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Falls and fall-related injuries pose a major threat to older peoples’ health, and are associated with increased morbidity and mortality. In the course of demographic changes, development and implementation of fall prevention strategies have been recognized as an urgent public health challenge. Various risk factors for falls and a number of effective interventions have been recognized. A substantial proportion of falls occur for people who are neither frail nor at high risk. Therefore, population-based approaches reaching the entire older population are needed.
The objective of the study presented is the development, implementation, and evaluation of a population-based intervention for the prevention of falls and fall-related injuries in a medium sized city in Germany.
The study is designed as a population-based approach. The intervention community is a mid sized city named Reutlingen in southern Germany with a population of 112,700 people. All community dwelling inhabitants 65 years and older are addressed. There are two main measures that are defined: (1) increase of overall physical activity, and (2) reduction of modifiable risk factors for falls such as deficits in strength and balance, home and environmental hazards, impaired vision, unsafe footwear, and improper use of assistive devices. The implementation strategies are developed in a participatory community planning process. These might include, for example, training of professionals and volunteers, improved availability of exercise classes, and education and raising awareness via newspaper, radio, or lectures.
The study starts in September 2010 and ends in December 2013. It is evaluated primarily by process evaluation as well as by telephone survey.
Physical activity as a key message entails multiple positive effects with benefits on a range of geriatric symptoms. The strength of the design is the development of implementation strategies in a participatory community planning. The problems that we anticipate are the dependency on the stakeholders’ willingness to participate, and the difficulty of evaluating population-based programs by hard end points.
Falls and fall-related injuries pose a major threat to older peoples’ health and well-being, and are associated with an increased morbidity and mortality. Moreover, fall-related morbidity poses a substantial burden on caregivers and families, and the economic burden on health care systems is highly relevant [
A variety of risk factors for falls have been identified, and a number of interventions have shown to be effective. Among these are, for example, different types of exercise, removal of environmental hazards, and improvement of vision [
In contrast to high risk approaches, Rose proposed a “population strategy” for common health problems by shifting “the whole distribution of exposure in a favorable direction” [
Few population-based programs for fall prevention provide evidence on their effectiveness and information on successful strategies for implementation and motivation [
The impact of fall prevention on a population level depends on the participation rates and on the wide availability of fall prevention strategies. There are few data on population-based interventions in the interest of estimating the exact participation rate to achieve an impact on the overall fracture rates. Based on Australian data, Day et al calculated 5440 falls prevented, assuming that 1.9% of the eligible Australian population 70 years and older took up Tai Chi classes [
Fall prevention activities require a substantial effort from the older people themselves; therefore, motivation is a key issue. However, older people are reluctant to get involved in fall prevention activities and uptake rates for interventions in the community are typically low [
In Germany, to the best of our knowledge, no population-based program for the prevention of falls in older people has been implemented so far. Therefore, the overall aim of the study presented in this paper is the development, implementation, and evaluation of a population-based intervention for the prevention of falls and fall-related injuries in a medium sized city in Germany. In the design of the study, two main measures are defined: (1) the increase of physical activity, and (2) the reduction of modifiable risk factors for falls using existing structures within the community. The strategies to implement these measures are developed in a participatory community planning. In this paper we describe the background and design of the study.
In Germany, care for the elderly by municipalities implies the coordination of services, policy making, planning, and building of infrastructure such as nursing homes. Self-employed physicians, therapists, and hospitals provide health care. The nursing care is provided by for-profit and nonprofit home care services and nursing homes, which are financed by compulsory long-term care insurances with considerable copayment from the older people themselves. Financing of health services is granted by health insurances and reimbursement of services is highly regulated by federal laws.
To date, there is no national German guideline or policy on fall prevention [
Physical activity in the general older population is promoted and offered by sports clubs and numerous local nonprofit providers, further exercise classes are offered by churches, welfare, and volunteer organizations. Most nonprofit exercise class providers rely on qualified volunteers as instructors. Financing for these classes is based on fees, public funding, and fund raising activities. Increasingly, privately run sports clubs are attractive to older people as well for these classes [
The study presented is designed as a population-based multi-strategic intervention. The author Last defines a community-based intervention when “the unit of allocation to receive a preventive regimen is an entire community” [
The intervention community is the city of Reutlingen, a mid sized city in southern Germany with a population of 112,700 people. About 20.00% (n=22,540) of the inhabitants are 65 years and older. The city was chosen for its proximity to the research center conducting the study (45 km), the medium size (compared to other German cities), and the willingness of local partners to cooperate. Reutlingen is characterized by the combination of an urban city center, and smaller rural districts. There are 103 clubs, various welfare, and volunteers’ organizations, as well as churches that all offer exercise classes. There are 73 general practitioners that are represented by a local body, and 16 for-profit and nonprofit ambulatory care services that provide nursing care. Policy making within the municipality has a strong focus on the prevention of institutionalization in old age, and on optimization of care for community dwelling older people with functional limitations. There is no policy regarding fall prevention. The geriatric unit conducting the study does not provide any services in the intervention community.
The study is designed not to identify and target high risk persons, but to address the general older population as defined. To clarify the terminology of the population-based intervention being presented, “measure” is defined as a certain protective factor (eg, increased physical activity), whereas “strategy” refers to the means by which the measure is promoted (eg, education, improved availability) [
The two following main measures were up taken: (1) the increase of physical activity, and (2) the reduction of modifiable risk factors for falls such as deficits in strength and balance, home and environmental hazards, impaired vision, unsafe footwear, and the improper use of assistive devices.
The population-based strategies to intervene on the individual, social, and environmental levels are developed in a participatory community planning. A variety of strategies are to be developed within the course of the study. These might include, for example, the training of professionals and volunteers; education and raising awareness via newspaper, radio, posters, and lectures; or improved availability of exercise classes in the form of the development of a directory. Physical activity and its benefits serve as the key message, whereas fall prevention is secondary to this. The immediate benefits, such as maintenance of independence and well-being, become embedded in the strategies as important messages. Consequently, the study is called “Schritt halten - Aktiv älter werden in Reutlingen” (“Keep Up - Active aging in Reutlingen”).
The study is structured in three stages: (1) Preimplementation period- from July 2010 to September 2011 stakeholders relevant for physical activity, fall prevention, and senior affairs in the community are identified and contacted (
Local stakeholders involved in the participatory community planning.
Population-based intervention programs are characterized by the shared ownership of the problem and its solution by experts as well as by community members [
In a second step, focus groups are constituted consisting of local experts, both professionals and volunteers. They discuss and develop portfolios of possible strategies. In dialogue, the steering committee and the researchers rate the proposed strategies. For implementation, teams of local partners are set up with professionals as well as volunteers (so called implementation teams).
The role of the research team is to provide good-practice examples and information for the professionals and volunteers in the field, to set up organizational structures, to coordinate implementation strategies, and to evaluate the processes and outcomes.
To illustrate the approach, an example of an already developed and implemented strategy is given, a Web-based platform of exercise classes.
An early conclusion of focus group meetings was the need for creating a directory of existing exercise classes for older people. After a positive vote by the steering committee, an implementation team was set up under the leadership of a researcher. It was decided by the implementation team not only to address older people, but also their caregivers, families, therapists, or exercise instructors with the intention for them to serve as mediators. The implementation team discussed the information need of older people with regards to usability in cooperation with therapists, physicians, and caregivers. The involved stakeholders and associations were the department of sports, association of sports clubs, community college, German Red Cross, senior citizens' office, and the local hiking club. A Web-based solution was chosen over a print version by the team. The pros for the website were that it was modifiable and updateable (eg, adding further information, categories, or new exercise classes), as well as the availability for mediators such as doctors, therapists, or relatives. A con was the fact that a minority of older people are equipped with Internet access. According to that, we assume mediators to be the key to success in order to motivate older inactive persons to exercise. In the future, the website could also serve as a template for an eventual print version. It was decided by the team to offer a detailed description of training methods, information about appropriate target groups, and accessibility of the location, the costs, and the details of contact. An Australian website was chosen as a template, and the same Web service provider was contracted. A questionnaire was sent out to all known providers of exercise classes. When their responses were received, their information was first checked for completeness, and then entered into the Web-based platform by a physiotherapist. The website was presented to and tested with senior citizens, and modified accordingly. The materials for promotion, such as flyers, posters, and newspaper articles were prepared and distributed. The platform [
The study is evaluated primarily by process evaluation as well as by telephone survey.
To guide other communities in future activities in the field of fall prevention, a process evaluation of strategies implemented in this study is planned. The appropriate evaluation methods have to be developed according to the strategies. Since the development of implementation strategies is part of the on going project, and will be done together with the local stakeholders, the final evaluation methods used cannot yet be presented. Possible methods might be, for example, the uptake of fall prevention activities by the institutions involved or compliance of the target group. To present the results of the evaluation, a website offers interested parties a “construction kit”, from which various measures and strategies for action can be “taken”. The platform shall inform, for example, about aims, procedures, costs, involved stakeholders, experiences, and barriers and catalyzers for implementation.
A control region is identified with the city of Ludwigsburg. The city of Ludwigsburg with 88,600 inhabitants, 18.96% of them 65 years and older (n=16,800), is situated 70 km northwest of the intervention region. The political and socioeconomic structure is comparable to the intervention region.
At baseline and at follow-up (two years later), we plan to recruit two independent samples of home dwelling people 65 years and older in both the intervention and in the control region. The baseline and follow-up samples are independent. The potential participants are identified with the help of two health insurance companies: (1) a random sample of 1000 members is identified in both cities, and (2) the health insurance company will contact them. Health insurance is mandatory for all employee and pensioners in Germany. The socioeconomic structure of the health insurance members is expected to be similar in both cities due to federal regulation of mandatory health insurances. Together, both health insurances cover approximately 12,500 members 65 years and older in Reutlingen, and 7000 members 65 years and older in Ludwigsburg. Those willing to participate are invited to contact the study team by post or telephone, resulting in a self selected sample. A response rate of 20% is expected. We will not control for multiple identification of members.
The respondents are asked for a written informed consent. The interview is conducted via telephone by a trained interviewer. An interviewer manual will be developed.
Physical activity is measured by the physical activity questionnaire recommended for older people [
The primary outcome is a change in physical activity between the baseline and the follow-up. The secondary outcome measures are a change in the fear of falling, change in behavior, and knowledge about risk factors. In descriptive analyses, frequencies and means/medians for discrete and continuous variables, respectively, will be calculated. Logistic and linear regression models will be applied to determine differences between the baseline and the follow-up. Adjustment for relevant covariates like age and sex will be performed. Adjusted odds ratios and regression coefficients will be shown with 95% confidence intervals. The Ethics Committee of Ulm University obtained institutional review board approval for the interviews (not for the design and implementation of the overall project).
The study starts in September 2010 and ends in December 2013. It is evaluated primarily by process evaluation as well as by telephone survey. A detailed description of the process evaluation results will be presented at the Schritt Halten website [
The aim of this study is to develop, implement, and evaluate a population-based intervention for the prevention of falls and fall-related injuries using existing structures and resources within the community.
The approach implies physical activity and its benefits as the key message, whereas fall prevention is secondary to this. Knowledge, skills, and attitudes concerning fall and fracture prevention are distributed primarily to health care professionals and exercise instructors. This decision is based on two reasons. First, the self-perceived risk of falling is often judged too optimistically, and older people might regard falls as a relevant problem for others, but not for themselves [
The strength of the study design is the joint development of implementation strategies in a participatory community planning, involving partners, for example, from the health care system, the community, and older people themselves. The risk of falling shares parallels with other chronic conditions, such as diabetes. In both conditions, the occurrence of an acute event (a cardiovascular event in the case of diabetes, or a fracture in the case of a risk of falling) can be reduced by preventive efforts, like changes in lifestyle by older people themselves, through professionals and providers [
A problem that we anticipate is the dependency on the stakeholders’ willingness to be actively engaged in the project. To maximize cooperation, potential barriers and facilitators for each partner have to be identified at the beginning. A further difficulty of population-based programs is the evaluation of hard end points. Fracture rates, awareness, or lifestyles might not change within the three year duration of the study. These processes, as well as changes of structures and procedures in communities, might take many years and require longer observation periods. During this observation period, other factors, like migration or secular trends, can influence the effects of these community level approaches, which might lead to dilution bias. Therefore, Lindholm and Rosén, for example, state that hard end points are inappropriate options for community-based primary interventions [
US Centers for Disease Control and Prevention
We are grateful to all the local stakeholders and institutions in Reutlingen taking part in the study. The Federal Ministry of Education and Research, Germany within the Prevention and Rehabilitation of Osteoporotic Fractures in Disadvantaged Populations Consortium funded this study. Funding reference number, 01EC1007A.
DK, KR, MK, CB, and PB contributed by conception of the study design, development, implementation of the measures and strategies, and by planning of the evaluation. DK and PB mainly drafted the manuscript. TF and GB contributed by conception and data management of the telephone-based evaluation. All authors read and approved this version submitted for publication.
None declared.