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Table of Contents
RESEARCH ARTICLE
Year : 2019  |  Volume : 20  |  Issue : 1  |  Page : 28-32

Effect of a Risk Reduction Intervention Strategy on Caregiver's Knowledge, Attitude and Practice related to Fall Prevention


1 College of Nursing, CIHSR, Dimapur, Nagaland, India
2 College of Nursing, CMC, Vellore, Tamil Nadu, India
3 Department of Community Health, CMC, Vellore, Tamil Nadu, India
4 Department of Biostatistics, CMC, Vellore, Tamil Nadu, India

Date of Web Publication09-Oct-2019

Correspondence Address:
Mrs. Imnainla Walling
College of Nursing, CIHSR, Dimapur, Nagaland
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCN.IJCN_13_19

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  Abstract 

Falls are the main cause of morbidity and disability in the older adults. The risk doubles or triples in the presence of history of previous falls. This study aimed to assess the frequency of falls and associated risk factors in older adults and the effect of a risk reduction intervention strategy on knowledge, attitude and practice related to falls prevention among the caregivers of older adults. One group pre-–post-test study design was used. A total of 60 older adults and 60 caregivers were selected using simple random sampling method. Data were collected using the fall assessment questionnaire for frequency of falls among older adults. Majority, i.e., 42 (70%) of the older adults had no fall and 18 (30%) of the older adults had falls during the last 5 years. The overall mean score of pre-test knowledge of the caregiver was 14.08 and the post-test was 37.90, and the difference was statistically significant (P < 0.001). The mean score of pre-test practice was 9.45 whereas the post-test was 17.53, and the difference was statistically significant (P < 0.001). In the current study, 40 (66.7%) caregivers had favourable attitude at both before and after intervention. There was a significant difference (P < 0.001) in the overall mean of existence of short-term modifiable risk factors before and after the risk reduction intervention strategy.

Keywords: Falls, older adults, caregivers, risk reduction intervention strategy, fall prevention


How to cite this article:
Walling I, Siva R, Immanuel SG, Abraham VJ, Gowri M, Simpson C. Effect of a Risk Reduction Intervention Strategy on Caregiver's Knowledge, Attitude and Practice related to Fall Prevention. Indian J Cont Nsg Edn 2019;20:28-32

How to cite this URL:
Walling I, Siva R, Immanuel SG, Abraham VJ, Gowri M, Simpson C. Effect of a Risk Reduction Intervention Strategy on Caregiver's Knowledge, Attitude and Practice related to Fall Prevention. Indian J Cont Nsg Edn [serial online] 2019 [cited 2019 Dec 14];20:28-32. Available from: http://www.ijcne.org/text.asp?2019/20/1/28/268691


  Introduction Top


With a falling birth rate and people living longer, there is a larger population of older adults in the community. It is no surprise that geriatric medicine, the medical care of the older adults, has quickly evolved into a major specialty. According to the United Nations population division, the number of people over 60 years of age is projected to grow from under 800 million currently (representing about 11% of the world's population) to over two billion by 2050 (accounting for about 22% of the world's population).[1] A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level. Falls are among the most common and serious problems for older adults. Falls are associated with an increase in morbidity and health care utilisation resulting in increased healthcare costs. Furthermore, people who have sustained a fall, are at a greater risk of falling again.[2]

Falls are the second leading cause of accidental or unintentional injury deaths worldwide. Each year, an estimated 424,000 individuals die from falls globally, of which over 80% are in low- and middle-income countries. Adults older than 65 suffer the greatest number of fatal falls and 37.3 million falls that are severe enough to require medical attention occur each year. The incidence of falls and severity of falls-related complications rise steadily after the age of 60. In the age of 65 years and over as a whole, approximately 35%–40% of community dwelling, generally healthy older people fall annually. After the age of 75 years, the rates are higher.[3] Falls are associated with considerable mortality, morbidity, reduced functioning and lead to premature nursing home admissions. Falls generally result from an interaction of multiple and diverse risk factors many of which can be corrected. The interaction is modified by age, disease and the presence of hazards in the environment.

A multifactorial fall risk assessment is recommended for all older adults who present for medical attention after a fall or who have gait or balance problems. This assessment assists with the identification of modifiable risk factors and with the implementation of targeted interventions for falls prevention.[4] A cross-sectional survey was carried out among 300 persons (≥60 years), sampled from urban, rural and slum areas of Chandigarh, India. About 31% (92/300) respondents reported one or more falls in the previous year. On an average, 0.67 fall episodes occurred/person/year (202/300). Most (68%; 63/92) falls occurred at home; 75% (47/63) occurred while carrying out activities such as toileting, bathing, sleeping and eating.[5]

A cross-sectional study was undertaken in Vellore, South India, to describe the knowledge, attitude and practice regarding prevention of recurrent falls among older adults with a previous history of fall and their caregivers. The study results revealed that 45% of the older adults had a repeat fall after the age of 60 years owing mainly to poor vision, osteoporosis, anaemia or the use of more than 3 chronic medications. Both the older adults and the caregivers were found to have poor knowledge regarding prevention of falls. Health education (odds ratio [OR] 0.418; 95% confidence interval [CI]: 0.176–0.991) and compliance to a prescribed intervention for at least 6 months (OR 0.088; 95% CI: 0.032–0.244) were found to be associated with less falls recurrence. Health education with emphasis on the benefits of compliance to prescribed interventions may help prevent recurrent falls.[6]

In a study done by D'souza et al.,[7] 190 older adults between the age of 60 and 93 years volunteered to participate. The mean age of the participants was 69.33 years. The sample included 81 older women and 109 older men. Older adults who participated in this survey were recruited from homes, parks, temples, churches and old age homes in Manipal. Among the study participants, 72 older adults (38%) had a history of fall, 47% women fell as compared to 31.2% men, 58.6% using mobility aids for ambulation had a fall as compared to 34.2% older adults not using mobility aids.

Evidence from literature reveals falls as common occurrence in older adults. Due to low education and lack of knowledge, some caregivers fail to exercise coherent actions for the safety of the older adults. Education and guidance with regard to preventing falls and promoting safety should be a priority for caregivers and other family members and even the very older adults. This will help them to identify the risk factors and promote knowledge on modifying environment in reducing falls.[5],[6]

Objectives of the study

  • To identify the frequency of falls in the older adults
  • To assess the effectiveness of a risk reduction intervention strategy on falls prevention
  • To determine the association between risk factors for falls and selected demographic variables of the older adults
  • To determine the association between risk factors for falls and frequency of falls among the older adults
  • To determine the association between changes in knowledge, attitude, practice and selected demographic variables among the caregivers
  • To determine the relationship between knowledge, attitude and practice of caregivers before and after the educational programme of risk reduction intervention strategy on falls prevention.


Conceptual framework

The conceptual framework of the study is based on general systems model as described by Von Bertalanffy[8] who wrote that every organism represents a system, which is a complex of elements on mutual interaction [Figure 1].
Figure 1: Conceptual framework based on general systems model by Von Bertalanaffy

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  Methods Top


One group pre-–post-test research design was used in the study. The study was conducted in a selected urban area in Vellore district, South India. The instruments used were structured questionnaire prepared by the investigator which consisted of demographic variables, checklist of short-term and long-term modifiable risk factors for falls which consisted of 18 items, semi-structured questionnaire with fifty items to assess the knowledge of caregivers, Likert scale for measuring attitude of caregivers with five items and semi-structured questionnaire to assess the practice of caregivers with twenty-two items. Content validity of the instrument was done by six experts in the field of community health nursing, medical nursing, statistics and community health. The feasibility of the methodology and instrument was checked by conducting the pilot study. The content validity was calculated for each item, and the score for content validity index was 0.91.

Data collection procedure

The individuals were selected by simple random sampling from selected streets of a village. After explaining the purpose of the study, written consent was obtained from the individuals who fulfilled the inclusion criteria. The sample size was calculated using the formula 4pq/d2, where P = 14% which was taken from the study 'Falls in Older People' by Krishnaswamy and Usha,[9]n = 4pq/d2. The sample size was 60. The study included older adults both men and women who were 65 years and above, who could communicate in Hindi and English and their caregivers who were family members who attended to all the needs of the older adults. Bedridden older adults who were critically ill, mentally ill, unconscious and/or living were excluded from the study. The study was approved by the institutional review board for research and ethics. A written consent was obtained from the older adults and their caregivers.

Pre-test was conducted to assess the associated risk factors for falls, frequency of falls, knowledge, attitude and practice on falls prevention with the questionnaires. Risk reduction intervention strategy was given as one to one educational session for 45 min using discussion, demonstration and slide show to the caregivers and older adults. The session included risk factors of falls, measures to prevent falls and necessary modifications in the home environment and falls prevention among older adults. Doubts were clarified. Every day, 4–5 older adults and their caregivers were assessed and educated. After 3 weeks of education programme, post-test was conducted for the caregivers.


  Results Top


Demographic data of the older adults revealed that majority (81.7%) of the older adults were between 65 and 75 years of age. The mean age was 71.4 (standard deviation [SD] = 8.3). Majority (60%) were females, 33 (55%) of the older adults were married, 32 (53.3%) of them were illiterate, 52 (86.7%) of the older adults lived in joint families, majority (70%) of the older adults had more than 10 family members and all 60 (100%) older adults belonged to Muslim religion. All 60 (100%) lived in pukka houses.

More than half (53.3%) of the caregivers belonged to 18–30 years of age. The mean age was 29.9 (SD = 7.05), majority (90%) of the caregivers were females, 47 (78.4%) were married and 32 (53.3%) of them were unemployed. About half (53.3%) of the caregivers earned < Rs. 5000 as family income/month. The mean family income/month was Rs. 5641.7 (SD = Rs. 3162.4).

[Figure 2] illustrates that majority, i.e., 42 (70%) of the older adults had no fall, 12 (20%) of the older adults fell once and 6 (10%) of the older adults fell more than once within the last 5 years. The present study assessed existence of short-term and long-term modifiable risk factors for falls among the older adults. Assessment of the short-term modifiable risk factors showed that majority, i.e., 58 (96.7%) houses had household articles in the pathway and also had slippery floors, 43 (71.7%) had household articles kept beyond easy reach of the older adults and 35 (58.3%) had inadequate lighting. Assessment of the long-term modifiable risk factors showed that 32 (53.3%) of the houses had uneven floors, 29 (48.3%) had steps at raised level, 13 (21.7%) had household fixtures and 11 (18.3%) had absence of handrails.
Figure 2:Distribution of frequency of falls among the older adults

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The pre-test revealed that only 50% of caregivers had adequate knowledge on fall prevention in older adults; but, after the education intervention, all (100%) the individuals had adequate knowledge. Majority, i.e., 40 (66.7%) of the caregivers had favourable attitude in both pre-test and post-test. There was no change in attitude related to fall prevention in caregivers after the intervention. Half of the caregivers had satisfactory practice in pre-test, whereas in the post-test, all 60 (100%) the caregivers had satisfactory practice on prevention of falls in the older adults [Figure 3].
Figure 3:Distribution of caregivers based on knowledge, attitude and practice in pre- and post-test

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Overall mean score of pre-test knowledge was 14.08, whereas the post-test knowledge mean score was 37.90. There was significant difference between the pre-test and post-test mean score (P< 0.001) with regard to knowledge of the caregivers. The mean score of pre-test practice was 9.45, whereas the post-test practice mean score was 17.53. There was significant difference between the pre-test and post-test mean score (P< 0.001) with regard to practice of the caregivers [Table 1].
Table 1: Comparison of pre- and post-test overall mean score of knowledge and practice of caregivers on falls prevention among the older adults (n=60)

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A positive correlation (P< 0.001) was identified between knowledge and practice of caregivers regarding falls prevention among the older adults at home [Table 2]. There was no significant association between inadequate lighting, slippery floors and demographic variables of older adults for falls. There was no significant association between short-term modifiable risk factors for falls and frequency of falls among the older adults. There was no significant association between long-term modifiable risk factors for falls and frequency of falls among the older adults.
Table 2: Correlation between knowledge, attitude and practice of caregivers regarding fall prevention in older adults

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  Discussion Top


The present study revealed that 18 (30%) had falls during the last 5 years and 6 (10%) fell more than once. The proportion is similar to the rate of falls occurring among older adults in one study done in North India (31%)[5] and is lower compared to another study carried out in South India (45%).[6] The current study findings were also contrary to the study done by Jayanthi[10] which showed a higher fall rate of 41%. Similarly, Honeycutt and Ramsey[11] also revealed that more than half of the sample (n = 71) reported at least one fall in a 2-year period and 11 fell once. Comparatively, lower fall rate noted in this study may be due to the fact that the participants were from the same community from one particular village where the cohesiveness of family is high and protecting elders is considered important which was revealed by their practice scores.

Assessment of the modifiable risk factors showed that the major causes of short-term and long-term modifiable risk factors were houses with household articles in the pathway (96.7%) and houses that had slippery floors. Slipping was the most common cause for falls noted in another study.[12] Similarly, it could have been a major risk factor for falls in older adults in this study. WHO report states that higher disability and consequent increasing distress are noted among those with a prior history of fall after 60 years of age and those with a history of three or more falls.[13] As number of falls increases, the resulting distress may further cause falls. Caregivers should be taught to encourage older adults during mobility and be cautioned of this fact.

This study also revealed that there was no significant association between long-term modifiable risk factors such as steps at raised level, uneven floors, household fixtures and absence of handrails with the frequency of falls among older adults whereas studies done by Yu et al.[14] and Li et al.[15] showed that occurrence of falls in elderly was significantly associated with extrinsic factors.

A significant association (P< 0.05) between uneven floors, type of family and family income and falls was identified in this study. These may be also because majority (86.7%) lived in joint family where they had more number of family members. Living in joint families can be a protective factor. Aras et al.[16] reported that among 135 older adults studied, the type of family was found to have some effect on freedom from risk of domestic accidents. Tinetti et al.[17] suggested that falls risk may be influenced more by a social determinant (i.e., education or income level). Although a direct relationship between falls and income has not been found, it was defined as another social determinant possibly indirectly linked to falls and fall-related injuries because of its known impact on health status.

The pre-test findings of this study revealed that only 50% of caregivers had adequate knowledge and satisfactory practice on fall prevention in older adults. Whereas, in the post–test, all (100%) of the caregivers had adequate knowledge and satisfactory practice. There was a significant improvement in the knowledge and practice of caregivers from pre-test to post-test (P< 0.001). The significant improvement shows that the intervention was effective. A similar study done by Huang[18] found that the experimental group individuals who were offered fall prevention intervention improved in their fall self-efficacy, environmental safety and knowledge of medication safety significantly (P< 0.01) as compared with those in the comparison group in post-test.

The association between knowledge, attitude, practice and selected demographic variables were analysed using Chi-square test. The present study showed no significant association between post-test knowledge, attitude and practice and demographic variables of the caregivers regarding prevention of falls among older adults. Contrary to this in a study by Braun,[19] it was found that participants who considered falls to be an important health concern attributed higher levels of importance to personal fall-related risk factors, particularly exterior environmental factors and physical factors, compared with participants who did not consider falls to be an important health concern for elderly people. There was a positive correlation (P< 0.001) between knowledge and practice of caregivers for prevention of falls in the older adults in this study. It showed that as knowledge increased, practice also increased among caregivers. The present study findings are in congruence with the findings of the study done by Jayanth[10] and Huang[18] which showed a positive relationship between knowledge (P = 0.001) and practice among caregivers regarding falls prevention. The incidence of falls was reduced in post-test in both groups compared to pre-test scores showing that improving knowledge improves practice of fall prevention.


  Conclusion Top


As the population ages, the problems related to falls are expected to grow and pose an even greater challenge to the healthcare system. Falls prevention is an important health promotional activity which improves the quality of life of older adults. On-going monitoring of fall risk can help caregivers as well as community health professionals to individualise their interventions to the specific needs of the older adults, thus helping to prevent falls among community-dwelling older adults. The study on the assessment of the risk factors for falls within the home environment can give the nurses impetus to think that minor modifications in the home environment can make a major difference in the life of homebound older people in preventing falls. Through health education and home visits, simple environmental modifications can be suggested to promote safety and a better quality of life among older adults.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Yu PL, Qin ZH, Shi J, Zhang J, Xin MZ, Wu ZL, et al. Prevalence and related factors of falls among the elderly in an urban community of Beijing. Biomed Environ Sci 2009;22:179-87.  Back to cited text no. 14
    
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Li W, Keegan TH, Sternfeld B, Sidney S, Quesenberry CP Jr., Kelsey JL. Outdoor falls among middle-aged and older adults: A neglected public health problem. Am J Public Health 2006;96:1192-200.  Back to cited text no. 15
    
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  [Full text]  
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    Figures

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    Tables

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