Stay On Your Feet WA Program Evaluation - Curtin...

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Overview of the Western Australian Centre for Health Promotion Research

The WACHPR is a multi-disciplinary research centre within the School of Public Health and the Curtin Health Innovation Research Institute (CHIRI) at Curtin University. The WACHPR was established in 1986 and was the first research centre in health promotion to be established by an Australian university.

Functions

The WACHPR views health promotion as a combination of educational, organisational, economic, social and political actions designed with meaningful participation, to enable individuals, groups and whole communities to increase control over, and to improve their health through attitudinal, behavioural, social and environmental changes. This comprehensive social justice perspective of health promotion is reflected in the WACHPR’s research foci and programs. The WACHPR is committed to building evidence and capacity in health promotion theory, practice and evaluation through applied and participatory research. Grounded in an understanding of social determinants of health and a commitment to social justice and ethical practice, the WACHPR conducts research with vulnerable or most at risk communities and populations and works in partnership with relevant community, government, research and private organisations to improve the health of regional populations.

Stay On Your Feet WA Program Evaluation WA Centre for Health Promotion Research

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The WACHPR is a multi-disciplinary research centre within the School of Public Health and the Curtin Health Innovation Research Institute (CHIRI) at Curtin University. The WACHPR was established in 1986 and was the first research centre in health promotion to be established by an Australian university.

Functions The WACHPR views health promotion as a combination of educational, organisational, economic, social and political actions designed with meaningful participation, to enable individuals, groups and whole communities to increase control over, and to improve their health through attitudinal, behavioural, social and environmental changes. This comprehensive social justice perspective of health promotion is reflected in the WACHPR’s research foci and programs. The WACHPR is committed to building evidence and capacity in health promotion theory, practice and evaluation through applied and participatory research. Grounded in an understanding of social determinants of health and a commitment to social justice and ethical practice, the WACHPR conducts research with vulnerable or most at risk communities and populations and works in partnership with relevant community, government, research and private organisations to improve the health of regional populations. In addition to these core functions, the WACHPR conducts health promotion - continuing education and capacity building courses for the health promotion sector, as well as tailored courses for the HIV sector and allied health staff. Further activities include consultancy and evaluation services, training and development, workplace health, implementation and evaluation of community based interventions and assistance and advice with public health policy activities.

Research Focus and Areas of Expertise The WACHPR research team has expertise in the development, implementation and evaluation of formative and longitudinal intervention research in key areas such as: early childhood health and nutrition; physical activity and nutrition; alcohol and other drug use; seniors’ health; mental health; and HIV and sexual health. The WACHPR is a unique research centre in that all core staff hold front-line research and teaching positions in the School of Public Health. The combined expertise of the WACHPR staff, together with the establishment of collaborative networks, aims to foster the practice of health promotion by encompassing the nexus between research and practice. The WACHPR has built and demonstrated high level expertise and research strength in:

The design, planning, implementation, evaluation and dissemination of quality integrated health promotion programs

Building sustained partnerships and collaborations with vulnerable and most at risk communities and relevant community, government and private sector organisations

Health promotion approaches using community and settings-based interventions, peer and social influence, social marketing, advocacy, community mobilisation and sector capacity building

Health promotion intervention research that improves outcomes in nutrition, physical activity, mental health, sexual health, drug use and injury prevention

Promotion and dissemination of evidence-based practice and building practice-based evidence

Provision of research training and capacity building techniques to undergraduate and postgraduate students, allied health promotion professionals and community workers

For further information or enquiries contact: Dr Jonine Jancey | Director WA Centre for Health Promotion Research School of Public Health | Faculty of Health Sciences | Curtin University PO Box U 1987 | Bentley | Western Australia | 6845 +61 8 9266 7988 | [email protected] www.wachpr.curtin.edu.au

Suggested citation: WA Centre for Health Promotion Research. 2013. “Stay On Your Feet WA Program Evaluation’ Perth: Curtin University. ISBN: 978-0-9874704-3-0

http://publichealth.curtin.edu.au/about/staff_new.cfm/J.Jancey

mailto:[email protected]

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Executive Summary

OVERVIEW

The Stay On Your Feet WA (SOYFWA) state-wide falls prevention program was launched in 2001 by the Injury Control Council of WA. Since its introduction, the program has been evaluated by the WA Department of Health Injury Prevention Branch in 2004 and TNS Social Research in 2006. In 2012, the WA Centre for Health Promotion Research (WACHPR) was approached to conduct an

evaluation on the SOYFWA Program. The evaluation sought to review SOYFWA with regard to brand awareness, attitude and behaviour change, along with preferences and perceived value of the program. WACHPR used a range of evaluation methods including:

a) a literature review; b) a resource review; c) a computer assisted telephone interview (CATI); d) an online survey with health professionals; e) telephone interviews with health professional; f) focus groups with community members and health professionals; and

g) telephone interviews with SOYFWA volunteers.

KEY FINDINGS

The findings demonstrate a number of areas of strength within SOYFWA strategies however

significant challenges were reported in the promotion of the SOYFWA Program and its strategies

to key target groups. ‘Cut through’ of SOYFWA and its associated strategies within existing health professional networks also proved challenging - along with the message salience. These challenges were consistent with the broader literature and provide opportunities for improvement. Literature Review Falls are a significant health issue for Australian adults aged 60 years and over. Population trends estimate that by 2031, 20% of Australians will be aged 60 years or over, increasing the need for effective initiatives to prevent falls. Literature on falls prevention programs has also demonstrated:

Limited guidelines exist for the transition of knowledge of falls prevention between health professionals within clinical settings.

Population-based falls prevention programs are cost-effective.

A gap exists for comprehensive, coordinated, population-based falls prevention programs. Resources Review

SOYFWA printed resources generally adhered to content and design features of effective health communication resources. Two significant areas of concern were found to be the size of the print used and the complexity of language. SMOG evaluation suggested that the language used in resources was too complex for the target group. Brand Awareness

Awareness of SOYFWA was found to be low (7%). However, brand awareness in 2005 was 5%

which is relatively consistent with 2012 findings. In addition, awareness of SOYFWA was higher

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than any other falls prevention program in WA. The Nine Steps to Stay on Your Feet also had low levels of awareness and it was suggested that the steps could be used as a falls prevention tool rather than as a message. Results indicated that some sub-populations of the target group may find some steps more relevant than others. Strategies

Stay On Your Feet Week was found to have a higher level of participation, relevance and

effectiveness than April No Falls Day. Participants indicated that SOYF Week provided a platform for professional development and was supported by project grants. The purpose of April No Falls Day and the effectiveness of the use of a ‘day’ was raised as issues for consideration. Participants also suggested simplifying the event. Printed resources were found to be an effective strategy to engage target groups. Suggestions for new printed materials included increasing font size and simplifying the language used in resources.

The SOYFWA website was highlighted as an area for improvement by both community members and health professionals particularly due to lack of visual appeal and images. The WA Department

of Health are currently constructing a new website for SOYFWA. The Falls Resource Information Centre had extremely low awareness and use by both health professionals and community members. Expansion of referral lists and services was suggested by health professionals. Volunteers noted that the volunteer program was well managed with all volunteers experiencing a high level of recognition for their service. However, the training program for volunteers was found to be inconsistent. Community presentations run by volunteers were also found to lack structure and consistency. Printed materials were found to be the most popular means of presenting information to community members. Health professionals preferred email and the website.

RECOMMENDATIONS

Results from the desktop review and evaluation strategies suggested:

Reviewing communication channels to increase awareness of SOYFWA and its strategies

Using the Nine Steps to Stay On Your Feet as a falls prevention tool with different population sub-groups (who may have differing risk of falls due to health issues).

Expanding the reach of SOYF Week and grants to ATSI and CaLD communities.

Reviewing the design and content of the SOYFWA website and printed materials with regards to print size, use of images and complexity of language.

Developing new resources for residential aged care, clinical settings and referral lists.

Testing new material through focus groups and SMOG analysis.

Reviewing the training program and presentation guidelines for SOYFWA volunteers.

Reviewing the role of The Centre and expansion of referral contacts.

Developing resources and presentations for residential aged care services. Expanding education and training for health professionals working in falls prevention.

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Glossary of Terms

Falls Unintentionally coming to rest on the ground, floor or other lower

level.

Falls Specialist A health professional who assesses a patient’s risk of having a fall,

and refers them to appropriate services.

Health Professional A person employed in a field of health in a clinical, allied health or

population-based context.

Acronyms

ABS Australian Bureau of Statistics

ANOVA Analysis Of Variance

ATSI Aboriginal and Torres Strait Islander

CaLD Culturally and Linguistically Diverse

CATI Computer Assisted Telephone Interview

AIHW Australian Institute of Health and Welfare

ICCWA Injury Control Council of WA

NCI National Cancer Institute (US)

SEIFA Socio-Economic Index For Area

SES Socio-Economic Status

SOYFWA Stay On Your Feet WA

SOYF Week Stay On Your Feet Week

SPSS Statistical Package for Social Science

WA Western Australia

WACHPR Western Australian Centre for Health Promotion Research

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Contents

Executive Summary ........................................................................................................................................... 3

1.0 Introduction ................................................................................................................................................. 9

2.0 Project steering group ............................................................................................................................... 10

3.0 Desktop review .......................................................................................................................................... 10

3.1 Literature Review ...................................................................................................................................... 10

3.1.1 Falls ................................................................................................................................................. 10

3.1.2 Trends in Australia’s ageing population ......................................................................................... 10

3.1.3 Culturally and Linguistically Diverse Populations ........................................................................... 11

3.1.4 Cost effectiveness of falls prevention programs ............................................................................ 11

3.1.5 Comprehensive, coordinated, population-based intervention strategies ..................................... 11

3.1.6 From knowledge to action in falls prevention ................................................................................ 12

3.1.7 Towards integration of strategies - WA Model of Care for Falls Prevention ................................. 12

3.1.8 Conclusions ..................................................................................................................................... 12

3.2 Resources Review ...................................................................................................................................... 13

3.2.1 Community Resources .................................................................................................................... 13

3.2.2 Higher Needs Resources ................................................................................................................. 16

3.2.3 Hospital Resources ......................................................................................................................... 17

3.2.4 Aboriginal Resources ...................................................................................................................... 17

3.2.5 A3 SOYFWA Posters .................................................................................................................... 18

4.0 Methodology ............................................................................................................................................. 20

4.1 Target groups ............................................................................................................................................. 20

4.2 Data collections methods .......................................................................................................................... 20

4.3 Evaluation Methods ................................................................................................................................... 21

5.0 Results ................................................................................................................................................. 24

5.1 Computer Assisted Telephone Interview .................................................................................................. 24

5.1.1 Demographics Characteristics of CATI Participants ........................................................................ 24

5.1.2 Reported Health Status .................................................................................................................. 25

5.1.3 Health Professionals and Support Services .................................................................................... 26

5.1.4 Physical Activity .............................................................................................................................. 27

5.1.5 Environment ................................................................................................................................... 27

5.1.6 Perception of Falls .......................................................................................................................... 27

5.1.7 Falls History .................................................................................................................................... 28

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5.1.8 SOYFWA Program ........................................................................................................................ 29

5.1.9 Nine Steps To Stay On Your Feet ................................................................................................. 32

5.2 Online Survey with Health Professionals ................................................................................................... 33

5.3 Health professional telephone interviews ................................................................................................ 42

5.3.1 Participants ..................................................................................................................................... 42

5.3.2 Results ............................................................................................................................................ 42

5.4 Focus Groups ............................................................................................................................................. 53

5.4.1 Participant Details .......................................................................................................................... 53

5.4.2 Language ......................................................................................................................................... 53

5.4.3 Nine Steps to Stay On Your Feet ................................................................................................. 55

5.4.4 Awareness of Stay On Your Feet WA Strategies ......................................................................... 59

5.4.5 Printed Resources ........................................................................................................................... 62

5.4.6 The SOYFWA Website ................................................................................................................. 64

5.5 Interviews with Volunteers ....................................................................................................................... 66

6.0 Discussion ............................................................................................................................................ 67

6.1 Awareness of SOYFWA ........................................................................................................................... 67

6.2 Nine Steps to Stay on Your Feet ............................................................................................................. 67

6.3 April No Falls Day and SOYF Week ......................................................................................................... 68

6.4 SOYFWA printed materials ..................................................................................................................... 68

6.5 SOYFWA Website ................................................................................................................................... 68

6.6 SOYFWA Falls Resource Information Centre .......................................................................................... 69

6.7 Volunteer Program, Speakers Kits and Presentations ............................................................................... 69

6.8 SOYFWA Services, Support and Communication ................................................................................... 69

6.9 The SOYFWA Program ............................................................................................................................ 70

7.0 Recommendations and Conclusions.................................................................................................... 71

8.0 References ........................................................................................................................................... 75

9.0 Appendix .............................................................................................................................................. 78

9.1 Efficacy of interventions in falls prevention .............................................................................................. 78

9.2 SMOG Calculation Procedure .................................................................................................................... 81

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LIST OF TABLES

Table 1. Summary of assessment of font, readability and images in print materials ..................................... 15

Table 2. 2006 census data - Highest school year completed by Australians aged over 55 years [26] ............ 16

Table 3. 2006 census data - Highest post-school qualification of Australians aged over 55 years [26] ........ 16

Table 4. Strategies and Evaluation Tool .......................................................................................................... 20

Table 5. Participant Characteristics ................................................................................................................. 24

Table 6. Medication used by participants ....................................................................................................... 25

Table 7. Health professionals regularly accessed ............................................................................................ 26

Table 8. Health professionals most useful for falls prevention ....................................................................... 26

Table 9. Average physical activity per day....................................................................................................... 27

Table 10. Cause of Falls ................................................................................................................................... 28

Table 11. Actions taken to prevent falls .......................................................................................................... 29

Table 12. Demographic characteristics of participants aware of SOYFWA .................................................. 30

Table 13. Community member awareness of SOYFWA through different information sources .................... 30

Table 14. Preferences of mediums for community members ......................................................................... 31

Table 15. Preventing a fall through the Nine Steps to Stay On Your Feet ................................................... 32

Table 16. Awareness of the Nine Steps to Stay On Your Feet in community members ............................. 32

Table 17. Professions of health professionals ................................................................................................. 33

Table 18. Work settings of health professionals ............................................................................................. 33

Table 19. SEIFA index of participant work settings ......................................................................................... 34

Table 20. Awareness of SOYFWA in health professionals through mediums .............................................. 35

Table 21. Awareness of SOYFWA events in health professionals through mediums .................................. 35

Table 22. Health professional participation in SOYFWA events................................................................... 35

Table 23. Effectiveness of SOYFWA events .................................................................................................. 36

Table 24. Assistance provided by SOYFWA events ...................................................................................... 36

Table 25. Awareness of The Centre through different media ......................................................................... 37

Table 26. Additional falls prevention referrals for The Centre ........................................................................ 37

Table 27. Navigation of the SOYFWA website ............................................................................................. 38

Table 28. Usability of the SOYFWA website for people aged 60 or over ..................................................... 38

Table 29. Ratings of the 'For Health Professionals' tab ................................................................................... 38

Table 30. Other content for the SOYFWA website ...................................................................................... 38

Table 31. Identification of the Nine Steps to Stay on Your Feet .................................................................. 39

Table 32. Importance of the Nine Steps to Stay On Your Feet .................................................................... 39

Table 33. Services not used by health professionals ...................................................................................... 40

Table 34. Preferred means of professional development ............................................................................... 41

Table 35. Preferred mediums for communication between health professionals and SOYFWA ................ 41

Table 36. Community member focus group participant demographics ......................................................... 53

Table 37. Health professional focus group participant demographics ........................................................... 53

Table 38. Importance of the Nine Steps to Stay On Your Feet (by community member) .......................... 56

Table 39. Importance of the Nine Steps to Stay On Your Feet (by health professional) ........................... 57

Table 40. Lists of steps created by community member focus groups ........................................................... 58

Table 41. List of steps created by health professional focus groups ............................................................... 58

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1.0 Introduction

Falls are a significant health issue for Australian adults aged 60 and over. Falls prevention has become an increasingly important public health intervention in the context of Australia’s ageing

population. Stay On Your Feet WA (SOYFWA) is a collaborative state-wide falls prevention program with an overarching aim to reduce the incidence and severity of falls-related injuries among adults aged 60 years and over. The Injury Control Council of Western Australia (ICCWA) is funded by the Department of Health

WA to coordinate the SOYFWA program. In 2012, the SOYFWA program was required to review all existing strategies, resources and initiatives so as to determine their impact in terms of:

branding awareness and understanding;

attitude, belief and behaviour change; and

preference and perceived value.

Previous evaluations of the Stay On Your Feet W.A program have included:

The 2004 Falls Prevention Risk Factor Survey conducted by the Department of Health WA Injury Prevention Branch. This primarily focused on behaviour change surrounding falls prevention.

The 2006 Social Marketing Program Evaluation conducted by Taylor Nelson Sofres (TNS), which covered media, regional activities, website analysis and resource distribution.

The Western Australian Centre for Health Promotion Research (WACHPR) was the independent university based research group contracted to undertake the 2012 review. The WACHPR was responsible for:

developing the research plan;

seeking project ethics approval from the Curtin University Human Research Ethics Committee;

leading the development of all instruments and tools used throughout the evaluation;

assisting to build the capacity of ICCWA staff to undertake such evaluation in the future;

implementation of evaluation tasks with health professionals and the primary target group (adults aged over 60); and

collating this report.

This report presents the evaluation methodology and results, a discussion of SOYFWA strategies and concludes with recommendations.

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2.0 Project steering group

Staff from the WACHPR and School of Public Health formed a project steering group to develop and implement this project. The project steering group was responsible for contracting, ethics, providing direction and feedback on documentation, research and overall conduct of the project. The staff involved included:

o Dr Jonine Jancey (Principal Investigator)

o Gemma Crawford o Dan O’Connor o Mark Petrich o Linda Portsmouth o Bree Shields

3.0 Desktop review

In consultation with ICCWA, the project steering group provided direction and resources to facilitate a review of the literature to provide context for the evaluation. A rapid scan of the grey and peer reviewed literature was conducted. 3.1 Literature Review 3.1.1 Falls Falls are the second largest injury-related field in relation to lifetime costs in Australia, and the largest injury-related people aged 60 years and over [1]. Without some change to the rates of falls and fall related injuries, these costs are likely to continue to rise due to Australia’s ageing population [2]. As befits such a significant health issue, there have been considerable research efforts in the field of falls prevention. However, developing conclusive evidence for falls prevention initiatives has been hampered by a number of factors. These include the multi-factorial contributors to people falling, including a range of intrinsic and extrinsic factors, many of which are modifiable. There is also substantial heterogeneity in falls causation between different subgroups of the older population, grouped by features such as age, level of frailty, type and level of activity, cognitive and physical impairment, as well as the setting [3]. The measures to determine success of interventions have also differed between studies. The measurable level of risk factors for falling, the rates of falls, and the rates of significant injuries from falls have all been used as dependent variables at times. In addition, secondary outcomes measures have varied substantially from fear of falling to those of balance [3]. The nature of falls requires long duration longitudinal studies to measure effects. However, changes in these variables have been measured across different time spans, limiting the comparability between studies. 3.1.2 Trends in Australia’s ageing population Currently, 13% of Australia’s population is aged 65 or over with predictions that by 2031, this figure will grow to approximately 20%. Nearly half of this population is experiencing five or more long-term physical health conditions, many of which increase the likelihood of having a fall [4].

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As at 2011, Australian males were reported to have a life expectancy of 83.7 years and reach the age of 80.2 without a severe limitation on a core activity (including self-care, mobility and communication). Australian females were reported to have a life expectancy of 86.6 years and to reach 80.2 without a severe limitation on a core activity [4]. 3.1.3 Culturally and Linguistically Diverse Populations Over the last 10 years, the population of culturally and linguistically diverse (CaLD) people aged 65 years and over has increased substantially in Australia. It is currently estimated that 22.5% of older Australians are CaLD, which is a considerable increase from the 17.8% of CaLD Australians aged 65 and over in 1996 [5].This figure is particularly pertinent as research demonstrates that CaLD Australians access health services less frequently than non CaLD Australians. Although health services are readily available, research has shown that CaLD people are reluctant to use health services due to “cultural differences, perceived racism and misunderstandings leading to existing health disparities” [6](pp.1). These changing demographics are significant and are important considerations for falls prevention in an ageing population, particularly as access to health services is vital to reducing morbidity and mortality related to falls. 3.1.4 Cost effectiveness of falls prevention programs The literature surrounding community based falls prevention programs suggests that programs vary greatly in the significance of the results. However, the Cochrane Collaboration review on falls prevention programs reports that “the consistency of reported reductions in falls-related injuries across all programmes support the claim that the population-based approach to the prevention of fall-related injury is effective and can form the basis of public health practice”[7](pp.1). Clinical studies have identified risk factors and sub-populations as the most important elements when considering the cost effectiveness of programs [2, 8, 9]. Strength and balance exercise programs (in particular Tai Chi) have repeatedly proven to be the most cost effective strategies when integrated into a community based program [2, 8]. 3.1.5 Comprehensive, coordinated, population-based intervention strategies Compared with clinical interventions designed to inform the management of individuals or small groups, there is limited research into comprehensive strategies to reduce falls and related injuries within the population. These comprehensive strategies combine expert led treatment style interventions with a wider suite of policy and program responses that may include a coordinated set of regulations, education, and population-based programs [10]. In a systematic review of population-based programs, McClure and colleagues identified five programs internationally with a suitable control population [7]. These five programs included the original Stay on Your Feet program in a NSW community [11]. This program targeted knowledge, attitudes and behaviours related to falls and a range of falls risk factors in community-dwelling people over 60 years. The program was delivered through a mix of community education via multiple media, engagement of health professionals, and local government policy development over four years [7, 11]. The program reach was estimated at around 77% of the target population, resulting in a 22% reduction in self-reported falls and a 20% reduction in falls-related hospitalisations compared with the control community. It is likely that the initial program concept

and its success justified the rollout of the SOYF style program to other areas in Australia. This includes initial work in south-west Western Australia before wider implementation across the state.

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Complex, comprehensive strategies are challenging to evaluate using a rigorous research design to confirm causality and effectiveness. It is difficult to control and measure the dosage and effect of individual strategies, as well as attribute causation through methods such as randomisation and control groups. McClure and colleagues acknowledged these issues in their review [7]. Whilst no randomised control trials were identified, they concluded that population-based strategies were probably effective given that all five controlled studies demonstrated reductions in falls-related injuries [7]. The comprehensiveness and intensity of the population-based strategy may be important ingredients for success. Further research found that lower intensity strategies did not reduce the rate of injuries from falls, whether using a top-down or community development approach [7]. The importance of a comprehensive, sustained, high intensity suite of activities across multiple domains of policy and practice was recommended. Key public health successes (such as tobacco control) have utilised multiple dimensions, requiring “extensive and prolonged attention with interventions ultimately engaging all aspects of society, including alteration of legal and cultural norms” [7](pp.86). This challenges shorter term funding models. One major key to ongoing effectiveness may be the incremental development of population-based strategies which is well aligned with changing norms.

3.1.6 From knowledge to action in falls prevention

Comprehensive, population-based strategies benefit from an organising framework to assist with conceptualisation and ongoing development, integrated with other health-related efforts in society. Three of the five studies included in the Cochrane Review were based on the World Health Organisation Safe Communities model of safety and injury prevention [7]. The initial Stay on Your Feet initiative was reportedly within an ‘active ageing’ framework [7]. There are a number of generic health promotion frameworks internationally, in Australia and Western Australia. There are similarly international and domestic frameworks for injury prevention and active ageing [12]. Utilisation of one or more of these frameworks, or a credible synthesis, may be valuable. There has been some theoretical work on translating knowledge into practice in falls prevention. For example, the Canadian Institutes of Health Research use the ‘knowledge to action cycle’ [13, 14], and discuss evidenced-based implementation [15]. Use of theory and frameworks can support incremental modification of current population-based strategies as evidence, practice and societal norms evolve.

3.1.7 Towards integration of strategies - WA Model of Care for Falls Prevention

Published reviews have been undertaken of falls services across the UK [16]. Locally, there has been considerable effort in producing the WA Health Network’s Models of Care, including the model of care for falls prevention [17]. This model of care document provides the organising framework for an integrated approach to falls prevention based on evidence, and general consensus on the application of this evidence into the WA context. This integration includes various dimensions, such as different settings (hospital, community, residential care), providers (expert specialist clinics, clinicians, health promotion) and strategies in both scope (individual, group, population) and target population (other frameworks targeting older people and their health).

3.1.8 Conclusions

Population level change in falls and injuries from falls warrants population-level strategies. These strategies should be comprehensive, multifaceted initiatives utilising multiple forms of delivery, considering both policy and program approaches. The strategies should be coordinated with

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clinical, individualised health care efforts. The content and delivery of population-based strategies should be informed by evidence of effective interventions in falls prevention, but also effective delivery systems and health promotion strategies. Long standing health issues require sustained funding, with incremental alteration of strategies within the field. Many longstanding and major health issues have the same or related distal factors (e.g. maintain physical activity, healthy weight, nutrition) that may be better coordinated through the use of an overarching framework or frameworks.

3.2 Resources Review

3.2.1 Community Resources

Stay on Your Feet Booklet

Home Safety Checklist

Shoe Safety Checklist

Falls Risk Checklist

It is understood that the above resources are aimed at community members over the age of 60. These resources generally adhere to the content and design features that have long been identified as essential to effective health communication via pamphlet/brochure materials [18]. The materials have generally good contrast between the print and the background through the use of shades of darker blue on white – or white font on a darker blue background. The font used is simple, well-spaced and justified to the left. The use of small size font, however, creates a ‘text-dense’ impression on many pages. More white space around text is more comfortable for readers. Headings are clear - a good size and bolded. Places where the headings are presented as questions are particularly effective. Information is generally presented one topic per paragraph and introduced with a topic sentence. There is generally good sequencing of information with a coherent flow and no ambiguity. There are instances of where terminology could have been defined in order to assist comprehension by readers unfamiliar with medical terminology (e.g. disease names, ‘cardiovascular stamina’, ‘core stability’). Where information is placed in an arbitrary order due to the key issues previously being numbered 1 to 9, this is heralded via clear numbered headings. Motivational messages clearly outline the required behaviours and outlined the risks in prose with the avoidance of probability statements. A positive, active voice presents positive choices after the risks are briefly presented. The photographs used in the Stay on Your Feet Booklet and the Home Safety Checklist are attractive, well-spaced, separated from text and mostly appropriate. Occasionally there was a mismatch between text and image (e.g. an image of a couple sitting down in page 30 of the ‘Walk Tall’ section of the Stay on Your Feet Booklet). The overall impression gained from the materials, due to the images used, is that they were designed for a Caucasian Australian audience. Only two of the 28 photographs used showed Asian faces – and these were towards the end of the booklet. The images would not have encouraged non-Caucasian people to identify with the messages being communicated. These overall impressions will need to be confirmed in a focus group setting with members of the

target group unfamiliar with the SOYF message and materials.

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There were two areas of significant concern, however. The first area of concern is the size of the print used in the materials – it is unsuitable for a large proportion of the target group. See Table 1. The font size used - Size 10 or 11 - was too small for the target group for all of these materials except the Shoe Safety Checklist (size 18 font). Long-sightedness, short-sightedness and presbyopia are among the five most common long-term health issues reported by people aged 55 years or more [19]. The 2004 National Health Survey indicated that 27.9% of people over 55 have self-reported presbyopia – difficulty focussing due to age related loss of eye lens flexibility [19, 20]. AIHW also stated that 9.4% of Australians aged 55 or older are visually impaired and about 1.2% are considered blind [19, 21]. It is interesting to note that a Canadian study has concluded that, after testing 183 participants aged 8 to 88, with varied income, educational and literacy levels – 83% of them were more comfortable with a size 14 than size 12 font [22]. Although 50% of them were aged over 57 years, age was not a significant variable in predicting font size preference – thus people of all ages prefer a larger font. The second area of concern is the level of language used in the materials. The sentences are too long and contain grammatical structures and vocabulary that is too complex for the majority of the target group. Readability was assessed using the original SMOG Formula [23] and, as required, the SMOG technique recommended by the National Cancer Institute for the assessment of written materials with less than 30 sentences was utilised [24]. The SMOG formula is one of the most common estimates of readability used in assessing health communication materials and has recently been compared to other readability formulas and recommended as the most reliable [25]. See Appendix for details of how the SMOG Grade levels in Table 1 were calculated. The Shoe Safety Checklist gained a SMOG grade level of 6 to 7 while the other checklists gained a grade level of 9 or 10. The Stay on Your Feet Booklet gained a grade level of 13 – first year university level. See Table 1. These grades indicate the level at which written material can be read with “complete comprehension” [23] (pp. 645). United States and Australian grade levels may differ slightly according to age, however McLaughlin [23] clearly stated that grade levels 13-16 indicate a university level Bachelor’s degree education. The National Cancer Institute recommended “aiming for a level that is two to five grades lower than the highest average grade level of your intended audience to account for a probable decline in reading skills over time” and that “a third to fifth grade level is frequently appropriate for low-literacy readers”[24] (pp. 162). The Australian Bureau of Statistics (ABS) reported 2006 census data which revealed that 30% of non-Indigenous Australian people aged over 55 completed Year 12 - with more than half of these gaining no further post-school qualification. Only 15.5% of people over 55 have completed a Bachelor’s degree or higher - while a sizeable proportion of 22% completed Year 8 or below (including those who did not attend school). See Tables 2 and 3 for a summary of high school completion levels and post-school qualifications gained by Australians aged over 55 years [26]. Schooling gained many years ago, however, can only be an estimate of the current reading level of people aged over 55 years. The Australian Bureau of Statistics undertook literacy testing via a random sample of almost 9,000 non-remote Australian households with a personal interview and testing of one randomly selected person aged 15 to 74 years from each home [26]. They assessed, amongst several skills, ‘prose literacy’ which was defined as “The knowledge and skills needed to understand and use various kinds of information from text including editorials, news stories, brochures and instructions manuals”[26](pp. 6). Level 3 literacy was considered the “minimum required for individuals to meet the complex demands of everyday life and work in the emerging knowledge-based economy" [26](pp. 5).

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The ABS [27] estimated that approximately 7 million (46%) Australians aged 15 to 74 years had scores at Level 1 or 2 on the prose scale, a further 5.6 million (37%) at Level 3 and 2.5 million (16%) at Level 4/5. The ABS noted that literacy levels decreased with age: 54.6% of 55-59 year olds; 62.2% of 60-64 year olds; and 73.9% of 65-74 year olds did not meet the level 3 prose literacy level [27]. Any written material aimed at current older Australians needs to recognise that their functional literacy levels are lower than that of the rest of the population - with the majority of people aged over 60 years not meeting a minimum level. Table 1. Summary of assessment of font, readability and images in print materials

Approximate Arial font size

SMOG Grade Level

Photos/Images Comments

COMMUNITY RESOURCES

‘Stay on Your Feet’ Booklet

Size 11 Arial Too small

13 Attractive colourful photos of mostly Caucasian people

Home Safety Checklist (Booklet)



Falls Risk Checklist (Sheet)


9 One blue image of feet

Shoe Safety Checklist (Sheet)

Size 18 Arial Excellent

6-7 One blue image of feet

HIGHER NEEDS RESOURCES

Higher Needs Booklet Size 18 Arial Excellent


‘higher needs’ label

acceptable?

Higher Needs Checklist Brochure



HOSPITAL RESOURCES

Information for patients in hospital: Brochure


10 Attractive colourful photos of Caucasian

people

Information for family and friends of patients: Brochure


11 Attractive colourful photos of Caucasian

people

Information for patient discharge: Brochure


12-13 Attractive colourful photos of Caucasian

people

ABORIGINAL RESOURCE

Falls prevention for Aboriginal people booklet


12 No images except seascape on cover

All brown

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Table 2. 2006 census data - Highest school year completed by Australians aged over 55 years [26]

Over 55 years non-Indigenous %

Over 55 years Indigenous %

Completed Yr 12 or equivalent 30.1 9.4




Yr 8 or below 20.4 45.6

Did not go to school 1.8 9.7

Table 3. 2006 census data - Highest post-school qualification of Australians aged over 55 years [26]

55-64 Non- Indigenous

%

65+ Non- Indigenous

%

55-64 Indigenous

%

65+ Indigenous

%

Bachelors + 15.5 8.1 5.5 2.3

Adv Dip/Dip 9 6.2 4.7 2.4

Cert 3 or 4 16 13.2 8.9 5.4

Cert 1 or 2 0.7 0.3 0.9 0.9

No post-school qual 54.7 68.7 77.5 87.7

3.2.2 Higher Needs Resources

Higher Needs Booklet

Higher Needs Checklist Brochure

Higher Needs A4 Poster- How to get up off the floor

It is understood that the above resources are aimed at people with a falls history and/or high identified risk of falls, mostly over the age of 80 years. As with the Community Resources discussed above, the Higher Needs Resources generally adhere to the content and design features that have long been identified essential to effective health communication via pamphlet/brochure materials [18]. The photographs used in the Higher Needs Booklet are attractive, well-spaced, separated from text and appropriate. Asian faces were visible in three of the 23 photographs used to illustrate the text. Again, the overall impression gained from the materials is that they were designed for a predominantly Caucasian Australian audience. AIHW [19, 21] stated that visual impairment is most prevalent in Australians aged 70 – 89 years. There is a clear increase in the prevalence rate of self-report presbyopia from 15.3% of 45-49 year olds to 40.1% of those aged 80 and over [19, 21]. Hypermetropia (long sightedness) also increases with age with a prevalence of 43% in people aged 85 and over [20]. While the Higher Needs Booklet recognises this by the use of a font size of approximately 18, the Higher Needs Checklist Brochure presents information in font that is far too small. Sentence length, grammatical structures and vocabulary choice in both the Higher Needs Booklet and the Higher Needs Brochure are inappropriate for this age group. The SMOG readability levels of grade 11 and 12 gained are far too high for this age group – see Table 1. Referring again to Tables 2 and 3, and the literacy data presented by ABS and discussed in the section above, the majority of older Australians do not meet minimum literacy levels and would not be able to read the information presented in the Booklet and Brochure [27].

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The ‘How to get up off the floor’ A4 Posters (Forward Lift Method and the Backward Lift Method) look to be well-made, useful materials. The photographs are well shot with good definition of the body positions against the pale background. The images clearly depict the required actions while the written instructions are short and simple. The ability to attach them to the fridge with a magnet is an advantage in terms of maximising recall due to frequent exposure to the depicted message. These overall impressions will need to be confirmed in a focus group setting with members of the

target group unfamiliar with the SOYF message and materials. Of particular concern is the use of the term ‘Higher Needs’ to label the materials – the use of this term will need to be discussed with the target group to discover their perception of it.

3.2.3 Hospital Resources

Information for patients in hospital

Information for family and friends of patients

Information for patient discharge

Two A4 ‘Falls can be prevented’ posters designed for hospital ward staff

The hospital resources are understood to be resources for people 60 or over who have had a fall. As with the Community and the Higher Needs Resources discussed above, the Hospital Resources generally adhere to the content and design features that have long been identified essential to effective health communication via pamphlet/brochure materials [18]. The titles inside the pamphlets may be confusing to older readers as they vary in size for stylistic purposes. These three pamphlets have SMOG grade levels of between year 10 and 13 with a font size of approximately 12 Arial. As noted in the above sections, referring again to Tables 2 and 3, this is inappropriate for this age group – particularly people over 80 years who are more likely to be hospitalised after a fall. The long sentences and small font contribute to a ‘text-dense’ impression from the three pamphlets which is not comfortable for readers. The three pamphlets only show Caucasian Australian faces in the attractive colour photographs, so again will not encourage non-Caucasian Australians to identify with the messages communicated. These overall impressions will need to be confirmed in a focus group setting with members of the target group unfamiliar with the

SOYF [4] message and materials. The two staff posters are clear but their usefulness would be impacted by how and where they were displayed. They would need to be displayed where staff would be frequently exposed and be able to stand close enough to read them in a situation where they have the time to read them. These overall impressions will need to be confirmed in a focus group setting with members of the

hospital staff target group unfamiliar with the SOYF message and materials.

3.2.4 Aboriginal Resources

Falls Prevention for Aboriginal People Booklet

Aboriginal A4 Poster- How to get up off the floor

Personal Action Plan

As with the Higher Needs ‘How to get up off the floor’ A4 Posters, the Aboriginal A4 Poster- How to get up off the floor is a useful resource. The photographs, however, are unfortunately not as well shot. There is poor definition of the body positions (in black trousers and a mid-blue shirt)

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against the dark blue background of the carpet. The actions are thus not as clearly depicted. The written instructions are excellent - short and simple. The ability to attach the poster to the fridge with a magnet is an advantage in terms of maximising recall due to frequent exposure to the depicted message. The Falls Prevention for Aboriginal People Booklet is subtitled ‘A tool for Aboriginal Health Workers and Aboriginal Communities’. This gives an impression that the booklet can be handed to members of the general Aboriginal community – although it is stated on page 3 of the resource that it is designed to “provide guidance to health workers when talking with older Aboriginal people living in the community... helping them to provide older people with information so they can prevent falls themselves.” This distinction between intended audiences needs to be made clear on the cover of the resource. This resource cannot be distributed to Aboriginal community members aged 55 or over. The font is too small (approximately Arial 11) and the SMOG grade level is 12 – see Table 1. Table 2 reveals that only 9.4% of Indigenous people over the age of 55 years completed Year 12. Indeed, 55.3% of Indigenous people over the age of 55 years completed Year 8 or below (including those who did not go to school at all). While the resource targets Aboriginal Health Workers (AHWs), it cannot be assumed that all AHWs have gained the minimum level of Certificate 3 qualification. Of the 156 Aboriginal Health Workers in Western Australia who identified themselves in the 2006 Census, more than half held a minimum certificate level qualification [28]. This means that a large proportion of AHWs in WA have not achieved this level of qualification. In order to ensure the resource is accessible to all AHWs, it should be written using shorter sentences, less complex grammar, simpler vocabulary and include more definitions of complex but necessary vocabulary items. One suggestion to improve this resource would be to work in partnership with AHWs to develop a resource suitable for them to show to community members. This would ensure a resource with a literacy level that is accessible by a larger proportion of community members over 55 years – and accessible by all AHWs. It would also remove workload and responsibility from AHWs as they would not be required to read what is essentially a ‘Year 12 textbook’ and then translate it for their community.

It is also noteworthy that the Aboriginal resource is not as attractive as the other SOYF resources. It is written in brown and black text with no illustrations. While it is acknowledged that there is an issue using photographs of recognisable Aboriginal community members in materials for Aboriginal communities, many other resources designed by/with Aboriginal people for Aboriginal people have worked with artists to produce realistic, attractive colour drawings to illustrate text.

3.2.5 A3 SOYFWA Posters

9 Steps To Stay On Your Feet Posters.

Available in English, Cantonese, German, Greek, Italian and Polish.

The poster is small and does not have impact from more than 1 metre away. It is thus best for positioning in places where people will be standing close to a wall or doorway for a long enough period of time to read the numbered list. Producing a larger poster would give more options as to where it can be placed.

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The size of font on the A3 poster is small, fine and difficult for a person with normal vision to read from more than 1 metre away. The main picture chosen is attractive & appropriate. The tiny thumbnail pictures beside numbered list are too small to be useful and should have been omitted. There are very real problems with the readability of the numbered list due to the font colour and background colours chosen. The further print media moves from black print on a white background, the more difficult it is for people to read. For the non-visually impaired, the black writing on pale pink used for point 6 is easiest to read as it has the greatest contrast. The white number 6 on the pink background, however, is the most difficult number to read. The others are more difficult to read – with the darkest brown, green, red and blue being the most difficult to read. The colour choices made in the poster are of particular challenge to colour-blind men. Birch reported prevalence of colour perception deficiency in men of European Caucasian background is about 8%, about 4% in men of Chinese ethnicity and approximately 2% Australian Aboriginal men [29]. Thus up to 12 to 13 in 100 men will have difficulties with colour perception. Colour-blindness impacts on the reader’s ability to perceive the text on the various coloured backgrounds of the A3 poster. The poster was tested with a red-green colour blind man as part of this review. He is a 48 year old male Caucasian, university-educated professional who works in an area where colour perception is important - and so has developed excellent adaptive skills. He reported that, while the sentences written for numbers 1 and 7 (blue backgrounds) were “sharp” and easy to read, the sentences written for numbers 2 and 8 (red and mustard backgrounds) were noticeably “out of focus.” The other sentences written on the pink, green or brown backgrounds also had “fuzzy text.” He found this perceived lack of focus impacted on his ability to comfortably read the poster. He found the bold white font on the coloured backgrounds in the Community and Higher Needs Booklets easier to read than the thinner black font on the coloured backgrounds of the poster. It is understood that the colours were chosen to match the colours used for the different numbered sections in the Community and Higher Needs Booklets. The posters, however, required colours that would ‘stand alone’ and work best in the poster media - rather than meet a requirement of matching colours in materials produced in other media. Good contrast between font and background colour is of paramount importance – particularly in a poster designed to be read over a distance. The use of colours that can be perceived comfortably by men with colour-blindness should be an automatic consideration.

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4.0 Methodology

Evaluation of the Stay on Your Feet WA resources was conducted using a number of measuring instruments and methods. These tools and approaches were selected to capture a range of qualitative and quantitative data from both community members and health professionals residing in WA.

4.1 Target groups

A) Community members were WA residents aged 60 and over.

B) Health professionals included the following disciplines:

Gerontologists; Physiotherapists; Occupational therapists; Falls specialists; Chiropractors;

Podiatrists; Nurses; General practitioners; Community development officers; and Health

promotion officers.

4.2 Data collections methods

The data collection methods (outlined in Table 4 below) included the following:

computer assisted telephone interviews (CATI’s) with adults aged 60+(n=500 );

online survey with health professionals (n=231 );

telephone interviews with health professionals (n=25);

focus groups with adults aged 60+ (n=37) and health professionals (n=26); and

telephone interviews with SOYFWA volunteers (n=5).

Table 4. Strategies and Evaluation Tool

Strategy/ Area Evaluation Tool

SOYFWA Program Awareness CATI, Online Survey

Nine Steps to Stay on Your Feet CATI, Online Survey, Focus Groups

April No Falls Day Online Survey, Focus Groups

SOYF Week Online Survey, Focus Groups

SOYFWA Printed Materials CATI, Online Survey, Focus Groups, Health Professional Telephone Interviews, Feedback Forms

SOYFWA Website CATI, Online Survey, Focus Groups, Health Professional Telephone Interviews

SOYFWA Falls Resource Information Centre CATI, Online Survey

Volunteer Program, Speaker’s Kit and Presentations Volunteer Interviews

SOYFWA Information and Communication CATI, Online Survey

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4.3 Evaluation Methods

4.3.1 Computer Assisted Telephone Interviews (CATI)

The Computer Assisted Telephone Interviews (CATI) aimed to determine community members’

awareness, knowledge and behaviours related to falls; and awareness of SOYFWA messages and resources. Demographic and health data was also collected.

Participants Participants were a random sample of West Australians aged 60 and over, sourced from the WA electoral roll. A sample of 500 community members participated in the CATI with 60% of the sample drawn from the metropolitan area and 40% from regional areas. Regional areas were divided into southern WA (n=100) and northern WA (n=100) using WA Country Health Service demarcations. The division of metropolitan and regional interviews was based on population distribution in WA. The CATI also specified equal numbers of male and female participants and equal numbers of participants in the age brackets of 60-69 (n=250) and 70+ (n=250). A pool of 3500 potential participants was created to adequately secure these 500 participants. Randomly selected community members were contacted by trained interviewers. Staff from Curtin University’s Centre for Behavioural Research in Cancer Control managed the CATI data collection and provided WACHPR with a de-identified data set

Instrument The survey instrument was developed after consideration of ICCWA’s objectives; WA Health Department contractual requirements; and was also guided by previous falls prevention questionnaires (The 2009 NSW Falls Prevention Baseline Survey and the 2004 Queensland Stay On Your Feet CATI). The instrument’s reliability was tested using at test-retest. Kappa scores were found to be within acceptable limits. 4.1.2 Online Survey with Health Professionals An online survey was conducted with health professionals to determine awareness of, and the

perceived effectiveness of SOYFWA resources and strategies.

Participants The survey used a convenience sample of health professionals listed on the ICCWA databases. In addition, other organisations such as the Falls Prevention Health Network (Department of Health WA), Australian Health Promotion Association (AHPA), Public Health and Advocacy Institute of WA (PHAIWA), WA Country Health Service (WACHS), and Curtin University were sent the survey invitation to be forwarded to all health professionals on their databases. In total, 318 participants returned their surveys. However, due to incomplete responses to the questions, only 231 were included in the final data analysis, resulting in a response rate of 72% (231/318). Potential participants were sent an email inviting them to participate in an online survey (Survey Monkey). The survey took approximately 10-15 minutes to complete.

Instrument Questions for the online survey were developed by ICCWA in consultation with WACHPR staff, after consideration of ICCWA’s objectives and the Department of Health contractual obligations. The survey was piloted tested with the target group to determine readability and suitability and to ensure it could be accessed via the link provided.

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4.1.3 Telephone Interviews with Health Professionals Telephone interviews were conducted with health professionals. These aimed to determine the effectiveness and suitability of falls prevention resources for patients, clients and other community members, along with the barriers and enablers to discussing falls prevention with clients. Participants A sub-set of 50 health professionals were selected from the ICCWA database. As the majority of the questions were concerned with the resources and website, it was essential that the health professionals selected had some exposure to the SOYFWA program. Of those health professionals contacted, 25 agreed to participate, resulting in a response rate of 50% (25/50).

Those health professionals who agreed to participate were mailed a pack of SOYFWA printed resources to review prior to the interview, along with the feedback form containing detailed questions about the resources/strategies/website. Participants were contacted at a pre-arranged time. Trained staff conducted the structured telephone interviews, which were of approximately 20 minutes duration. Instrument The structured interview schedule was developed by WACHPR staff after consideration of ICCWA’s objectives and the Department of Health contractual obligations. The interview schedule was pilot tested for suitability. A feedback form was also created in order to quickly capture information about individual resources. 4.1.4 Focus Groups with Community Members and Health Professionals Focus groups were conducted with community members and health professionals to explore/determine the appropriateness and suitability of the program’s messages, resources and strategies. Participants A total of eight focus groups were conducted (total n=63). Four were conducted with community members aged 60 and over (n=6, n=9, n=9 and n=13) and four with health professionals (n=5, n=6, n=7 and n=8). Community members were recruited from the ICCWA database along with the Council of the Ageing (COTA), Seniors Australia (WA Branch), the Seniors Recreation Council (SRC) and Carers WA. Health professionals were recruited through the ICCWA database and the Falls Prevention Network, along with AHPA, PHAIWA and the WA Department of Health. Of the eight focus groups, seven were conducted in the ICCWA meeting rooms in West Perth. One focus group was conducted in the Willagee Community Centre in order to provide a more convenient location for community members residing in the southern suburbs of the Perth. Participants who registered their interest were provided with a reminder, along with transport to and from the focus group venue. The initial focus groups were conducted by WACHPR staff. Subsequent focus groups were conducted by ICCWA staff, with a WACHPR staff member present. Instruments WACHPR developed the focus groups schedules, which were modelled on previous focus groups conducted with this target group. Questions were designed to elicit an in-depth discussion among participants and to gather information not captured by the other research methods.

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4.1.5 Telephone Interviews with SOYFWA Volunteers and Presenters Telephone interviews were conducted with ICCWA volunteers to assess the effectiveness of the

SOYFWA Volunteer Program and community presentations. Participants

Eight volunteers were randomly selected from the SOYFWA volunteer database, of whom five were able to participate. The volunteers interviewed included those who delivered community presentations (n=3) and those who participated in other volunteer activities (n=2). The WACHPR staff conducted the telephone interviews. The interviews were approximately 20 minutes in duration. Instrument The interview schedule was developed in consultation with ICCWA staff members, after consideration of ICCWA’s volunteer program objectives and guidelines developed by Volunteering Australia. 4.2 Incentives Health professionals participating in the online survey went into a draw for an iPad and a $100 book voucher, while those participating in the telephone survey went into a draw for a $100 movie gift voucher. All focus group participants received a movie voucher. 4.3 Data Analysis Quantitative data collected by evaluation instruments was analysed using SPSS Version 19. In addition to frequency extraction, cross-tabulations and correlation testing were conducted to obtain more meaningful data. Qualitative data was themed into popular responses and key quotes were extracted to be published in the ‘Results’ of this report. 4.4 Ethics Informed consent was obtained from the participants after informing them: that participation in the study was entirely voluntary; that participants had the right to withdraw at any stage; the purpose of the research; the type of involvement required of them; who was conducting the research; and that confidentiality would be respected. Ethics approval for low risk research was obtained from the Curtin University Human Research Ethics Committee (HREC), approval number SPH-30-2012. 4.5 Capacity Building Capacity building of ICCWA employees was integrated into the development and implementation of this evaluation as it was seen as important output of the research. All instruments were created in consultation with ICCWA staff; the initial focus groups were conducted by WACHPR as a demonstration of best practice in focus group facilitation and as a training exercise for ICCWA staff. Subsequent focus groups were conducted primarily by ICCWA staff with a WACHPR staff member present. ICCWA staff were also provided with additional training materials developed by WACHPR to inform future focus groups conducted by the organisation.

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5.0 Results

5.1 Computer Assisted Telephone Interview

5.1.1 Demographics Characteristics of CATI Participants

Table 5 summarises the demographic characteristics of participants.

Table 5. Participant Characteristics

Characteristics % Participants

Gender Male 50

Female 50

Age 60-69 50

70+ 50

Education Level Primary school 13

Year 10 34

Year 12 13.4

TAFE/trade 18.2

University/college 19

Relationship status Married/de facto 69.8

Divorced 8.2

Single/widowed 21.0

Employment status Retired 71.8

Semi-retired/volunteers 3. 6

Paid employment 21.6

Language spoken English 98

Other 2

Socioeconomic status (SES)

Low SES (SEIFA Decile 1-3) 10.4

Medium SES (SEIFA Decile 4-7) 46.8

High SES (SEIFA Decile 8-10) 42.7

Unknown 3.0

Birth country Australia 59.4

Other 40.6

Living arrangements Separate house 88

Other 12

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5.1.2 Reported Health Status

Participants were asked about their general health status across a range of domains. Medications Data revealed that 87% of participants have had their medications reviewed by pharmacists in the past six months, 7.2% in the last year, 1.4% in the last two years, 0.9% over two years ago and 2.9% had never had their medication reviewed. Medication taken by participants is shown in Table 6 below. Table 6. Medication used by participants

Medication % Participants

Cardiovascular medication 88.8

Vitamins/ minerals 53.6

Sleeping aids and pain killers 29.3

Other over the counter medication 26.4

Anti-inflammatory medication 23.0

Bone health medication 18.7

Respiratory medication 12.2

Cholesterol medication 7.9

Mental health medication 6.1

Diabetes medication 4.3

Note: Participants were able to list one or more medications, totalling over 100%.

Eye Care When asked about eye health, 41% of participants had their eyes tested in the past six months, 28.8% in the last year, 20.2% in the last two years, 8.4% over two years ago and 1.6% have never had their eyes tested. Foot Care The majority of participants (92.2%) stated comfort as important when buying shoes, 17.8% stated appearance, 13.4% stated price and 10.2% stated safety. General Health Few participants (9.2%) reported their health as excellent, although 29.2% of participants reported their health as very good, 45.6% reported good health, 13.6% reported fair health and 2.2% reported poor health.

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5.1.3 Health Professionals and Support Services

Participants reported that they access the following health professionals regularly (see Table 7

below).

Table 7. Health professionals regularly accessed

Health Professional % Participants

General Practitioner 88.2

Pharmacist 51.4

Podiatrist 11.4

Physiotherapist 10.6

Chiropractor 7.0

Optician/ Optometrist 3.0

Occupational Therapist 1.6

Exercise Physiologist 0.6

None 6.0


Discussing falls Few participants (11.4%) discuss falls with a health professional. The health professionals that participants find MOST useful in communication about falls are listed in Table 8 below: Table 8. Health professionals most useful for falls prevention

Health Professional % Participants



Pharmacist 7.0

Chiropractor 5.3

Exercise Physiologist 3.5

Occupational Therapist 1.8

Podiatrist 1.8

None 1.8

Barriers to health services Few participants (4.8%) reported barriers to accessing health services. Of those, 45.8% reported limited availability of health professionals as the barrier, 37.5% reported geographical location, 20.8% reported finance, and 8.3% reported transport. Home care and help 11.8% of participants reported receiving home care or help. Of those, 52.5% reported home help (e.g. gardeners/cleaners), 33.9% reported professional carers (e.g. Silver Chain) and 20.3% received help from a spouse, partner, friend or family member. Meal preparation Almost three quarters of participants (71.4%) prepared their own meals. The remaining 28.6 % had their meals prepared by: spouse/partner (96.5%); family member (1.4%); and take away services (1.4%).

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5.1.4 Physical Activity

When asked how many minutes of physical activity per day is required for health benefits, 15.4% stated under 30 minutes, 51.6% stated 30 minutes exactly, 22% stated between 30 and 60 minutes, 3.4% stated over 60 minutes and 7.6% did not know. Participants were asked how many minutes of physical activity they performed per week. Responses were divided by seven to achieve the average amount of physical activity per day.

Table 9. Average physical activity per day

Average physical activity per day % Participants

29 minutes per day or less 41.2

30-59 minutes per day 30.8

60 minutes or over 25.4

Not sure 2.6

TOTAL 100

Strength and balance Almost two thirds (31.8%) of participants reported doing strength-based physical activity (e.g. lifting weights) and 20.4% of participants reported doing balance-based physical activity (e.g. tai-chi or yoga). Good balance was reported by 65.8% of participants, while 25.4% reported average balance, 8.2% reported poor balance, 0.4% reported very poor balance and 0.2% did not know. Assistive Devices Assistive devices were reportedly utilised by 6.8% of participants. Of those, 70.6% reported using canes/walking sticks, 17.6% reported using walking frames, 5.9% reported using wheelchairs 5.9% reported using mobility scooters and 0.6% reported using elbow crutches.

5.1.5 Environment

Home modifications Some participants (4.3%) made the decision to relocate to a safer home while 18.6% of participants reported having their home modified to prevent them from having a fall. Of those, 84.9% had handrails installed, 11.8% had steps replaced by ramps, 7.5% replaced or removed rugs, 4.3% removed clutter and 2.2% removed loose cords. Other modifications noted included levelling uneven floors (2.2%) and adding non-slip surfaces to stairs (2.2%). A third (33.3%) of home modifications were reported to be conducted by health professionals, 31.2% by the participants themselves, 18.3% by spouses/partners, 7.5% already existed in the participants’ residence, 5.4% by a family member, 5.4% by tradesmen, 2.2% by friends and 1.1% of participants did not know.

5.1.6 Perception of Falls

Inevitability of falls Participants were asked their opinion of the following statement: “Older people fall and there’s nothing that can be done about it.” 1.2% of participants strongly agreed, 10.2% agreed, 7.4% were neutral, 37.4% disagreed, 38.8% strongly disagreed and 5% didn’t know. Priority of falls Compared to other health issues for people aged 60 or over, 27.4% of participants thought falls prevention was a very high priority, 41% said high priority, 21.6% said average, 5% said low priority, 0.6% said very low priority and 4.4% didn’t know. Falls Prevention in people aged 60 or

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over generally was found to be a very high priority for 26.6% of participants, a high priority for 48%, average for 19.4%, a low priority for 2.4%, a very low priority for 0.4% and 3.2% didn’t know. Falls Prevention for the participant personally was found to be a very high priority for 30% of participants, a high priority for 30.6% of participants, average for 25.8% of participants, a low priority for 9.4% of participants, a very low priority for 4% of participants and 0.2% of participants didn’t know. Fear of Falling and Limitations Around a third of participants (30.8%) reported being afraid of having a fall, 20.2% of participants reported limiting household activities because they are afraid they may have a fall, 30% of participants reported limiting outside activities because they were afraid that they may have a fall.

5.1.7 Falls History

Falls frequency and location of fall Participants were asked about frequency of falls in the past 12 months. Around a third of participants (30%) had reported having a fall in the past 12 months. Of these, 68% had fallen once, 20% twice, 6% three times, 3.3% four times and 2.7% more than four times. Of those who have had a fall, 71.3% reported sustaining an injury (e.g. bruises, cuts). Participants were asked about the location of the fall, and 40.7% of participants reported falling in their own yard, 19.3% in their own home, 4.7% in a sporting ground/area, 3.3% in a park, 2.7% in somebody else’s yard, 16.7% in some other public outdoor setting and 8.7% in some other public indoor setting. Of those who had a fall inside a house, 26.7% fell in the lounge room, 23.3% in the kitchen, 10% in the bedroom, 6.7% in the shower, 3.3% in other areas of the bathroom, 0.4% in the hallway/passage, 0.4% in the computer room/study, and 0.4% in the laundry. Cause of falls Participants were asked about the causes of their falls and their responses were summarised in Table 10 below: Table 10. Cause of Falls

Cause of Fall % Participants

Trip/ Slip 36.0

Overbalance 15.3

Not taking care 12.7

Bumped/hit by person, animal or object 8.0

Being clumsy 4.7

Misjudged distance 4.0

Broken/ Unsupportive objects/ surfaces 4.0

Other health issue 3.3

Fainted 2.6

Dizziness 1.3

Legs gave way 1.3

Other 6.8

TOTAL 100

Note: Participants were able to list one or more causes, totalling over 100%.

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Conversations about falls Of those who had a fall, 70.7%, reported speaking to somebody about the fall. Those participants spoke to: their spouse/partner (46.2%); to a professional carer (39.6%); to a family member (14.2%); to a friend (13.2%); and to a health professional (8.5%). Action after the fall After their fall, 49.3% of participants thought about taking actions to prevent falls in the future. A large majority (87.8%) of participants reported taking actions to prevent falls in the future. Participant responses, with regards to the Nine Steps to Stay on Your Feet, were categorised below in Table 11. Table 11. Actions taken to prevent falls

Nine Steps to Stay on Your Feet % Participants

Foot Care and Safe Footwear 12.3

Be Active 9.2

Improve Your Balance 9.2

Regularly Check Your Eyesight 9.2

Manage Your Medicines 7.7

Eat Well for Life 7.7

Manage Your Health 6.2

Walk Tall 3.1

Other: Be more careful/aware 38.5

Other: Limiting normal activities 10.8


5.1.8 SOYFWA Program

Falls Prevention Program Awareness Around a quarter of participants (27.6%) reported being familiar with a falls prevention program.

Of those, 26.8% named SOYFWA (7.4% overall), 18.8% named Living Longer, Living Stronger, 4.3% named Stepping Out, 3.6% named No Falls and 2.9% named W.A Country Health Service Falls Prevention Program. Other programs mentioned at 0.2% (n=1) were:

Act Belong Commit

Be Active

Health for Life

Keeping your Feet

Keeping mind and Body Strong

Movement for the Aged

Over 60’s Initiative

Prime Movers

Stay Upright

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SOYFWA Awareness When asked “Have you heard of the Stay On Your Feet WA Program?” 27% of participants replied ‘Yes’. The following table demonstrates awareness against demographic indicators. Significance was tested using one-way ANOVA tests with the significance level set to 0.05. Gender and location (regional – north) were significant. Table 12. Demographic characteristics of participants aware of SOYFWA

Participants were asked where they heard about SOYFWA (outlined in Table 13 below). Community newspapers and events were the most frequently cited responses, however around

10% of participants indicated that they were made aware of SOYFWA via television. Table 13. Community member awareness of SOYFWA through different information sources

Medium % Participants

Community newspaper 17.3

Community event 16.7

Brochure 13.0

TV 11.7

SOYFWA presentation 8.6

Friend 6.8

State newspaper 6.2

Health Professionals other than GP 5.0

Other publications targeted to seniors 5.0

Word of mouth 4.9

Radio 4.3

Workplace 4.0

G.P 3.7

G.P 3.7

Newsletter 3.1

Local venue 1.9

Website 0

Note: Participants were able to list one or more information source, totalling over 100%.

Yes %

No %

Don't Know %

Significance (p <0.05) Sig.

Gender

Male 17.1 81.7 1.3 Male and Female Sig<0.001 Yes

Female 37.7 59.6 2.7

Location

Metropolitan 23.5 74 2.5 Metro. and Reg. (Nth) Sig.= 0.415 No

Regional (North) 30.4 67.4 2.2 Metro. and Reg. (Sth) Sig. = 0.048 Yes

Regional (South) 34.9 65.1 0 Reg. (Nth) and Reg. (Sth) Sig.= 0.621 No

Age Category

60-69 24.5 74.2 1.3 60-69 and 70-79 Sig.=0.885 No

70-79 29.3 68 2.7 60-69 and 80+ Sig.=0.838 No

80+ 37.5 62.5 0 70-79 and 80+ Sig. =0.930 No

Socio-Economic Index for Area

Low SES (SEIFA Decile 1-3) 30.4 67.4 2.2 Low and Medium Sig.=1.000 No

Medium SES (SEIFA Decile 4-7) 29.8 68.8 1.5 Low and High Sig.=0.686 No

High SES (SEIFA Decile 8-10) 24.3 73.3 2.5 Medium and High Sig.=0.357 No

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SOYFWA Printed Materials

Around a third of participants (36.4%) recalled reading SOYFWA printed materials. More than half of participants (57.6%) reported that the printed materials were very useful, 30.5% said somewhat useful, 6.8% were neutral and 5.1% did not know.

SOYFWA Falls Resource Information Centre One fifth of participants (19.8%) were aware of The Centre. Behaviour Change

Participants were asked whether the SOYFWA program had prompted them to change their behaviour in relation to falls prevention. Around one fifth of participants (18.5%) indicated that

they had made changes to prevent falls in the future as a result of SOYFWA. Receiving Information

Participants were asked how they would like to receive information from SOYFWA. Table 14 below indicates participant preferences with brochures, booklets and via a health professional most popular.

Table 14. Preferences of mediums for community members


Brochure 30.0

Booklet 25.0

Health Professional 23.0

Website 22.6

Newsletter 15.6

The Centre 5.4

Do not need information 7.0

SOYFWA Website

4.4% of participants were aware of the SOYFWA website. Of those, 9.1% of participants had used the website (0.4% of all participants). Of those who had used the website, 9.1% reported it as very useful, 18.2% as somewhat useful, 13.6% as neutral, and 59.1% didn’t know.

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5.1.9 Nine Steps To Stay On Your Feet

Falls Prevention Participants were asked: “What do you think you can do to prevent having a fall?” Responses were

unprompted and categorised into the Nine Steps to Stay on Your Feet and ‘other’.

Table 15. Preventing a fall through the Nine Steps to Stay On Your Feet

Nine Steps to Stay on Your Feet % Participants


Be Active 44.2




Walk Tall 23.4



Other: Awareness/ Being Careful 23.2

Other: Installing/ Using Hand Rails 3.2

Other: Reduce Alcohol Intake 1.6

Note: Participants were able to list one or more action, totalling over 100%.

Awareness of the Nine Steps to Stay On Your Feet Only 9% of participants were aware of the Nine Steps to Stay On Your Feet. Participants who were aware of the Nine Steps to Stay On Your Feet were asked to list all the steps they could remember, outlined in Table 16 below. Participants were most likely to report being aware of Foot Care and Safe Footwear, Regularly Check Your Eyesight and Be Active.

Table 16. Awareness of the Nine Steps to Stay On Your Feet in community members

Nine Steps to Stay On Your Feet % Participants



Be Active 42.2

Identify, Remove & Report Hazards 40.0




Walk Tall 20.0


Other 6.7

Usefulness of Nine Steps to Stay On Your Feet Of the participants who were aware of the Nine Steps, 57.8% reported that the Nine Steps as very useful, 20% said somewhat useful, 4.4% were neutral and 17.8% didn’t know.

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5.2 Online Survey with Health Professionals

The online survey was conducted with 231 health professionals from a range on disciplines. Responses were categorised into Participant Demographics, Discussing Falls Prevention and

SOYFWA Program Awareness and Strategies.

5.2.1 Participant Demographics Participants were asked to provide their professions which are outlined in Table 17 below. Around a quarter of respondents were physiotherapists and another quarter hospital based nurses. Table 17. Professions of health professionals

Profession % Participants


Hospital based nurse 25.4

Health promotion officer 14.6

Community nurse 11.5

Occupational therapist 10.0

Pharmacist 5.4

Podiatrist 3.8

Specialist 2.3


TOTAL 100

Participants were asked to indicate the setting in which their work takes place. The responses are

outlined in Table 18 below. Around a third worked in the community with the largest proportion

of participants indicating that their work took place in the hospital setting.

Table 18. Work settings of health professionals

Work Setting % Participants

Hospital 42.9

In the community 34.7

Aged care or disability residential setting 7.1

Community health centre 6.6

Private practice (including G.P.) 6.1

Outreach i.e. Aged Care Assessment Team (ACAT) or Home-visit services (e.g. Silver Chain)

2.6

TOTAL 100

The SEIFA (Socio Economic Index For Area) was applied to the workplace postcodes provided by participants. The SEIFA was analysed using deciles with ‘1’ being the lowest level of socioeconomic status for area and ‘10’ being the highest level of socioeconomic status for area. Table 19 below provides the results which are categorised into low, medium and high Socio-Economic Status (SES) using SEIFA Deciles. Just under half of participants (45.9%) worked in area categorised as high SES.

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Table 19. SEIFA index of participant work settings

SEIFA Index of Work Setting % Participants

Low SES (SEIFA Decile 1-3) 7.8

Medium SES (SEIFA Decile 4-7) 34.2

High SES (SEIFA Decile 8-10) 45.9

Unidentified 6.4

TOTAL 100

5.2.2 Discussing Falls Prevention The large majority (89.3%) of participants discuss falls prevention with their patients/clients community members. Of those, more than half (52.5%) discuss fall prevention with ALL, 28.5% with MOST, and a little under one fifth (19%) with only SOME patients/clients/community members. Two-thirds (67%) of participants reported that their patients/clients/community members initiate falls prevention discussion with them. When asked what patients/clients/community members discussed, the most common responses were: balance/unsteadiness (17.3%), fear of falling (14.7%) and falls history (9.52%). Barriers to Discussing Falls Prevention One-fifth (19.9%) of participants reported facing barriers to discussing falls prevention with patients/clients/community members. Of those, 86.7% stated time as a barrier, while 20% stated cognitive disability/dementia of the patient/client/community member, and 10% stated that it was not their role. Other barriers to discussing falls prevention were identified by a small number of professionals, including; a lack of available resources (6.7%), that it is not relevant to their patients (6.7%), a lack of knowledge/skills (3.3%), and 3.3% stated they were unaware of falls prevention resources. Enablers to Discussing Falls Prevention Most of the participants (89%) reported that knowledge of falls prevention was an enabler to discussing falls and falls prevention with patients/clients/community members. Other enablers described by participants included the use of printed resources (72.8%) and non-print resources (37.2%), while 39.8% reported that having someone to contact for advice was an enabler to discuss falls and falls prevention. 1% were not sure of any enablers.

SOYFWA Program Awareness and Strategies

Participants responded to a series of questions specific to the SOYFWA Program in the online

survey. These questions included feedback on a number of SOYFWA strategies including

awareness of the SOYFWA brand, awareness of major SOYFWA events and participation in these events.

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Awareness of SOYFWA Program and Events

The majority of participants (93.9%) were aware of SOYFWA before the online survey.

Participants became aware of SOYFWA through a variety of media, with the responses listed in Table 20 below. Table 20. Awareness of SOYFWA in health professionals through mediums


Email 61.8

Brochures 51.5

Website 48.5


Newsletter 34.5

Workplace/ Training 30.9

e-Newsletter 27.3

Community Newspaper 23.0

State Newspaper 9.1

Radio 8.5

TOTAL 100

Note: participants could indicate multiple sources hence total not equal to 100%

Participants were also asked how they became aware of SOYFWA events. Table 21 below outlines the most frequent and least frequent media.

Table 21. Awareness of SOYFWA events in health professionals through mediums

Medium Stay On Your Feet® Week Stay On Your Feet® Grants April No Falls Day

Radio 4.1 1.4 2.6

Community Newspaper 8.2 4.2 3.6

State Newspaper 2.7 1.9 1.8

Newsletter 11.1 10.0 10.3

Brochures 11.5 3.9 8.5

Website 12.3 14.2 12.6

Email 23.4 29.2 25.7

Community event 13.3 8.0 11.5

e-Newsletter 9.2 10.0 10.8

Haven't heard of it 4.1 17.2 13.6

TOTAL 100 100 100

Participation in SOYFWA strategies

Professionals were asked about their participation in key SOYFWA strategies. Table 22 reports the level of

participation in SOYF Week, the SOYF Week Grants program and April No Falls Day. Around two thirds

of professionals had participated in SOYF Week whilst less than half had participated in the other strategies. Table 22. Health professional participation in SOYFWA events

Participation % Participants

Stay On Your Feet Week 66.5

Stay On Your Feet Week Grants 37.3

April No Falls Day 41.6

TOTAL 100

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SOYFWA Event Feedback

Each strategy (SOYF Week and April No Falls Day) was rated by participants according to effectiveness, relevance, and usefulness to their organisation. Participants were invited to comment on the strategies and suggest improvements. Effectiveness was defined to participants as “how well the strategy works, and whether we are getting the right things done in relation to

the prevention of falls.” Almost two thirds of participants rated SOYF Week as effective (61.7%) while less than half of participants rated April No Falls day as effective (43.1%). Table 23. Effectiveness of SOYFWA events

Effectiveness SOYF Week

% Participants

April No Falls Day

% Participants

Very effective 11.9 10.1

Effective 49.8 33.0

Neutral 24.3 43.2

Somewhat effective 11.9 8.4

Not effective 2.2 5.3

TOTAL 100 100

Comments provided by participants in relation to the effectiveness of SOYF Week concentrated on effective targeting of the strategy. Issues regarding targeting rural (n=2) and Indigenous communities (n=2) were commented on, as well as issues with engaging new community

members (n=1). Survey participants suggested that participation in SOYF Week is high in community members who have already reduced their risk factors (n=3). Comments provided by participants in relation to the effectiveness of April No Falls Day included achieving greater awareness of the day, in particular awareness through existing health networks (n=3), the use of a ‘day’ may not be effective, and needs to be continuous (n=3). Participants were asked to rate the relevance of each of the strategies. Relevance was defined as “how pertinent and applicable the strategy is to the prevention of falls.” More than three-quarters

of participants (84.6%) rated SOYF Week as relevant, whilst two thirds of participants (65.9%) rated April No Falls Day as relevant.

In relation to SOYF Week, participants suggested that grant money should be available all throughout the year (n=1), not just for awareness raising one week out of the year (n=1). Comments received relating to April No Falls Day included: “Ties in with April Fools’ Day so it makes remembering the day easier” (n=2). As outlined in Table 24 below, more than 50% of

participants indicated that SOYF Week assisted their organisation. Less than half of participants indicated that April No Falls Day assisted their organisation. Table 24. Assistance provided by SOYFWA events

Assistance SOYF Week

% Participants

April No Falls Day

% Participants

Assisted organisations 55.8 41.8

Did not assist organisations 44.2 58.2

TOTAL 100 100

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Comments from participants regarding SOYF Week noted provision of printed materials (n=25), grants (n=22) and awareness-raising (n=13) as assisting their organisation. Comments from participants regarding April No Falls Day noted awareness-raising of fall prevention (n=30) and training/ education events for staff (n=16) as assisting their organisation.

Comments made by participants regarding SOYF Week noted that improvements could be made

on awareness of SOYF Week (n=16), constant provision of services (not limited to SOYF Week)

(n=3), the distribution methods of printed resources during SOYF Week (n=9) and more assistance for ATSI projects (n=2). Comments made from participants regarding April No Falls Day noted that it needs to be promoted more (n=32).

SOYFWA Falls Resource Information Centre

Participants were asked about their awareness of the SOYFWA Falls Resource Information Centre. Less than half of respondents (42.3%) of participants had heard of the Centre. Table 25 indicates the ways in which participants became aware of The Centre.

Table 25. Awareness of The Centre through different media


Email 38.0

Website 37.0


Workplace 9.0

Newsletter 6.0

Brochures 6.0

Radio 2.0

Community newspaper 0

State newspaper 0

TOTAL 100%

Participants were asked about their use of the Centre. Only 10.9% of participants had referred a client/ patient to The Centre, while around a third (32.3%) had contacted The Centre themselves. Half of participants were in favour of The Centre providing referrals to other services and

resources outside of SOYFWA. Participants had preferences for the services outlined in Table 26 below. The most commonly cited services included falls clinics, community physiotherapy services and Living Longer Living Stronger. Table 26. Additional falls prevention referrals for The Centre

Falls Prevention Service % Participants

Aged care assessment 64.6

Community physiotherapy services 55.4

Falls / balance / mobility clinics 48.2

Living Longer Living Stronger TM 45.6

Home medication review 43.6

Falls specialist program 38.5

Commonwealth Carelink and Respite Service 31.8

Rehabilitation In The Home 31.3

Enhanced Primary Care Program / Medicare Benefits Schedule primary care items 24.6

Over 75 year health check up 22.6

TOTAL 100

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Website

The Stay on Your Feet WA website was rated by participants for ease of navigation, usability for people aged 60 years and over, and opinion of the ‘For Health Professionals’ tab. Tables 27, 28 and 29 below outline participant responses. Two thirds of participants indicated that the site was easy to navigate (66.3%), and had good useability for those aged over 60 years (65.1%). More than three quarters of participants rated the tab for health professionals positively (79.5%).

Table 27. Navigation of the SOYFWA website

Ease of Navigation % Participants

Very Easy 19.7

Easy 46.6

Neither Easy nor Difficult 16.3

Difficult 2.4

Very Difficult 0.5

Not Sure 14.4

TOTAL 100

Table 28. Usability of the SOYFWA website for people aged 60 or over

Usability for People aged 60 or over % Participants

Excellent 2.9

Very Good 17.7

Good 44.5

Poor 11.0

Very Poor 1.4

Not Sure 22.5

TOTAL 100

Table 29. Ratings of the 'For Health Professionals' tab

Rating of the ‘For Health Professionals’ Tab % Participants

Excellent 6.8

Very Good 32.7

Good 40.0

Poor 3.9

Very Poor 1.0

Not Sure 15.6

TOTAL 100

Participants were asked to provide suggestions about additional website content, with the most popular additional areas outlined in Table 30 below.

Table 30. Other content for the SOYFWA website

Other Content % Participants

Resources for clients/ patients/ community members 49.0

Additional printable resources for health professionals 46.0

Referral links 39.9

Community presentation information 30.8

News and events information 24.7

No other content needed 9.6

TOTAL 100

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Other content suggested: includes more pictures/videos (n=3), links to continence information (n=2), information on foot care/ podiatry (n=2), resources for ATSI communities (n=1) and resources for rural communities (n=1).Additionally, 39% of participants would like to see separate

SOYFWA websites for health professionals and community members. 5.2.3 Nine Steps to Stay on Your Feet

Awareness

Participants were asked about their awareness of the Nine Steps to Stay on Your Feet. Around

three quarters of participants (74.7%) were aware of the Nine Steps to Stay on Your Feet. In

order to test the recall of steps, the Nine Steps to Stay On Your Feet were provided along with

five ‘false’ steps. Participants were asked to identify the Nine Steps to Stay on Your Feet from the list of 14 true and false steps. Table 31 below shows the percentage of participants who correctly identified each of the steps. Table 31. Identification of the Nine Steps to Stay on Your Feet

Nine Steps to Stay On Your Feet % Participants One of the Steps

Be Active 98.1 True

Foot Care and Safe Footwear 97.5 True

Manage Your Medications 96.9 True

Regularly Check Your Eyesight 95.6 True

Improve Your Balance 95.0 True

Identify, Remove and Report Hazards 95.0 True

Eat Well For Life 88.7 True

Walk Tall 83.0 True

Manage Your Health 80.5 True

Regularly Visit Your GP 22.0 False

Have A Personal Action Plan 12.6 False

Improve Your Walking Patterns 10.7 False

Increase use of Vitamin D 8.2 False

Wear A Personal Alarm 3.1 False

Importance

Participants were asked to rank the Nine Steps to Stay On Your Feet in order of importance from 1-9, with 1 being very important and 9 being least important. Rating averages were calculated to

determine the level of importance of the Nine Steps to Stay On Your Feet to participants. Table 32 below shows the order of importance of each step. Table 32. Importance of the Nine Steps to Stay On Your Feet

Nine Steps to Stay On Your Feet Rating Average

Be Active 2.53


Manage Your Medications 4.21



Identify, Remove and Report Hazards 5.32


Walk Tall 6.62

Eat Well For Life 7.01

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Discontinued steps

Participants were asked if any of the Nine Steps to Stay on Your Feet should be discontinued. The most common responses were Walk Tall (n=12) and Eat Well for Life (n=3). Some participants suggested that some steps could be combined, however the majority of participants did not suggest any steps to be discontinued.

Additional steps Participants were asked if any additional steps were required as part of the Nine Steps to Stay on

Your Feet . The majority of respondents did not recommend additional steps. Of those who did, the following steps were recommended: Vitamin D/Calcium intake (n=8); Bone Health/ Bone Scan (n=4); the use of Assistive Devices (n=3); Social Connections (n=3); Personal Action Plans (n=2); Personal Alarms (n=1); Blood Pressure (n=1); Avoidance of Bifocals or Varifocals (n=1); Reduction of Alcohol (n=1); Hearing (n=1)and Continence (n=1). Specific comments received included: all steps are important (n=4) and there needs to be an opportunity to tailor steps to individual (n=1). Other comments included renaming Walk Tall to Improve your Posture (n=1), developing an acronym (n=1) and focusing on 2 steps at a time during educational sessions (n=1).

Support, Services and Communication Participants were asked about the level of support that they received from the program to conduct their work in falls prevention. More than two thirds of participants indicated that they felt

either very supported (20.3%) or supported (48.5%) by the SOYFWA program. Around one per cent of participants did not feel supported with just under a third of participants (30.2%) providing

a neutral response to this question. In order to identify the use of SOYFWA services, participants

were asked which SOYFWA services they had not previously engaged with. A total of 204 participants responded to this question (27 participants provided no response). Results are listed in order from least used services to most used services.

Table 33. Services not used by health professionals

Services Have not used

Video conferences 20.7

Falls Prevention Summit 16.0

On site staff training 15.9

Community Education Sessions 13.5

Media 12.0

April No Falls Day 12.0

Stay On Your Feet® Week 5.9

Resources 4.2

TOTAL 100

Other services Around a quarter of participants (25%) reported that there were additional services which

SOYFWA could offer to support them to undertake falls prevention strategies. The most common responses were: training and guidelines for health professionals (n=15) and services for regional communities (n=5). Other suggestions included education for community members (n=3), online education (n=1) and a referral list of health professionals (n=1).

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Professional Development Participants were asked about their preferred means of professional development. Table 34 below indicates that workshops and the website were the most popular ways for participants to receive professional development. Table 34. Preferred means of professional development

Professional Development % Participants

Workshop 61.3

Website 50.5

Summit (one day conference) 39.7

Videoconference 24.2

I’m not interested in professional development

11.9

Teleconference 8.2

TOTAL 100

Other suggestions included webinars/webcasts (n=3), online learning packages (n=1) and

SOYFWA professional development days (n=1). Barriers included time (n=1) and high turnover (n=1).

Communication with SOYFWA

Participants were asked to report their preferences for communication with SOYFWA. Table 35 below indicates that digital communication was most popular with email by far the most common response, followed by use of the website. Table 35. Preferred mediums for communication between health professionals and SOYFWA


Email 83.4

Website 8.5

Newsletter 6.0

Radio 1.0

Post 0.5

Newspaper 0.5

Phone 0

TOTAL 100

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5.3 Health professional telephone interviews

5.3.1 Participants

Participants comprised 25 health professionals involved in falls prevention in Western Australia.

Professions included:

Clinical Health Professionals: General Practitioners(n=1), Nurses (n= 1), Geriatricians (n=1)

and Clinical Services (n=1)

Allied Health Professionals: Physiotherapists (n=4), Pharmacists (n=2), Occupational

Therapists (n=1), Therapy Service Mangers (n=1) and Nutritionists (n=1)

Population-based Health Professionals: Health Promotion Officers (n=7), Community

Development Officers (n=1)

Residential/ Home Care Health Professionals: Aged Residential Care (n=3) and Home care

services (n=1)

The health professionals worked in one or more of the following settings:

Homecare (n=8)

Community-based (n=7)

Hospital based (n=6)

Residential/ Aged care (n=3)

Private practice (n=2)

Community health centres (n=1)

Organisations ranged in size, location (metropolitan and regional) and included both government

and non-government agencies.

5.3.2 Results

Barriers to Discussing Falls Prevention Participants were asked about any barriers that they experienced in discussing falls preventions with patients, clients or community. Interestingly, the most common response provided by health professionals was that there were ‘no barriers’ (n=9) to discussing falls prevention. This was followed by issues relating to attitudes of older adults to falls and ageing in general, including their perception that they are not at risk of falling (n=5). Some health professionals reported that timing was important, with patients, clients or community members more amenable to discussing the risk of falls after experiencing one. Risk factors reported as being difficult to address were the implications around medication use, such as using sleeping tablets.

… the major issue is that people don't foresee a fall to be a problem until they have one. (Allied Health Professional)

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…the problem that we've got, is that people don't really want to know about falls, in my experience, unless it's become an issue for them and even when they have had falls, often it's hard for them to understand why they had falls, and they'll just say, “well, I tripped up,"…

(Allied Health Professional)

….Probably the biggest barrier for us is those clients with dementia. (Allied Health Professional)

Falls specialists, geriatricians, inpatient or other referral type roles generally identified fewer barriers to discussing falls prevention. This may be due to their clientele being referred due to having a history of falls or risk factors related to falls (e.g. unsteady gait, hypotension). These patients or clients are likely to be more amenable to a conversation on falls prevention, having already accessed a clinical service and experienced a fall.

Not really because that is my role, that is what I do [inaudible] my job every day.


And some groups are more difficult to talk to than others. I find men to be a little bit resistant to the idea…

(Population-based Health Professional)

In contrast, health professionals involved in community based programs were concerned with client access. These concerns included ensuring clients or community members had transport to places to engage in falls prevention activities; and accessing individuals of higher need, rather than those already engaged with falls prevention programs and activities. Geographical and cultural access issues were also raised, along with engaging those individuals with dementia.

The only barrier of course, is accessing the people that really need it. It's a general health promotion problem anyway.


The people who are open to it are the people who have had falls and experienced falls and had terrible falls. But then it's really hard to target the people who are over 65 and who have not had a fall…and the other thing is that they really don’t see that they are going to have a fall and the big falls only happen to people who are 80 or 90 or so.

(Population-based Health Professional) …what actually helps is basic things like making a transportation available for them to come down to the Centre.

(Population-based Health Professional) Only people's reluctance to say that they're getting old and that they're at risk of falls.

(Population-based Health Professional) Limitations around resources to support health professionals in falls prevention were also

identified as a barrier. These included time restraints for falls prevention due to workload,

competing requirements (other activities engaged in with exercise groups) and lack of support

from the management hierarchy for falls prevention.

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...I don't think falls is on the radar as much as it should be in pharmacy and in kind of with general health care ….

(Allied Health Professional) … I think falls are a huge problem in the community…and I think the Stay on Your Feet program is great. But I'm just not convinced it doesn't seem to be the flavour of the month as it used to be.

(Allied Health Professional) Falls prevention is not taken seriously…I know that sounds strange, but certainly not in this hospital. I find it quite disturbing. People are dying because of a fall, and they shouldn't have to. So there needs to be a lot more consumer input, a lot more input from staff across all health areas as to what we need.

(Clinical Health Professional) Yeah, falls prevention isn't given much priority at the moment so it can actually be really hard to justify to management that you should be out there and actually focusing on that.


Enablers to Discussing Falls Prevention Fall resources were the most commonly reported facilitator for discussing falls prevention (n=16).

These were identified as being print and non-print SOYFWA resources, along with other non-

SOYFWA resources. The second most frequently reported barrier was the health professional’s

own knowledge (n=9), followed by use of networks (n=3). There were variations between

respondents largely based on roles, with professionals in clinical falls prevention roles reporting

knowledge and expertise as crucial, using resources to summarise and reinforce information.

These professionals tended to carefully select specific resources for individuals, whereas

professionals in more population-based falls prevention were more inclined to simply distribute a

broad range of resources.

I certainly always give out the Stay On Your Feet booklet …So, it's used like a summary of basically what we've been through together...


Yeah. I guess the Stay on Your Feet resources are very helpful. Just in the way that they're easy to take and they look neat…


The printed resources are always really excellent. (Population-based Health Professional)

My own knowledge in terms of falls and anything else, we discuss it. Obviously, the use of physical resources, as well as all those and titles from the internet, that kind of thing.


Your knowledge is very important. The way you approach the patients is very important. (Clinical Health Professional)

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Probably just the reinforcing, you know, the need for the client to be aware of their surroundings and give them information and, you know, just ongoing reminders to them about the different hazards that can cause falls…

(Residential/ Home Care Health Professional) Whilst also a barrier, the timing of the falls discussion could be an enabler, with a discussion

following a fall or following a change in medical status (e.g. commencing a medication) making

discussions more acceptable.

I guess when they have a fall, or when they're starting on medication, that might make them more prone to fall- that's a good way of bringing up the issue.

(Allied Health Professional) I usually -- I kind of market it, talking about avoiding these falls and talking about maintaining independence and healthy living and, you know, and trying to find out what the patient’s goals are. What they want to achieve and talking about falls prevention in that context.

(Clinical Health Professional)

Printed falls prevention resources- Key features of the resources

Falls prevention resources were generally perceived as valuable and at times crucial to fall

prevention, particularly for those working with people living in the community.

I guess I always just give out the stuff, that's in this resource pack that's under general community. So that's the information I do give out, and the rest of it, it's not really relevant to the people I deal with.


[[

I promote them (resources) a lot as well, for my presentations and things. So, it certainly would be problematic if I didn't have access to these resources.

(Allied Health Professional) Probably the downside to the resources is having enough of them up to date and having a box of resources in your car. But quite often what we find is that, we'll have a collection of them, and then we'll use them and give them out until we run out. It's quite labour intensive keeping your stocks up to date.

(Residential/ Home Care Health Professional)

I think that it (resources) presents a really good guide for our younger therapists, to make sure that they're covering all the bases, in terms of falls prevention, a bit of a cheat sheet and a checklist for them to use.


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All health professionals reported using the printed SOYF prevention resources or reported that

they knew that someone in their organisation who used them. The majority of participants were

not aware of the suite of SOYF resources, especially those targeting individuals with higher

needs and Aboriginal people. Those working in population-based programs were more familiar

with the SOYF kits; community based clinicians were more familiar with community materials

(notably SOYF); and hospital based clinicians used a mixture of SOYF and other resources. The

other resources that were used were on alcohol consumption, nutrition, medications, Living

Longer: Living Stronger and Health Department resources.

I'm giving self-care advice to patients…and they're (resources) written at quite a low level so that are geared towards patients with those motivating skills and what have you.


I think that it's easy to understand actually… Cause I want them to have a little summary of what I've already told them.


But we've also created our own falls confidence questionnaire. (Population-based Health Professional)

We have a couple of leaflets, one that we have designed ourselves. Some we use at the base to start discussion, and then we have some other leaflets which are from SOYF Week that we utilise as well.


Health professionals indicated a need for a ‘freshening up’ of the SOYF poster and booklet

design. Whilst content may stay the same, a new appearance may help to re-engage the audience.

Other suggestions included possibly combining some of the content, such as checklists, or using

the high needs resources for all the target groups.

I just think a lot of time it just needs to be, I guess, spruced up so to speak and…and made new and exciting.

(Population-based Health Professional) I think it would be nice to see some further development, but no, not discontinued (resources).

(Allied Health Professional) You know the information is good within it. There's a bit too much of it, and I hate the layout. I hate the colours.

(Clinical Health Professional) [referring to the SOYF Booklet] I think it's just too wordy and it's very small font. I think people wouldn't read it. Looking at it myself, I couldn't bring myself to read it. I think it needs to be streamlined … And I think it is targeting middle class. There is no representation of Aboriginal people…and just didn't seem to be very diverse.


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The ones (resources) I use quite often are the community ones ….which are the falls checklist and the Stay On Your Feet booklet and the home safety one, I like. I'm not even going to address the other ones because I haven't had a good chance to look at them and I don't use them. My suspicion is sometimes the writing is just far too small for older people to look at and the colours can make them not want to read it.


The key features of the resources that were identified by the health professionals, were that they

should be very easy to read and understand (n=18), accurate and informative (n=9) and attractive

(n=4).

.. that it's attractive to look at to make people pick it up… And then that it's easy for them to use and read.


The information certainly has got to be correct, but if it's not an attractive package no one's going to look at it.


Engagement and effectiveness of resources The health professional perceptions of client engagement when using the resources ranged from ‘good or very good’ (n=6) to poor (n= 2). Six health professionals felt the engagement was difficult to measure or dependent upon individual and context more than the resource itself.

It depends on the patient and where they're at in their journey. (Clinical Health Professional)

A lot of time they're given a packet (resources) and I don't see them again so it's hard to gauge if they're actually making any change as a result of it.


Yes and no. I think the clients that we see often have already received a lot of information either about their current condition or a lot of health-related literature.


The effectiveness of the resources in supporting behaviour change was difficult to determine (n-6),

with those involved in population-based programs reporting that they had little or no follow-up to

determine behaviour change. However, a number of health professionals reported the resources

to be an important adjunct to their clinical interventions (n=4), and three health professionals felt

the resources themselves were influencing behaviour change.

Recommendations regarding the resources Health professionals suggested specific resources for various subgroups and health issues. These included resources for people with visual impairment, bladder and bowel issues and those who

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were cognitively impaired. Recommendations were also made for resources on the management of medications, exercise and other activities, along with falls screening tools.

…specific exercises that people could undertake at home, just simple exercises that might help them to build on their muscle strength and improve posture.


Three health professionals recommended specific resources for people from culturally and linguistically diverse (CALD) backgrounds. However, there were differences in opinion on resources for Aboriginal people with suggestions that they could be specifically targeted or could be generalised. A number of health professionals (n=7) either felt no need to use the Aboriginal specific resource or were unaware of them. Two professionals suggested that the materials needed to be marketed better to health professionals.

The Aboriginal people down here, you know, very capable of reading the normal resource… (Allied Health Professional)

I don't want to generalise but a lot of people don't read English and so it would be good if …probably look at key languages...Maybe create video resources so those who can't read, can actually listen … get something out of it.


Australia is getting more multicultural- there are a lot of migrants being the parents here...We need to have them (resources) in Mandarin, Arabic, Italian, Portuguese, different European languages.


We don't have anything specific for our Aboriginal clients, and that might be certainly something that we can look at in the future, but we're just trying to keep it simple.


I'm not sure whether there's any CALD resources? (Residential/ Home Care Health Professional)

ICCWA Website Features of the ICCWA website

Although a number of health professionals used the SOYFWA website, there was a general lack of familiarity with it. Many professionals seem unaware of the website’s existence, did not use the site or rarely used it. However, none of the health professionals suggested that the site should be discontinued. Many health professionals struggled to distinguish between the WA Department of

Health, ICCWA and the SOYFWA websites. It was suggested that there could be could be better links between these sites. There was general dissatisfaction with the ‘government’ look and feel of the site.

…it can be difficult to find information you want. It's a bit of an odd structure. (Population-based Health Professional)

Is this the one that's directed to the Department of Health?


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Which is the Stay On Your Feet website? Is that the one -- the Department of Health one? (Residential/ Home Care Health Professional)

..if you type in "Stay On Your Feet," then get directed to this government website, which some people might think, "Oh, I've made a mistake" because I've been automatically redirected to a government website, as opposed to one that says "Stay On Your Feet."…So I think the logo, the Stay On Your Feet WA logo needs to be more prominent.


Well, it's just pretty bland. It's really difficult, I find, the Stay on Your Feet, whether it's with the health department…


the contact details (for Stay on your feet ) need to be somewhere that's much more obvious and much larger…..the older age user can't navigate around it


Website suitability for community members While five professionals stated that the website was fairly easy to navigate, numerous comments were made about perceived limitations of the website for community members. The website was critiqued on features such as its passive design and lack of visual appeal (n=3), lack of linkage or information on events and other resources (n=7), including local groups and services (n=4).There were concerns that the website was not user friendly (n=12), was difficult to read due to the small font size and was too ‘wordy’ (n=9). There was also expressed uncertainty about the varied levels of Internet access and computer literacy of people over 60 years (n=8), and how this may impact on the websites usefulness. There was a request for an 1800 contact number for country residents.

…older people don't like the sort of the Stay on Your Feet tab where it pops out. They kind of find it hard to stay on that and come across and then click…So, a drop down menu from clicking on Stay on Your Feet might be a little bit better

(Residential/ Home Care Health Professional) I would like the website to be more simplified than what it is right now, and maybe bigger in font size as well…. and also more easy to read… and more interactive.

(Residential/ Home Care Health Professional) But I'm just wondering, older people who are at risk of falls and their ability to actually use IT, But I'm not sure what the population of people that are over 65 actually have or using Internet.


Yeah, it doesn't seem very well set up for, especially if it's for people over 60. (Population-based Health Professional)

I would say it's not necessarily age that is the problem; it's more people of different computer literacy… In my experience, we can have 80-year-olds who know how to use computers and 50-year-olds who don't.


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There’s a lot of content on the homepage. And I wonder whether, if I was looking for some resources and not really that computer-savvy, whether that homepage could be a little -- have less information, …There's no pictures. There's nothing very inviting. It's a lot of text.


I don't think it's particularly engaging. I think it's probably a little difficult for them to navigate.

(Allied Health Professional) There's a wide range of abilities in terms of technology in older people. For some, they embrace it and use it and some just don't.


Website suitability for health professionals Most of the health professionals (n=15) found the website easy to navigate, however six reported that it was not easy to use. Concerns about the website included that it was difficult to find (n=6), was too basic and not up to date (n=3) for health professionals. It was suggested that there be a focus on specific professions. Others felt a more integrated information approach was warranted.

Yeah, referral links to other services would be good. I find the information quite dumbed down…

(Allied Health Professional) Weird design, isn't it?... You usually have some pictures and icons or things you can go in to. It's not very inviting. It's poor, possibly very poor... There's not much there right?...It's just a bunch of pages with information on the pages linking one to the other.

(Clinical Health Professional) Pharmacists don't need to necessarily just know the information that's relevant to them. They need to know where to send people, where to refer people.

(Allied Health Professional) …..too much emphasis is on producing the information rather than disseminating it… it's just packaging it in a way and making sure that people know about it …they just don't need the information, they need to know how to organise it into their practice.


…….health professionals are looking to get as much information as we can about falls, and that includes recent research, trials that are going on, research that's happening out there. Falls is an enormous area that's growing so fast, and yet there's nothing on the website to indicate that.


It's hard to read and it's not very interactive or visually appealing….it looks okay in terms of content, but some of it, even looking at the physio stuff and clicking through, there was an error...


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It's sorry looking… maybe making it a bit easier to use, the visual aspect of it, the writing is too small, there's too much going on. For the health professionals I think there probably could be a bit more information.


Recommendations for the website Suggested developments included links to services; current reports such as Cochrane Reviews and other evidence-based guidelines; fact sheets on falls levels and trends; news and current events information. Clinical resources should be in PDF format for downloading, and links to other clinical resources are required, such as the Independent Living Centre website.

Resources should be downloadable easily and clearly presented… when you click on the 9 steps or whatever it should not go to the individual pages but to one of the pamphlets for you to read as a PDF. You should be able to save that PDF.

(Clinical Health Professional) ..current trends on falls and also the hospitalization…Like that sort of statistics would be good to, like, just on a fact sheet, not very elaborated.


Links to groups that are actually involved. There could be a link to the podiatry association for people that need advice on footwear or managing foot problems …links to continence issues and how people could get referred.


It was recommended that the SOYFWA website have a strong central message, well-coordinated with other programs and resources, such as Active Ageing, Living Longer, Living Stronger, and Exercise is Medicine. It was also suggested that technologically advanced tools be developed, such as a Smartphone app (n=2).

….resources, especially for health professionals, could be marketed a little bit better. I feel apart from the hospital setting, not a lot of people are aware that they are there. I'm talking about private practice, therapists, and clinics that are too busy.


….a great project overall. In the past whenever I have conducted it, I got great feedback… it's a good opportunity for us to link in with other community groups, as well, all within the local government. I think it's just a great initiative.


I would like to see short DVDs that patients can watch or we can load up onto our free view…television. Anything that's multimedia.

(Clinical Health Professional) …..a link on the website- "Here's some information about the specific falls clinics that are around…


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I'm still not convinced that handing out pamphlets is the best way to get the information across ...maybe just rethinking the way they're (ICCWA) interacting with the public

(Population-based Health Professional) Stay on Your Feet Week gives out a thousand dollars or less funding, and I don't think that's money well spent. I think it's just a big party for a week, and the people that come to those things are mostly already engaging with us…

(Allied Health Professional) Overall falls prevention message Some professionals felt that the falls message is not taken seriously by those at risk, and indeed some are not honest about their falls history. Other health professionals felt the message is not taken seriously by their organisation, and limited resources are allocated to the area. Others felt the message should shift to a healthy ageing message, as it would be potentially more engaging, and also address the common distal issues in many high burden and chronic diseases.

More thought needs to go into these resources and who should administer them and try and pinpoint rather than just producing resources, ad hoc.


I think it's the dissemination of the information that's possibly missing. (Clinical Health Professional)

I think it's really important that we have one sort of central message for Stay On Your Feet resources. There's so much around about falls prevention, it can get a bit lost in all the different versions. We try to keep it very simple and very straightforward by using the resources that are there. We don't have to reinvent the wheel, and clients can answer "Oh, yeah, I've got that already" or "I've already seen that".

(Residential/ Home Care Health Professional) ….there's a beauty about the Stay On Your Feet program. It's a health promotion program, promoting health… if you're looking at the 9 Steps to Stay On Your Feet, they're really the 9 steps for all older people to stay well.


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5.4 Focus Groups

Four focus groups were held with community members (n=6, n=9, n=9 and n=13) (total n=37) and

four with health professionals (n=5, n=6, n=7 and n=8) (total n=26).

5.4.1 Participant Details

In order to collect additional data about the participants, a participant detail form was provided at

the beginning of each focus group.

Table 36. Community member focus group participant demographics

Characteristic % Participants Participants (n)

Gender

Male 27 10

Female 73 27

Age

60-69 30 11

70-79 57 21

80+ 14 5

Falls History

Had a fall in the last 12 months 16 6

Did not have a fall in the last 12 months 84 31

Table 37. Health professional focus group participant demographics

Characteristic % Participants Participants (n)

Gender

Male 12 3

Female 88 23

Work Setting

Hospital 50 13

Other 50 13

Profession

Physiotherapist 46 12

Falls specialist 19 5

Occupational Therapist 15 4

Other 19 5

Work experience in falls and falls prevention

Range: 6 months- 20 years Average: 5 years (Calculations omitted one participant with 40 years experiences)

5.4.2 Language

Falls Community members were asked for some of the words that come to mind when they heard the word ‘falls’. This question aimed to discover the attitudes and perceptions community members have about falls. Many responses were centred on the causes of falling (e.g. ladders and pavement) and consequences (e.g. broken bones and injury). Some responses were more emotive (e.g. embarrassment and fright) while others considered prevention (e.g. yoga and strength based exercises). The figure below represents their responses with words in larger fonts being mentioned more commonly.

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Figure 1. Word cloud of community members association with the word 'falls'

Community members were then asked what their thoughts were in response to terms such as ‘seniors’, ‘ageing’ and ‘elderly’. Seniors The word seniors received a relatively positive response compared to the other terms. Some groups were content with the term ‘seniors’ while some didn’t like any of the terms.

Seniors is better than the others. I’m a member of the National Seniors Association… (their) interpretation is anyone over 50, so when I hear seniors I think anyone over 50… I didn’t feel like being old or ageing until I turned 85 earlier this year. Well you get your senior’s card at 60.

Ageing Ageing was seen as a confusing term and was not received well.

I don’t like that at all. From the day you are born you start ageing.

Elderly All participants disliked the word elderly. The word was frequently linked to frailty.

What I hear on the media…on the news…is like, elderly grandmother of 62 bashed, and as I feel that as I am much older than that, it’s not a nice term. The journalists need to have the definitions explained to them, they often say ‘the elderly person of 60’ or something.

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I prefer senior… elderly is like you’re 100 years old. It conjures up frailty. It’s loaded.

All terms Some participants did not favour any of the terms.

I’m 76, and maybe 96 is getting senior, elderly, aged. I don’t consider myself that. Those to me- senior, elderly, aged have connotations of being old…losing their marbles.

Possible new terms Participants were then asked to suggest alternative terms. The terms ‘mature’ and ‘experienced’ were the most commonly mentioned.

Straight away I think over-60s. Mature... like a good wine. Older. A veteran. Experienced. Wise.

Higher Needs

The term ‘Higher Needs’ is used by SOYFWA to describe community members who are at a higher risk of falling due to a combination of elements such as age, falls history and risk factors of falls. This term was evaluated by the community member focus groups, most of whom perceived ‘higher needs’ to describe people dependent on aged care services.

(higher needs refers to) somebody very fragile, that needs a carer or supervising. I immediately thought of someone who needs assistance at home. …needs help with basic things like getting dressed or showered. Someone not independent.

5.4.3 Nine Steps to Stay On Your Feet

Awareness The eight groups were asked what actions they would recommend to prevent falls. This question served to test participants’ knowledge of risk factors associated with falls. Participants were not

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required to list the Nine Steps to Stay On Your Feet verbatim, but responses were included if they were highly associated with a particular step. Community Members

Three out of four groups identified: Manage Your Medicines, Foot Care and Safe Footwear, Regularly Check Your Eyesight and Identify, Remove and Report Hazards.

Two groups identified: Be Active.

One group identified: Manage Your Health, Improve Your Balance and Walk Tall.

None of the groups identified: Eat Well for Life.

In addition to the Nine Steps to Stay On Your Feet, actions frequently mentioned included:

Being aware and

Being careful.

Health Professionals

All four groups identified: Be Active, Manage Your Medicines, Manage Your Health, Improve Your Balance Foot Care and Safe Footwear and Identify, Report and Remove Hazards.

Two groups identified: Improve Your Eyesight.

One group identified: Eat Well and Walk Tall.

In addition to the Nine Steps to Stay On Your Feet, actions frequently mentioned included:

Managing continence

Being aware of falls

Correct use of mobility aids and

Personal alarms/ Pendant alarms. Preferences

The full list of the Nine Steps to Stay On Your Feet were then formally listed by the focus group facilitators. Focus group participants were asked to allocate three votes each to the three steps which they viewed as the most important for falls prevention. The results are illustrated in the Tables 38 and 39 below. Table 38. Importance of the Nine Steps to Stay On Your Feet (by community member)


Be Active 24

Improve Your Balance 15

Foot Care and Safe Footwear 14

Regularly Check Your Eyesight 12

Eat Well for Life 10

Manage Your Health 9

Identify Remove and Report Hazards 7

Walk Tall 6

Manage Your Medicines 3

TOTAL 100

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Table 39. Importance of the Nine Steps to Stay On Your Feet (by health professional)

Be Active and Improve your Balance achieved the highest number of votes in both community member focus groups and health professionals. Community Members:

I think it (Be Active) gives people a wide range of activities to do, while some of the others are defined and singular. I think if you’ve got a good balance you’re less likely to have a fall. One thing I’ve noticed as I’ve got older is that my balance is not as good.

Health Professionals:

If you look at the Cochrane review, they’ve actually statistically analysed it, strength and balance exercises together as a program alone are five times more effective than any single intervention. The main reason I voted for that one (Improve your balance) is that it’s very evidence based.

Eat well for Life and Walk Tall were voted the least important. I would disagree with Eat Well for Life being part of the message… I tend to think that once people are frail…eating becomes a real focus and they do need to eat to regain their strength…so people in their 90s who are very frail- they would be the ones I would have that big discussion with but I wouldn’t say that’s a message I give to younger older people. The Walk Tall…other things seem to be more important. Some of the older, frail patients we see… their posture is not correctable. It does depend on the group.” I would see Walking Tall as encompassed in the Be Active step.

A new list of steps Based on the voting activity, both community and health professional participants were asked if a new list of steps should be created. They were encouraged to add, remove or combine steps as


Be Active 22

Improve Your Balance 21

Identify Remove and Report Hazards 20

Manage Your Medicines 12

Manage Your Health 6

Regularly Check Your Eyesight 6

Foot Care and Safe Footwear 5

Eat Well for Life 4

Walk Tall 4

TOTAL 100

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they deemed appropriate. Table 40 and 41 outline the steps created by community members and health professionals. Table 40. Lists of steps created by community member focus groups

Group 1 1. Physical Steps

a. Be Active b. Improve your Balance c. Walk Tall

2. Manage your Health a. Improve your Eyesight b. Manage Your Medicines c. Foot Care and Safe Footwear d. Eat Well

3. Identify, Remove and Report Hazards

Group 2 1. Manage Your Health

a. Improve your Eyesight b. Manage Your Medicines c. Eat Well for Life

2. Be Active a. Improve Your Balance b. Foot Care and Safe Footwear c. Walk Tall

3. Identify, Remove and Report Hazards

Group 3 1. Identify, Remove and Report Hazards /

Improve your Eyesight 2. Manage Your Health 3. Be Active/ Walk Tall/ Improve Your

Balance

Group 4 1. Manage Your Health/ Manage Your

Medicines/ Eat Well for Life/ Regularly Check Your Eyesight

2. Walk Tall/ Be Active/ Improve Your Balance

3. Foot Care and Safe Footwear 4. Identify, Report and Remove Hazards

Table 41. List of steps created by health professional focus groups

Group 1 1. Be Active/ Strength/ Balance/ Walk Tall 2. Manage your Health/ Manage Your

Medicines/ Improve Your Eyesight/ Foot Care and Safe Footwear

3. Identify, Report and Remove Hazards

Group 2 1. Be Active

a. Improve Your Balance b. Walk Tall

2. Identify, Report and Remove Hazards a. Foot Care and Safe Footwear

3. Manage Your Health a. Manage Your Medication b. Improve Your Eyesight c. Eat Well for Life d. Continence

Many groups agreed that nine steps are too many to remember, and some of the steps could be combined. Some groups suggested combining steps under a new heading while others suggested keeping all the steps or grouping them.

I think there’s a risk when you have as many as nine that you lose the message part way through. Three is a good number, it’s enough information for people to remember as opposed to nine. You would need to come up with different terminology to describe each step, but within those steps then you have a couple of things that we’d want to be covering.

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However, two out of four of the health professional focus groups did not develop a new list of

steps, as they were in favour of keeping the original Nine Steps to Stay On Your Feet. These

groups offered the following comments:

Group 3

I agree that some of those could go together but trying to link too many of them together...

there’s a risk, because they’re all significant risk factors in themselves. While I think, it’s a lot

of information to give as a package to someone, I think it’s all important information.

Embedded in some of those is the beginning of your action plan, and who’s specialised in

dealing best with those areas ... from a strategy point of view it’s useful to keep those

separate.

I’d be reluctant to join the big ones together.

I actually go through all of these with all of the patients…by incorporating them together, I’m

losing that value of that (Nine Steps) message.

Group 4

The list is fine, it’s just how the list is delivered.

Health professionals also frequently reported that the importance of particular steps often change

depending on the age or current health status of the individual.

The message there (nine steps) is a generic message that has to go across, but you’d have

this message mentally divided in your mind… you probably wouldn’t tell a 68 year old person-

you wouldn’t discuss mats with them.. but you might start to talk to that person about eye

checks or blood pressure medication.

There’s an opportunity to develop resources for specific groups. Is (sic) there so many steps

for people who are frail? Is there so many steps for might have had a fall because they were

exercising and they fell? Is there a younger person (list of steps)? I think it’s (the nine steps)

good for the spectrum but there is a possibility of resources to be developed for each area.

5.4.4 Awareness of Stay On Your Feet WA Strategies

Awareness of SOYFWA strategies was explored within the health professional focus groups

before the strategies were discussed.

All four groups identified: the printed resources, SOYF Week and April No Falls Day

strategies.

Two groups identified: the community displays and SOYFWA Speaker’s Kits.

One group identified: the Volunteer Program.

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No groups identified: Radio and community newspaper media, the SOYFWA website,

video conferences, partnerships with health organisations and the WA Falls Prevention

Resource Information Centre.

Evaluation of Stay On Your Feet WA Strategies

Health professional focus groups were asked for feedback on SOYFWA strategies in terms of what works well, what doesn’t work well and where the gaps are. What Works Well? All groups reported the printed resources as working well.

One of the best things ICCWA has done for me is… it’s a very credible resource. I can be sure it’s the right message, it’s up to date and it’s a balanced message. I can pass it on to new graduates or students. If they weren’t there, you’d be drawing it up yourself so it’s very effective. I use ICCWA resources every time I see a patient.

Three groups reported SOYF Week and April No Falls Day as working well.

It’s really good the support we get to run April No Falls Day. The hospital looks forward to that day every year and they get quite excited about it. They’ve been great for us because we’ve now linked targets to those weeks and we have educational components for those weeks particularly for staff, so it’s been really useful for us to tie it in with an event each year. It reminds us. We’ve had access to grants through Stay on Your Feet Week before, and I’ve found it really useful because it’s allowed us to run activities that we may not have been able to fund otherwise.

Two groups also reported that community presentations were working well. Other strategies that were reported as working well included:

The SOYFWA E-bulletin

Have a Go Day

The Volunteer Program

Speaker’s Kits

What Doesn’t Work Well?

Three health professional focus groups reported the website as not working well.

It just needs to be updated, I think it’s very- Department of Health type of website. I think

something separate would be good. Something that is attractive to the consumer, because

we I think if we can engage with people, more and more older people are getting on the

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internet now and if there is a website that’s accessible and easy to use, it’s a good source of

information.

Two groups reported awareness and marketing of April No Falls Day and SOYF Week as not

working well.

I know we have various weeks, and they’re great and then everybody forgets about them the

following month…but we really need to have something all the time.

It’s (SOYF week) not really well known amongst allied health professionals, and I don’t know

about the community.

For Stay On Your Feet Week. We went into shopping centres and had displays and

everything. But we felt very unsupported… We managed the stalls, we couldn’t afford to

have other boards to display what it was. When it takes up three senior staff’s time it’s not

efficient. We don’t have that time allocated. It’s sort of a big commitment. There just really

isn’t much support actually to put on an event.

It (SOYF Week) might be effective if there was a more uniform approach. What should we

do? What are examples? What did they do last year? What do they do at other hospitals?

Images used in SOYFWA resources were reported as not relating to all community members, in

particular to those of ethnic backgrounds. Education of hospital staff was also reported as not

working well.

Where are the Gaps?

All four health professional focus groups reported an absence of falls prevention knowledge,

professional development and events for allied health staff at their place of employment/within

their employing organisation.

I would like to see more health professional events. Things that they have done, for physios

or health professionals have been extremely useful… and I would like to see more of it.

I think it would be valuable to have a nine steps person to provide education to the

(residential aged care) staff… it would satisfy them with their annual education requirements

and it would leave us to deal with the more difficult cases.

Two groups commented on gaps in residential aged care services.

Residential aged care is something I think we can do a lot more… we get a lot of referrals

from residential aged care facilities and we get asked to do a lot of presentations. That’s

something that we need to tailor a lot more because the nine steps, they’re relevant but I

think that this would have to take a different tack compared to somebody who’s living

independently.

Two groups reported a lack of services for regional and Aboriginal and Torres Strait Islander (ATSI)

and CaLD people.

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There’s a gap amongst the ATSI resources. There’s a need for something specific, things like if

you’re getting up off the floor it would be great to have (a picture of) a person getting up

outside somewhere in the bush… and using pictorial information.

And not brochures with the white person there, and not too written. We do quite a lot of

research in the……. area and it’s their second or third language English, so it would need to

be a different thing all together really.

Other gaps identified in the focus groups include:

Falls prevention education and awareness through technology;

Partnerships with local government;

CaLD resources and links to CaLD community groups;

Ongoing awareness of the SOYFWA program and resources;

Guidelines for falls prevention in pharmacies;

Peer education for people over 60;

Addressing societal views of falls and falls prevention; and

Using ‘life stories’ in resources.

5.4.5 Printed Resources

Impressions When community members were asked about their first impression of the resources, participants commented on their appearance.

They’re quite colourful and the pictures of the ladies and gentlemen… we can relate to. They’re very user-friendly the way they are presented.

What do community members like about the resources? All four community focus groups were in favour of the printed resources. The layout and content was complimented repeatedly.

I thought they were brilliant, I think it’s a really good program. I think it’s really improved people’s knowledge. I think they’re quite comprehensive, they give people ideas. Even if people in the community just pick them up and read them, they get quite a lot of knowledge from them. Very helpful, informative and helpful. I would read about all the changes and I would make them. They’re a good reference if … you’ve forgotten the information, they’re reliable. And if not pass them on to other people who you think might need them. I think they work well together.

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What don’t community members like about resources? This question returned very few responses. Most comments related to the inadequate dissemination of the resources more than the design or content features of the resources themselves. There was also some feedback that the resources are too ‘text-heavy’ and would benefit from more pictures, diagrams and a condensed format.

I don’t think we’re targeting the right target audience. These are all very good, but you’ll notice that it’s only people who are concerned are reading it, most of the audience that you want to get to, don’t read this stuff. Like different socio-economic groups etc, but to pick something up like that (A4 poster- How to get up off the Floor) they may well read it, because it’s got pictures in it. Show me a picture, brief description, minimum words, whereas this approach (SOYF Booklet) is only for those who are really interested and will sit down and read it. My doctor’s got a huge wooden cabinet in his waiting room with all sorts, there’s not one of the packs of these (printed resources) in there, if there was I’d take one home and read it. I would like the resources to be more concise. I’d just like one book, with everything in it that I could take home. Sometimes you can have too much of one thing lying around the house… you could condense it down, to one publication or even two… You could have a folder and keep all the information together…

Responses also referred to the images used in the booklets.

There are so many happy couples, there’s nobody on their own which is in issue in itself in terms of health, you can be happy but not happy together. There’s no photos here of someone from Asia or India, they’re all white middle class people.

Other resources that could be created Contact and referral lists and personal alarms were also mentioned in the community focus groups. In addition, some groups mentioned that they would like to see more practical guidelines around the nine steps.

If you had the contact list separate, and you could stick it on the fridge or somewhere so that if there was an emergency, that it would save having to get the book and going through and trying to find it. There is never a comprehensive guide to the services we need- personal alarms, physios, age assistance. With the dietary things… I’d like to see more of a guideline… just go in depth a bit more with your day-to-day diet. I think you need to bring in exercise advice, like a higher strength training, posture balance.

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5.4.6 The SOYFWA Website

Community members were shown the SOYFWA website and asked for their feedback Impressions First impressions of the website were a mixed reaction, with some participants in favour of the format, while others found it unappealing.

I would put it on the favourites section on my computer. Quite busy. A bit dull. (It needs) some other colours and pictures. I can’t read it (font size).

Internet use by community members Participants were asked if they would use the website for falls prevention information. The vast majority of responses suggested that paper based resources were preferred.

Well if I’ve got it all here (printed resources) then I wouldn’t need to go on the website. I actually prefer reading information in this form (printed resources) rather than reading off a computer screen. Not everybody is computer minded, I don’t have a computer.

However, a few participants suggested that they do frequently use the Internet for health information in general.

I use it (the internet) for health information all the time. What community members want for the website Most of the suggestions put forward by participants were more focused on the design and layout of the website including the use of colours and pictures. Some participants wanted the website to emulate the printed resources format.

It really needs some more pictures, I just find it uninteresting, I didn’t get past the first page. The colour of Stay On Your Feet is Blue, is there any blue there?... I think it could be a bit brighter. Just all of this (printed resources) on the website.

Some participants also suggested up to date information and tips.

What’s happening next week, or today. Tips on how to maintain health.

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Key Messages Health professionals, as the last task within their focus groups, were asked to think about the key messages for falls prevention that they would like to see in future falls prevention resources.

Be Independent

Stay Independent

Keep Moving

Safety

Active

Health

Self-Management

Look After Yourself

Stand Up for Yourself

It Can Happen to You

Prevention

Simple Changes

Help you Stay at Home

Falls not Inevitable

Falls are Not Part of Growing Older

Be Aware Focus Group Summary Community Members Community member participants engaged well in focus groups and were interested in the

SOYFWA strategies discussed. Participants preferred the terms ‘seniors’, ‘mature’ and ‘over 60’ to refer to adults aged 60 years and over. Community members suggested that nine steps were too many to use as a falls prevention message, but maintained that all steps were important. They found the resources useful, preferring printed resources, but noted that the resources did not suit everyone, were too text-heavy and could be made more available. Community members were not

in favour of the SOYFWA website due to its lack of visual appeal and small font size. Health Professionals Health professionals noted that while the Nine Steps could be condensed into a shorter list, all of the Nine Steps are important and messages could be lost in eliminating steps. Health professionals

reported SOYFWA events as working well for staff education and raising falls prevention

awareness. SOYFWA events, however, were reported as being insufficiently promoted. Health

professionals reported the SOYFWA printed materials worked very well for them, but that the website as not working well due to its similarity with other WA Department of Health websites and its lack of visual appeal. Health professionals identified professional development for health professionals, residential aged care services and resources for ATSI communities as gaps in the

SOYFWA program.

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5.5 Interviews with Volunteers

Interviews conducted with volunteers covered questions relating to the management of the volunteer program, along with their experience in volunteering with community members aged 60 and over. Responses have been themed based on popular responses from participants. 5.5.1 Motivation for Volunteering Most volunteers indicated that they participated in the volunteer program for altruistic purposes with some enjoying the social side and enjoying the attention received as a presenter. 5.5.2 Peer-based Model for Volunteers

The participants interviewed were all in favour of the use of peer-based volunteering in SOYFWA as the needs of the target group were perceived to be better addressed. Participants also were sceptical of the capacity of younger volunteers to understand health and social concerns that the target group may have. 5.5.3 Volunteering Australia Guidelines Participants were questioned on how well the program functions using areas derived from the Volunteering Australia Guidelines [30] including:

Recruitment, selection and orientation

Training

Management

Policy and

Recognition ICCWA generally received positive comments on all areas, in particular the recognition that volunteers were provided. All participants cited certificates and events as being an appropriate reward for their efforts. In addition some aspects of the training program were praised including the use of guest speakers and support meetings. It was, however, reported that the length, depth and consistency of training programs had declined over the years which was explained by two participants as being the result of a high staff turnover. 5.5.4 Use of Speaker’s Kit Many volunteer presenters relished the opportunity to individualise their presentation through personal stories which were reported to provide the presenter with a degree of confidence and comfort. However comments from some participants demonstrated significant deviation from the script by focusing on some steps and not others, and providing their own statistics. Many participants only supported the introduction of a new or revised script on the condition that they were still permitted to add their individual touches.

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6.0 Discussion

Instruments used to evaluate SOYFWA awareness and strategies have revealed largely consistent results with some contrast found in opinions regarding the Nine Steps to Stay on Your

Feet and April No Falls Day.

6.1 Awareness of SOYFWA

Results from the CATI showed a low awareness of SOYFWA with only 27% of adults aged 60 or

over recognising SOYFWA when prompted and 7% unprompted. However the 2006 SOYFWA program evaluation revealed an unprompted brand awareness of 5%, which indicates a 2% rise in

awareness of SOYFWA. The mass media campaign which ran from 2005-2006 was responsible

for 56% of the target group being aware of SOYFWA at that time. This evaluation identified community newspapers (17.3%), community events (16.7%) and brochures (13%) to attribute the most to awareness. Television advertising accounted for a remarkable 11.7% despite the absence of television advertising since 2006. The program also compared well with other falls prevention programs with 5% of participants identifying Living Longer, Living Stronger (unprompted) and 1.2% identifying Stepping Out (unprompted).

Awareness of SOYFWA was high amongst health professionals (94%), however, given recruitment sources were primarily from the ICCWA database this was not surprising. Email (61%), resources (51.5%) and the website (48.5%) were the most common media for health professionals

in terms of branding awareness. Despite its population-based approach, awareness of SOYFWA

in health professionals could benefit from the integration of the SOYFWA program into clinical practices and policies.

6.2 Nine Steps to Stay on Your Feet

Reported preferences for the components of the Nine Steps to Stay On Your Feet varied with the evaluation instruments, although Be Active and Improve Your Balance were consistently voted the most important. The majority of participants across evaluation tools agreed that all the Nine Steps are essential for falls prevention. Some health professionals have noted that the Nine Steps are a useful tool for falls risk assessments and personal action plans. Therefore, elimination of any of the steps could have an adverse effect in organisations where falls prevention knowledge and training are limited.

The evaluation has revealed that ‘how’ the Nine Steps to Stay On Your Feet are used should be strongly considered. Of the 9% of community members who were aware of the Nine Steps to Stay

On Your Feet, recall of the actual steps ranged from 15% to 44.4% indicating that unprompted recall of ALL Nine Steps as a falls prevention message may be unrealistic. Some health

professionals suggested condensing the Nine Steps to Stay On Your Feet, however this was countered by other health professionals claiming that key messages would get lost. Other health

professionals proposed a tailored use of the Nine Steps to Stay On Your Feetin a clinical setting based on the community member’s age and physical condition. The latter was forwarded as a more appropriate option as age brackets are not always representative of a person’s mobility and health needs. Volunteer presenters also suggested tailoring the presentation of the Nine Steps to

Stay On Your Feet based on the health needs of the audience, however this may prove problematic at community events with a range of attendants.

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6.3 April No Falls Day and SOYF Week

April No Falls Day was found to be less popular than SOYF Week with 41.6% of health

professionals participating in April No Falls day compared to 66.5% for SOFY Week. This was attributed to the differing levels of awareness and perceived effectiveness between the strategies. In addition, the minority (41.8%) of participants who were aware of April No Falls Day said that it

did not assist their organisation as opposed to 55.8% for SOYF Week. Further qualitative analysis has revealed that the use of a ‘day’ was challenged by some health

professionals. SOYF Week was seen as providing a platform for organisations to run education and training sessions for staff over the course of a week, which may be preferable to the April No Falls Day due to time and scheduling constraints. In addition, the use of grants provided some

organisations with the capacity to run projects during SOYF Week. However, other health professionals supported April No Falls Day, stating that it serves as a

reminder and increases awareness of falls prevention between SOYF weeks. Time and financial constraints of participating in April No Falls Day were noted by some health professionals who suggested that more direction and resource packages are necessary to improve participation.

Proposed improvements for SOYF Week were centred on including more Aboriginal and Torres Strait Islander (ATSI) people and regional communities. In addition, health professionals noted that regular attendants at these events are usually by people who are already actively reducing their risk of having a fall, and there needs to be more attention directed at high risk community members.

6.4 SOYFWA printed materials

Printed materials have been identified as an effective resource by both community members and health professionals. Community members found the resource to be a practical tool with suggestions for referral lists to be added as a separate resource, rather than be included in the booklet. The expert review conducted on printed materials suggested that some of the font (size and density) and language be reviewed with suggestions of defined terminology and matching text and pictures also noted. Health professionals have identified the printed resources as providing them with more assistance

than any other SOYFWA strategy. Resources were found as an indispensable tool for health professionals with limited falls prevention knowledge or limited time to discuss falls prevention with community members. However, telephone interviews revealed that many health professionals were not aware of the full range of printed materials and may have benefited from having better access to them. Other health professionals suggested that some materials needed to be redesigned. Health professionals also suggested that distribution channels should be reviewed.

6.5 SOYFWA Website

Website awareness (2.2%) and use (0.4%) by community members was very low. Preferences were given to printed resources. The website was criticised for its lack of visual appeal by both community members and health professionals. Health professionals said the website was easy to navigate and provided satisfactory information with potential to include more evidence based materials.

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Internet use by community members aged 60 and over was investigated via focus groups and yielded mixed responses. While some participants reported that they use the Internet for health information, others reported that they were computer illiterate. Some health professionals were also quick to discount online resources as suitable for people aged 60 and over while some recognised its value. Community members demonstrated a strong preference for printed resources over online resources.

6.6 SOYFWA Falls Resource Information Centre

The Centre did not perform well overall in the evaluation. Community members awareness of it was low (6.4%) and it was not a favoured means of receiving information (5.4%). Use of The Centre by health professionals was also low (30% of those who are aware of it). The Centre was however, found to be a useful resource for those who did use it. Preferences for additional services to be provided by The Centre were awarded to referral information on aged care assessment services, community physiotherapy services and falls/ mobility clinics. Evaluation instruments, coupled with the literature have suggested that a sizeable gap exists in the referral and cross-referral of falls prevention services and resources within existing health networks. Health professionals have indicated a need for education and resources which can be used in a clinical setting. Increased awareness and subsequent use of The Centre may work address these issues.

6.7 Volunteer Program, Speakers Kits and Presentations

Consultation with SOYFWA volunteers has shown the peer-based model for the volunteer program to work well. Guidelines set forth by Volunteering Australia have been found to be addressed, with the training of volunteers the only exception. Interviews with volunteers have identified the lack of consistency between training programs for volunteers which could benefit from a more stringent policy. In addition, community presentations were found to differ substantially in their content and format which proposes a review for presentation guidelines.

6.8 SOYFWA Services, Support and Communication

Community members benefited the most from printed materials as a source of falls prevention information, with brochures (30%) and booklets (25%) achieving a higher preference than consultations with health professionals (23%). Unfortunately, the material was found to be reviewed primarily by proactive community members who have already addressed many falls risk factors, or by community members who have recently had a fall. There exists a challenge in disseminating information to community members who are at high risk and/or have not recently had a fall. Health professionals reported feeling very supported (20.3%) and supported (48.5%) by

SOYFWA. Preferences for services were awarded to workshops (61.3%) and the website (50.5%). Health professionals also suggested the addition of training and education services and services for regional communities.

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6.9 The SOYFWA Program

As a population-based program, SOYFWA strategies target both community members and health

professionals working in the falls prevention field. As a suite of strategies, SOYFWA addresses these target groups through increasing awareness of falls prevention, as well as the provision of resources and services that work to reduce falls. The suite of strategies cover most areas of falls prevention services with the residential aged care services and education/training programs being the largest gaps identified. However, there does appear to be some overlap in strategies such as

April No Falls Day, SOYF Week and community presentation which could benefit from clear objectives and protocols being developed for each strategy. In addition, health professionals have requested comprehensive but easy-to-follow directions and resources for running events amidst their already heavy workloads. Community Members As a multi-faceted health issue, falls prevention provides a challenging context for community members to address and reduce associated risk factors. The provision of printed materials has been found by both community members and health professionals, to be a valuable tool for informing community members of the necessary steps to take. Across evaluation tools and strategies, access to high-risk community members remains a considerable challenge for

SOYFWA strategies to address. In addition, services and resources for regional and ATSI communities have been consistently identified through evaluation instruments as a gap in falls prevention programs. Health Professionals

Health professionals have complimented the services and resources provided by SOYFWA. However, integration of training and resources into clinical practice has been proposed as the next step. Facilitating communication, resources and services between falls prevention networks has also been identified as a significant gap in Western Australia. The literature has identified the WA Model of Care for Falls Prevention as a powerful framework for the provision of evidence based research and services for falls prevention across settings and target groups, which will assist

SOYFWA in this endeavour.

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7.0 Recommendations and Conclusions

1. Program Awareness

Community Members

Expand awareness of SOYFWA in populations with low awareness and high risk; male community members and community members living in southern regional communities.

Utilise effective and acceptable mediums (community newspapers, events and brochures) and review ineffective mediums (the website and GPs).

Investigate the cost effectiveness of mass-media strategies including radio or local television.


Expand awareness of SOYFWA through existing and new falls prevention and allied health and other non-traditional networks.

Utilise effective and acceptable mediums (email and printed resources) and review ineffective mediums.

2. Utilisation of the Nine Steps to Stay On Your Feet

Community Members

Use the Nine Steps to Stay On Your Feet as a falls prevention tool (not a falls prevention message). Develop a more succinct message for falls prevention.

Provide practical guidelines on how to use the Nine Steps to Stay On Your Feet including available health and wellbeing services.

Consider creating sub-groups of the target population based on their risk of falls due to existing health issues. Identify the level of importance of each of the Nine Steps to Stay On

Your Feet to these groups (see example in Figure 2 below).

Figure 2. Importance of the Nine Steps to Stay On Your Feet for subgroups (example)

The Nine Steps Stage A: Does not have any

core activity limitations

Stage B: Has one or more

core activity limitations

Stage C: Higher Needs, requires care

Be Active

Manage Your Medicines

Manage Your Health

Improve Your Balance

Walk Tall

Foot Care and Safe Footwear

Regularly Check Your Eyesight

Eat Well For Life

Identify, Remove and Report Hazards

*Core activity health limitations= self-care, mobility or communication limitations [4]

KEY: = Very Important = Fairly Important = Somewhat important

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Use the Nine Steps to Stay On Your Feet to create clinical resources to inform risk assessments and personal action plans for health professionals.

3. Reach of SOYF Week

Engage more ATSI, CaLD and regional communities in projects during SOYF Week

including SOYF Week Grants.

4. Review of April No Falls Day

Reconsider the use of a ‘day’, investigate what a ‘day’ is best used for.

Reconsider the objectives of the day- Aim for awareness over behaviour change.

Amend and simplify the ‘April No Falls Day Event Coordinator’s Pack’ (Consider testing with

health professionals).

Create a more uniform approach to events held on April No Falls Day.

5. Review of Website (Currently under construction from the Department of Health)

Review font size, colour and use of graphics.

Include more evidence-based materials for health professionals.

Upload printed materials in a printable format online.

Provide links to health and community services appropriate to adults aged 60 and over.

Create an interactive website with online risk assessment tools.

6. Design and Content of New Printed Materials

Use size 14 font.

Consistently use dark fonts on light backgrounds.

Provide ‘white space’ around text heavy areas.

Use simple language and define complex words and terms.

Use the words ‘senior’, ‘over-60’ or ‘mature’ when describing the primary target group.

Only use the term ‘higher needs’ to describe people in need of care and assistance.

7. Additional Printed Resources

Create a suite of resources for health professionals including:

A residential aged care resource.

A clinical risk assessments resource.

A stand-alone referral contact list for health professionals.

Create a stand-alone referral contact list for community members.

Create resources for community members with visual impairment, cognitive impairment

and bladder and bowel incontinence.

Create a resource with practical guidelines to the Nine Steps to Stay On Your Feet e.g.

exercise plans, how to manage medicines.

Review ATSI and CaLD resources working closely with members of the target group when

developing new resources.

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8. Testing Printed Materials

Conduct a SMOG analysis on all new printed resources.

Conduct focus groups with members of target groups for new printed resources at both

the development stage and when pre-testing before undertaking large print runs.

9. Volunteer Program and Presentations

Develop a structured a consistent training program for volunteers.

Develop guidelines for the content and presentation style of presentations

Audit community presentations.

10. The Centre- referrals and services

Export some of the services that are provided by The Centre to the SOYFWA Website

including referral services and printable resources.

Review the role of The Centre after the launch of the new SOYFWA Website.

Expand service referrals to include (in order of preference):

o Aged Care Assessment

o Community Physiotherapy Services

o Falls/ balance/ mobility clinics

o Living Longer, Living Stronger TM

o Home Medication Review

o Falls Specialist Program

o Carelink and Respite Services

o Rehabilitation In the Home

o Enhanced Primary Care Program/ Medicare Benefits Scheme Primary Care Items

o Over 75 years health check up

11. Communication with Community Members and Health Professionals

For communication with community members use: brochures/booklets; health

professionals; and the new website.

For communication with health professionals use: email; the website and newsletters.

12. Residential Aged Care Services (Currently being developed by SOYFWA)

Conduct presentations to residential aged care.

Create resources specific to residential aged care.

13. Education and Training of Health Professionals (Currently being developed by SOYFWA in

partnership with Falls Specialists. Education and training of Health Professionals is currently conducted

at Falls Prevention Events (e.g. G.P Network State Forum) and through videoconferencing)

Conduct professional development education and training sessions in new settings e.g.

residential aged care facilities.

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Provide online and/or printed training modules for falls prevention for health

professionals.

Stay on Your Feet has been both a community awareness message and an umbrella term for the

population-based falls prevention strategies. It has been successful in many facets, such as

coordination of a single unifying message to society, and acceptance in the WA falls prevention

community as evidenced by the recommendations in the WA Model of Care.

The success of this overall message may be improved by greater coordination with other WA falls

prevention strategies, to extend aspiration or vision to provide a clearer picture of short and long

term objectives, for both the whole suite of strategies as well as each strategy. The message and

information can be further targeted for different audiences, in concert with other population-

based interventions such as active or healthy ageing and injury prevention. Policy and program

initiatives will benefit from a coherent mix of top-down and community development approaches.

Ongoing evaluation should use a mix of continuous improvement/incremental modifications to

content and design, as well as medium term reviews. Evaluation can include meeting primary and

secondary outcomes, informed by objectives. This combined with changes in the research base

and societal norms, can provide guidance for future development.

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27. ABS, Adult Literacy and Life Skills Survey, 2006, Australian Bureau of Statistics: Canberra. 28. Australia, H.W. Aboriginal and Torres Strait Islander Health Worker Project Environmental Scan.

2011 January 7 2013]; Available from: http://www.hwa.gov.au/sites/uploads/aboriginal-torres-strait-islander-health-worker-project-environmental-scan-version7.pdf.

29. Birch, J., Worldwide prevalence of red-green color deficiency. Journal of the Optical Society of America, 2012. 29(3): p. 313-320.

30. Volunteering Australia, National Standards for Involving Volunteers in Not-for-Profit Organisations, 2001, Volunteering Australia: Victoria.

31. Gillespie Lesley, D., et al. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 2009. DOI: 10.1002/14651858.CD007146.pub2.

32. Cameron Ian, D., et al. Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database of Systematic Reviews, 2010. DOI: 10.1002/14651858.CD005465.pub2.

33. Campbell AJ, R., M.C., Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized, controlled trial. Journal of the American Geriatrics Society 1999. 47(7): p. 850.

34. Pit, S.W., J. E. Byles, Henry, D.A, Holt, L., Hansen, V., Bowman, D.A., A Quality Use of Medicines program for general practitioners and older people: a cluster randomised controlled trial. Medical Journal of Australia 2007. 187(1): p. 23.

35. Zermansky, A.G., Aldred, D.P., Petty, D.R., and Raynor, D.K., Striving to recruit: the difficulties of conducting clinical research on elderly care home residents. Journal of the Royal Society of Medicine, 2006. 100(6): p. 258-261.

36. Crotty, M.R., D., Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial. The American journal of geriatric pharmacotherapy, 2004. 2(4): p. 257-264.

37. Burleigh, E., J. McColl, and J. Potter, Does vitamin D stop inpatients falling? A randomised controlled trial. Age and Ageing, 2007. 36(5): p. 507-513.

38. Gates, S., Yano, E., Saliba, D., Shekelle, P.G., Design of a continuous quality improvement program to prevent falls among community-dwelling older adults in an integrated healthcare system. BMC Health Services Research, 2009. 9(206): p. 1-11.

39. Polinder, S., et al., Systematic review of general burden of disease studies using disability-adjusted life years. Population Health Metrics, 2012. 10(1): p. 21.

40. Davis, J.C., Robertson, M.C., Does a home-based strength and balance programme in people aged >= 80 years provide the best value for money to prevent falls? A systematic review of economic evaluations of falls prevention interventions. British Journal of Sports Medicine, 2010. 44(2): p. 80-89.

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41. Frick, K.D., Kung, J.Y., Evaluating the Cost‐Effectiveness of Fall Prevention Programs that Reduce Fall‐Related Hip Fractures in Older Adults. Journal of the American Geriatrics Society, 2010. 58(1): p. 136-141.

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9.0 Appendix

9.1 Efficacy of interventions in falls prevention

The evidence for efficacy of a number of interventions is relatively strong, particularly in areas frequently

studied such as exercise, medication usage, environment modification and multifactorial interventions.

Exercise

For example, exercise programs for community dwelling older people with more than one category of

exercise (e.g. Strength, balance) are considered effective in reducing both risk of, and rate of, falling [31].

These multi-component exercise programs seem effective in both high and low risk populations. The types

of exercise programs studied and determined to be effective include multi-component group exercise, with

Tai Chi as a specific form of this [3], and home based individually prescribed programs. It is not certain what

components matter in these exercise programs, but balance is considered important. Together with

research to determine the effective exercise components, there is need for further study on dosage, mode

of delivery, and compliance.

In contrast to community-dwelling populations where exercise programs are considered effective [31], the

evidence for exercise programs in hospital and residential care settings is more conflicted [32]. Supervised

exercise programs in subacute hospital settings may be effective. Multi-component exercise in nursing

homes saw an increase in falls. The authors concluded that this result may be due to differences between

community-dwelling and nursing home participants, providers of the interventions, type or intensity of

exercise, or time period of review [32].

Medication usage

The research on medication has included polypharmacy, psychotropic medication use, and Vitamin D

supplementation. From their systematic review of RCTs, Gillespie et al. concluded that there was limited

evidence for the effectiveness of interventions to address medication usage in community-dwelling older

people [31]. The gradual withdrawal of psychotropic medication reduces the rate of falls, but not risk of

falling [31, 33]. The risk of falling for their clientele was reduced by an education program for primary care

physicians [34].

There is also limited evidence for intervention with older people in transition from hospital either back to

community or entering a nursing home for the first time. A medication review by a pharmacist

communicated to the primary care physician reduced the rate of falls [35]. However, use of a pharmacist

transition coordinator did not reduce the rate of falls compared with usual care [36]. Both these studies

had limited follow up for rate of falls, respectively around six and two months.

Vitamin D supplementation

Despite substantial study, vitamin D supplementation has shown some inconsistent results and its value

remains unclear [31]. The evidence seems to be that vitamin D supplementation is not independently

effective in reducing falls across groups of older people, but may be for certain sub groups. For example,

vitamin D supplementation in nursing homes is effective [32], but not in hospitals [37]. Supplementation

may be effective in reducing rate and risk of falls in people with pre-existing lower vitamin D levels [31].

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Impairments

Whilst broadly effective, there is limited evidence for exercise programs in some specific subgroups, such as

people with severe vision impairment and people with mobility problems [31]. Cataract surgery on the first

eye reduced the rates of falls, but not risk factors or rates of injuries. Pacemakers reduced rate of falls in

people with carotid sinus hypersensitivity.

Multiple and multifactorial interventions

In a previous systematic review, Gates et al. concluded that “Evidence that multifactorial fall prevention

programmes in primary care, community, or emergency care settings are effective in reducing the number

of fallers or fall related injuries is limited. Data were insufficient to assess fall and injury rates [38].

Pooled data from multifactorial trials showed a significant reduction in hip fractures, but not rate of falls or

risk of falling in nursing homes [32]. Longer stay hospital patients may be at lower risk of falling following

multifactorial studies. Many of the included studies include exercise which is independently effective, and it

is unclear how individual factors contribute to the evidence, both in independent and interactive effects.

Economic evaluation

The quality of economic evaluation studies in the injury prevention field has been questioned, with

differences noted in methodology including type of evaluation, cost categories and perspective (e.g.

whether all direct and indirect societal costs or health system costs), outcomes and time horizon. These

authors found that the most commonly studied interventions in injury prevention were hip protectors and

exercise programs for older people.

Economic studies of falls prevention can take four major forms, analysis of cost minimisation, cost

effectiveness, cost benefit and cost utility [39]. Most economic studies to date report in the first two forms

(i.e. costs of intervention, or costs per fall averted), rather than net monetary benefit or cost per QALY

which can include other effects on quality of life [2]. Most studies also report on single interventions rather

than a comparison between different interventions.

There is some evidence that falls prevention strategies can be cost saving. In a systematic review of

economic evaluations in falls prevention, Davis et al. concluded that the Otago home-based exercise

program in people over 80 years, individually customised multifactorial program for people with four or

more of the eight targeted risk factors, and a home safety program in a subgroup of people with a previous

fall were cost saving [40].

Frick et al. and Church et al. estimated falls prevention interventions cost utility [2, 41]. Both concluded

that Tai Chi particularly and other forms of group-based exercise are cost effective in the general

population of older people, as was controlled withdrawal of psychotropic medication . Group-based

exercise and home assessment/modifications are the most cost-effective in high risk populations. Cardiac

pacing was also cost effective, with inconsistent conclusions on cataract surgery and vitamin D [2, 41].

Issues

As can be seen above, a number of interventions have been found to be effective in reducing risks of falls,

rates of falls, and/or injuries from falls. However, there are issues with effectiveness in subgroups of the

older population, such as frailer people, people in residential care [32]. In some cases, broadly effective

interventions may not only be ineffective in these subgroups, but may cause adverse effects.

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Other issues include factors such as method of delivery of intervention, dosage and ongoing compliance

and adherence. There is ongoing work on delivery by education, individual and group supervision, by

professionals and peer facilitators. Adherence rates with home exercise programs have been found to be

relatively low[42]. Further research is indicated to examine the dose–response relationship between the

prescription of exercise and the prevention of falls.

Consensus based guidelines

Research has provided a large body of evidence on falls prevention interventions. However, there are

obvious limitations to applying this research in practice. Features such as the overall complexity,

heterogeneity and multifactorial nature of falls have contributed to recent widespread development of

guidelines that form expert consensus on best practice [7]. These are available for many countries

internationally, and also for Australia and its jurisdictions.

See: Australian Commission on Safety and Quality in Health Care:

http://www.safetyandquality.gov.au/publications-resources/publications/?acsqhc_programs=16

http://www.safetyandquality.gov.au/publications-resources/publications/?acsqhc_programs=16

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9.2 SMOG Calculation Procedure

SMOG technique from McLaughlin (1969): 10 consecutive sentences are taken from each booklet or pamphlet from near the beginning, middle and end. Words with 3 or more syllables are counted – including repetitions. A sentence is considered to be a string of words punctuated with: . ! or ? Hyphenated words were counted as one word and abbreviations and numbers are counted as they are spoken aloud. This review did not include titles or subtitles as sentences as - as some would be considered a sentence by the SMOG criteria (as they end in a full stop or ?) while others would not as they had no punctuation at the end. Occasional bullet point lists in the materials are thus counted as one sentence if they do not contain full stops at the end of every point. All text including the ‘case studies’ presented in dark boxes and white text were included. Pamphlets with less than 30 sentences used the revised SMOG technique recommended by the National Cancer Institute. (2002). Making health communication programs work. (2nd ed.). http://www.cancer.gov/cancertopics/cancerlibrary/pinkbook COMMUNITY Community Booklet: 10 sentences taken from beginning (page 2 ‘Introduction’), 10 sentences taken from middle (page 28-30 ‘Walk Tall’) and 10 sentences taken from end (page 44 “Indentify, Remove and Report Hazards’). 106 words with three or more syllables per sentence = approx grade 13 (first year university). Home Safety Checklist: Pages 3, 7 and 11 used to calculate SMOG. 53 words with three or more syllables per sentence = approx grade 10. SMOG = 53, Grade 10. How many of these questions do you fall down on? (Self test questionnaire). Only 23 sentences in entire pamphlet. SMOG 32 words = Grade 9. Are your shoes safe? (Self test questionnaire). SMOG = Grade 6-7. HIGHER NEEDS Higher Need Booklet:10 sentences taken from beginning (pages 6-7 ‘Step 1 Be Active’), 10 sentences taken from middle (pages 18-19 from ‘Step 7 Regularly Check Your Eyesight’) and 10 sentences taken from end (pages 24-25 ‘Falls Action Plan’). 84 words with three or more syllables per sentence = approx grade 12. Higher Need Brochure: Only 23 sentences in entire pamphlet. SMOG 61 words = Grade 11 HOSPITAL BROCHURES Information for patients in hospital: Only 23 sentences in entire pamphlet. SMOG 44 words = Grade 10 Information for family and friends of patients: Only 23 sentences in entire pamphlet. SMOG 52 words = Grade 11 Information for patient discharge: Only 24 sentences in entire pamphlet. SMOG 76 words = Grade 12-13 ABORIGINAL RESOURCE Falls prevention for Aboriginal people booklet: 10 sentences taken from beginning (page 4), 10 sentences taken from middle (pages 9-10) and 10 sentences taken from end (page 14). 88 words = approx Grade 12.

http://www.cancer.gov/cancertopics/cancerlibrary/pinkbook

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