.5
20.0
55.0
Going to the shop
37.5
25.0
20.0
17.0
Getting in or out of a chair
10.0
22.5
27.5
40.0
Going up or down stairs
7.5
42.5
25.0
25.0
Walking around in the neighborhood
17.5
30.0
30.0
22.5
Reaching for something above your head
or on the ground
12.5
17.5
25.0
45.0
Going to answer the telephone before it
stops ringing
17.5
22.5
25.5
22.5
Walking on a slippery surface (e.g. wet or
icy)
30.0
32.5
17.0
20.0
Visiting a friend or relative
10.0
27.5
22.5
40.0
Walking in a place with crowds
27.5
22.5
17.0
32.5
Walking on an uneven surface (e.g. rocky
ground, poorly maintained pavement)
37.5
25.0
20.5
17.0
Walking up or down a slope
7.5
17.0
20.5
55.0
Total
12.5
17.5
25.0
55.0
Table (7): Percentage distribution of the geriatrics safety homes environmental
conditions (n=2).
Geriatric safety homes environment
Present
No.
%
Easily moves in/out & through room without bumping/tripping into
anything.
1
50.0
Lamp, extension & telephone cords are located outside of walking path.
2
100.0
Flooring is free from rips & holes.
2
100.0
Older adults use furniture for support while ambulating.
2
100.0
Table tops & floor are free of excessive clutter.
1
50.0
Lighting is adequate.
2
100.0
The older adult easily opens/closes at least one window & all blinds or
shades.
2
100.0
Mattress is supportive & does not sag when sat on.
1
50.0
Bedside commode available if nighttime trips to bathroom are difficult.
1
50.0
Floors & tabletops are free of clutter.
2
100.0
Closet clothing is accessible without client standing on tiptoes or chair.
2
100.0
Pathway to bathroom is lit at night (by nightlights, flashlight or light left on).
2
100.0
Older adults can easily get on & off the toilet.
2
100.0
Faucets are easy-to-use.
1
50.0
Table (8): Relations between the older adults' total knowledge scores& their socio-
demographic characteristics (n=40).
Non-skid safety treads or mats on bottom of bathtub.
1
50.0
Socio-demographic
Characteristics
Total knowledge
Chi –Square
Before- program (%)
After- program (%)
X2
P-value
Good
Average
Poor
Good
Average
Poor
Age / years
34.57
> 0.05
< 65
22.2
44.4
33.4
55.5
33.4
11.1
65-
30.8
38.4
30.8
38.5
46.
15.4
70-
30.0
20.0
50.0
40.0
40.0
20.0
≥ 75
12.5
12.5
75.0
37.5
50.0
12.5
Gender
Male
27.8
11.1
61.1
55.6
22.2
22.2
18.55
< 0.001**
Female
18.2
27.3
54.5
50.0
40.9
9.1
Residence
44.57
< 0.001**
Separate
45.8
29.2
25.0
66.7
33.3
0.0
Conjoint
40.0
30.0
30.0
60.0
40.0
0.0
Triple
33.3
16.7
50.0
66.6
16.7
16.7
Educational levels
31.07
< 0.001**
Illiterate
18.2
18.2
63.6
36.4
45.4
18.2
Basic Education
25.0
25.0
50.0
50.0
50.0
0.0
Secondary Education
33.3
27.0
38.9
50.0
33.3
11.7
High Education
42.9
42.8
14.2
71.4
28.6
0.0
Marital status
3.63
> 0.05
Single
50.0
50.0
0.0
100.0
0.0
0.0
Married
66.6
33.4
0.0
100.0
0.0
0.0
Divorced
50.0
50.0
0.0
100.0
0.0
0.0
Widower
30.3
33.3
36.4
48.5
39.4
12.1
** Highly statistically significant difference (P < 0.001).
Table (9): Relations between the older adults' total practices scores & their socio-
demographic characteristics (n=40).
Socio-Demographic
characteristics
Total practices
Chi –Square
Before- program (%)
After- program (%)
X2
P-value
Satisfactory
Unsatisfactory
Satisfactory
Unsatisfactory
Age / years
22.85
< 0.001**
< 65
55.5
44.5
77.8
22.8
65-
46.2
53.8
69.2
30.8
70-
30.0
70.0
50.0
50.0
≥ 75
37.5
62.5
50.0
50.0
Gender
24.73
< 0.001**
Male
33.4
66.7
55.5
44.5
Female
36.7
63.3
45.5
54.5
Residence
32.38
< 0.001**
Separate
54.2
45.8
75.0
25.0
Conjoint
30.0
70.0
80.0
20.0
Triple
33.4
66.6
66.6
33.4
Educational levels
26.93
< 0.001**
Illiterate
36.4
63.6
81.8
18.2
Basic Education
50.0
50.0
75.0
25.0
Secondary Education
61.1
38.9
83.3
16.7
High Education
71.4
28.6
100.0
0.0
Marital status
10.56
< 0.001**
Single
50.0
50.0
100.0
0.0
Married
66.7
33.3
100.0
0.0
Divorced
50.0
50.0
100.0
0.0
Widower
45.5
54.5
60.6
39.4
** Highly statistically significant difference (P < 0.001).
Discussion
Falls are a serious threat to the lives, health, and older adults, falls are a threat
to the health of older adults and can reduce ability to remain independent. Falls are
caused by complex interactions among multiple risk factors, which are characterized
as intrinsic (older adults related) or extrinsic (external to the older adults).
Understanding the risk factors is the first step to reducing older adult falls and
effective interventions can prevent older adult falling(CDC,2008;Michael, 2010).
Concerning the socio-demographic characteristics of older adults, the study
finding in Table (1) revealed that about more than half of them were females, this
finding is congruent Masbah (2007), who found that more than two thirds of the
studied subjects were females. This could be attributed to the females have more
live than men. Regarding the studied subjects' educational level less than half of the
older adults had secondary education ,this finding is disagree with Ebrahem
(2013),who found that more than half of older adults were illiterate. These
differences may be due to the difference of the setting of the study, where the study
was conducted in Out Patient Clinic. Regarding the marital status, it was found that
the majority of the studied subjects were widowed. This finding goes with the same
line with Ahmed (2009), who found that more than three quarters of study subjects
were widowed. While this result is in contrast with Taha and Ali (2011), who
clarified in the study the majority of the study subjects were married.
As regards to past medical history of older adults, finding in Table (2)
showed that about the majority of the study subjects had hypertension, less than
three quarters had arthritis, and osteoporosis. These findings are in agreement with
Eliopoulos (2010), who mentioned that more than one third of the older adults have
hypertension, arthritis, and osteoporosis. This finding also supported by Nies&
McEwen (2011), who stated that many of the physiological changes that occur with
aging as well as a variety of chronic diseases can affect balanced and make falls.
This is could be attributed to the multi disease associated with aging process.
Regarding risk factors of falls, findings in Table, (3) showed that about less
than half of the studied subjects had fear from previous falling, these findings was
supported by WHO (2007), who stated that fear of falling is frequently reported by
older adults, fear can lead to a decline in overall quality of life and increase the risk
of falls through a reduction in the activities needed to maintain self-esteem,
confidence, strength and balance. In addition, fear can lead to maladaptive changes
in balance control that may increase the risk of falling. Older adults who are fearful
of falling also tend to lack confidence in their ability to prevent or manage falls,
which increases the risk of falling again.
Also, the findings in Table, (3) elaborated that the majority of the older adults
had risk factors of falls due to take medication, this finding agree with Nies&
McEwen (2011), who stated that medication such as anti-hypertensive drugs,
diuretics and tranquilizers may increase risk of falling among older adults. The
finding of the current study also revealed that more than half of study sample had
risk factors of falls due to vitamin D and calcium deficiency, this finding is in
agreement with WHO (2007), who stated that older adults with low dietary intake of
calcium and vitamin D may be at risk for falls and therefore fractures resulting from
them, dietary calcium and vitamin D intake improves bone mass among persons
with low bone density and that it reduces the risk of osteoporosis and falling.
Concerning research hypothesis; the educational health program will
improve knowledge and practices related to intrinsic and extrinsic risk factors of
older adults to prevent them from falling(tables 4-7, Fig., 1&2). Concerning the
older adults' knowledge about falling, findings in Table, (4) and figure (1)
showed that knowledge about falling was improved significantly after
implementation of the program (P < 0.001). Jennifer (2012) stated that
education program for older adults can minimize the risk for falls by using
specific assessment and prevention strategies, and WHO, (2012) recommended
that effective fall prevention programmes aim to reduce the number of people
who fall, the rate of falls and the severity of injury should a fall occur. For older
adults, fall prevention programmes can include a number of components to
identify and modify risk factors.
The current study findings in Table, (5) and Figure,(2) indicated that; total
practices of the older adults' physical exercises (modified mountain pose ,heel raise,
stand on one foot ,side leg raise ,back leg raise ,sit to stand, heel-toe pose,
backwards steps, and shift forward and back)improved significantly after the
implementation of the program (P < 0.001).
In accordance with these findings, there has been considerable research
demonstrating a positive effect of exercise on reducing fall risk among community-
residing older adults (American Geriatrics Society et al., 2001). However, as is the
case with other intervention research, these studies have not been replicated in
nursing-home residents, probably due to their higher incidence of physical frailty
and cognitive impairment. Studies have shown; however, that exercise even in very
frail nursing-home residents improves balance, mobility, and flexibility, though
these studies did not note a reduction in falls (Toulotte et al., 2003).Similarly, (Pai
and Bhatt, 2007;Mansfield et al., 2010),its results demonstrated that one-third of
falls in this study were attributed to tripping or slipping. Promising falls
interventions include techniques for teaching individuals in laboratory settings how
to regain their balance. Although, these may not be practical on a population level.
Recent work with healthy older adults showed that under laboratory conditions,
training that used surface perturbations to simulate slipping and induce backwards
falls improved both proactive (pre-slip) and reactive (post-slip) balance strategies.
The result was fewer backward falls (Mansfield et al., 2010; Wang et al., 2011).
Concerning to total falls efficacy scale-international Table (6), more than half
of older adults were very concerned. Slightly above half were very concerned as
regards taking a bath or shower and walking up or down a slope. Also, less than half
of older adults were cleaning the room fairly concerned. As regards going up or
down stairs 42% of older adults were somewhat concerned. Meanwhile more than
one third of subjects were not at all concerned related to going to the shop and
Walking on an uneven surface.
A similar finding was reported by (Fletcher &Hirdes, 2004; Camargos et al.,
2010), who clarified that There are a number of studies were reported that being a
multiple faller significantly increases fear of falling that may cause activity
restriction. On the other hand, (Kato et al., 2008) studied a study to investigate the
relation of the Falls Efficacy Scale (FES) to quality of life (QOL) among nursing
home residents. They found FES score as 45±22.3, while it was found as 36.7±11.9.
This difference may be related with age difference of participants of their study (age,
mean: 85.6±6.1).
Concerning study setting as geriatrics safety homes environment(Table7),
had lamp extension& telephone cords are located outside of walking path, flooring
is free from rips & holes, older adults uses furniture for support while ambulating,
lighting is adequate, older adults easily opens/closes at least one window & all
blinds or shades, floors & tabletops are free of clutter. All this items is important to
prevent extrinsic factors of falling.
On the same line, all studies conducted in nursing homes have included
environmental modifications as part of a multi factorial prevention
intervention. Ambulatory residents may fall when attempting to transfer to and from
the bed, chair, or toilet. The height of these devices (e.g. the distance between the
floor and the top of the bed mattress) is crucial to safe standing. Research on chair
height recommends a seat height that is approximately 100% to 120% of the lower
leg length; this facilitates rising by requiring less knee extension, forward leaning,
and strength of lower-extremity muscles. For shorter (less than 5 feet in height)
residents, the standard nursing-home bed may be too high, and so low beds that can
be manually, hydraulically, or electrically adjusted to promote transfer are suggested
(Weintraub and Rubenstein, 2004).
The present study findings in Table, (8)revealed that; there were high
statistically significant differences between the older adults' total knowledge scores
and their gender, residence, and educational levels (P < 0.001).On the other hand
there were no statistically significant differences between the older adults' total
knowledge scores and their age and marital status (P > 0.05).In agreement with this,
(Lewis, 2001) no significantly post intervention compared to pre-intervention
related to age and marital status. This result stand on line with (Gillespie et al.,
2012)trials testing interventions to increase knowledge/educate about fall prevention
alone did not significantly reduce the rate of falls (RaR 0.33, 95% CI 0.09 to 1.20;
one trial; 45 participants) or risk of falling (RR 0.88, 95% CI 0.75 to 1.03; four trials;
2555 participants).
The present study showed that in Table, (9); there were high statistically
significant differences between the older adults' total practices scores and their age,
gender, residence, educational levels, and their marital status (P < 0.001).This
finding was in the same line with a study done by (Grabiner et al., 2012) explored
whether task-specific training could reduce trip-related falls among 52 healthy
middle-aged and older women. Using a treadmill to simulate tripping, the 22 women
who had received training had significantly fewer falls (4.5%) than the 30 control
women (26.6%). However, it is not known if laboratory training would benefit less
healthy older adults or if it would translate into fewer falls from unexpected trips
and slips in real life settings.
These findings are inconsistent with other studies which have found there were no
significant differences between women’s and men’s physical functionality, men
tended to have a greater overall strength and physical functioning, while women
tended towards, having a greater upper body flexibility (Smeeet al., 2012).
Conclusions
According to results & research hypothesis concluded that: Educational
health program has showed a highly statistically significant effect on knowledge and
practices related to intrinsic and extrinsic risk factors of the older adults to prevent
them from falling post program. Total practices of the older adults' physical
exercises (modified mountain pose ,heel raise, stand on one foot ,side leg raise ,back
leg raise ,sit to stand, heel-toe pose, backwards steps, and shift forward and
back)improved significantly after the implementation of the program (P < 0.001).
Recommendation:
Well-designed educational health program are needed in Geriatric Homes to
prevent falling include intrinsic & extrinsic risk factors.
Further research is also needed on the interventions that may contribute to the
prevention of falls in older adults.
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