Author
BUNN Frances; et al.;
A systematic review of older people’s perceptions of facilitators and barriers to participation in falls-prevention interventions.
Journal citation/publication details
Ageing and Society, 28(4), May 2008, pp.449-472.Summary
Twelve quantitative and twelve qualitative studies from the UK, USA, Australia and Canada are reviewed, all but one described as exploratory studies of older people’s views and attitudes. Among the important facilitators of participation in falls prevention programmes is social support (both individual and societal), while many barriers derive from the negative way in which older people may see themselves, or believe they are seen by others.
Context
Several reviews of falls prevention interventions have been conducted but most have focused on quantitative evaluations of effectiveness and have failed to take account of participants’ views about the acceptability of programmes. Providers thus have little information on which to base changes to improve programme acceptability or adherence.
Methods
What sources were used?
Table 2 lists the twelve, primarily health, databases that were searched. In addition, the reference lists of relevant retrieved studies were checked and ‘field researchers and experts’ were contacted, including the guideline development group at the National Institute for Health and Clinical Excellence.
What search terms/strategies were used?
Table 2 reproduces the search terms and search strategy. A combination of free text and MeSH (Medical Subject Heading) terms was used.
What criteria were used to decide on which studies to include?
Table 1 lists the inclusion criteria. Eligible studies were randomised controlled trials, controlled trials or controlled before-and-after studies with participants aged 65 or over in all settings. Outcomes of interest were rates of compliance/adherence with the intervention, predictors of adherence/compliance, and participants’ view and experiences of the intervention.
Who decided on their relevance and quality?
The searches delivered 6,191 records which were independently screened on the basis of titles and abstracts by two unnamed authors. Disagreements were resolved through discussion. A total of 134 studies were acquired in full, and assessed against the inclusion criteria and a range of referenced methodological quality criteria that are summarised in Table 3.
How many studies were included and where were they from?
Twenty-four studies were reviewed and are summarised in Table 4. They were conducted in the UK (7), USA (7), Australia (5) and Canada (5).
How were the study findings combined?
The papers were categorised by study design; the type, location and duration of the intervention; the characteristics of participants and providers; main study aim; and outcome measures. The results are presented narratively in two ways: as reactions to three types of intervention; and as cross-cutting themes relating to the barriers and facilitators to participation in falls prevention interventions.
Findings of the review
The general quality of the evidence base ranged from ‘low to fair’ for the twelve quantitative studies. Among the twelve qualitative studies, most had clearly defined aims and gave ‘adequate’ descriptions of sampling and data collection. However, ‘there was limited evidence of sample validation, triangulation or assessments of generalisability’.
The studies were generally exploratory in nature and only one focused specifically on an intervention designed to promote participation. However, a range of factors affecting participation in falls prevention interventions was identified, including: denial; fatalism’ self-efficacy; past exercise habits; fear of falling; general health and functional ability; health expectations; under-estimation of the personal risk of falling; stigma; embarrassment; and ‘the inconvenience of some assistive devices’. Many of these themes concern the often negative way older people perceive themselves, and believe they are perceived by others. Thus the providers of falls prevention interventions need to be aware of, and address, the factors that sustain the marginalised position of older people.
Factors that improved participation and adherence included social support and interaction, low intensity exercise (such as walking), education and a perception that the programme was relevant and beneficial. Social support, in particular, was very important both at the individual level (e.g., from family, friends, health care professionals) and at the societal level (e.g. cultural norms that support the idea of older people remaining active). However, the authors stress that in most cases the studies examined beliefs and attitudes, rather than actual behaviours. The facilitators of participation were generally inferred by researchers rather than objectively measured as a statistically significant effect from a controlled study, but there was nonetheless ‘impressive consistency in the prominent themes’.
Authors' conclusions
‘Currently, the health care and other professionals that are developing or providing falls prevention services have little knowledge of either older people’s views or the barriers to participation that older people perceive.’ This study provides a preliminary overview of these issues, and identifies where there are gaps in the evidence base (for example, the impact of gender, ethnicity or socioeconomic status on participation). Further research will help to improve service design and effectiveness.
Implications for policy or practice
‘Several paradoxes that are challenges for those designing falls prevention programmes emerged from this review.’ For example, some people reject interventions that stereotype them as ‘old’, while others value the opportunity for contact with people of a similar age and outlook. Another issue of importance is how to make older people aware of their potential risk of falling without causing either distress or denial.