Falls prevention education for older people designed using the Health Belief Model

Background Falls in hospital are a substantial problem for older patients and for health care systems. Falls account for more than 40% of reported adverse events in hospitals, and are three times more likely to be injurious than falls among community dwelling people. In-hospital falls are also associated with poorer rehabilitation outcomes, prolonged length of stay, increased health costs and risk of requiring residential care. A small number of randomised controlled trials of multifactorial interventions have produced conflicting results. These interventions had some effect in reducing falls, but are difficult to replicate and the relative effectiveness of each component is unknown. There is limited evidence for preventing falls in high risk cohorts of the older population after hospital discharge and only a few studies have reported rates of falls during this period. Review of the literature indicated two key areas that warranted further investigation. First, the effect of providing patient education to reduce falls in hospital was unknown, although research findings in the community suggested that falls prevention programmes are limited by low levels of patient adherence. Second, there were sparse data about falls rates and falls prevention in the post discharge period. Aims The aim of this thesis was to examine whether falls prevention patient education could be designed and delivered using a theoretical model of health behaviour change, the Health Belief Model (HBM). The studies examine the sustained effect of providing inpatient education on falls rates following discharge and investigate risk factors for falls in the population after discharge. Secondary aims were to investigate whether the constructs of the HBM could be used to explain older people’s awareness of and knowledge about falls, and their engagement in falls prevention strategies after hospital discharge. Methods The education materials were evaluated by conducting a randomised trial (n=100) in a population of older hospital patients. The materials were designed and delivered using the constructs of the HBM and principles of adult education. An observational study (n=343) also followed up participants, who were enrolled in a multi-site randomised controlled trial, to examine the effect of inpatient education on rates of falls in the six months after discharge. Risk factors for falls, patients’ self-perceived risk of falls, knowledge about falls prevention and engagement in exercise after leaving hospital were investigated. Results The education achieved key changes in participants’ awareness, self-perceived risk and knowledge about falls, and their self-efficacy to engage in falls prevention behaviours. However providing inpatient education did not have a sustained effect in reducing falls rates in the six months after discharge. Falls rates in the cohort, including injurious falls rates, were increased for six months following discharge when compared to the general community population. Forty percent of participants fell and over 50% of these sustained an injurious fall. Three protective interactions: receiving assistance with Activities of daily living if a participant had depressed mood at discharge, receiving assistance with Activities of daily living if the participant had fallen in the six months prior to hospital admission and being a male participant with a visual impairment, lowered the risk of falls outcomes. Participants were found to have low levels of knowledge about suitable falls prevention strategies to use after discharge and only 35% were engaging in exercise when surveyed at six months post discharge. Those participants who believed that they were at risk of sustaining a serious injury if they fell were significantly more likely to be engaging in exercise. Discussion This research programme was the first to investigate older patients’ response to falls prevention education designed using the HBM. The constructs of the HBM, utilised with adult education principles, were effectively applied to design and delivery of falls prevention education for older patients. The HBM was a suitable model of health behaviour change to explain older people’s attitudes towards and knowledge of falls, and engagement in exercise following discharge. The results of the research also demonstrate for the first time that older people are at increased risk of sustaining a fall and falls-related injury in the six months after leaving hospital. Feedback provided by older people in this study suggests that low levels of knowledge and adherence to falls prevention strategies may contribute to falls risk in this population. Identification of risk factors for falls in the post discharge period highlighted that receiving assistance with ADL reduces falls risk and injurious falls risk in high risk cohorts of the post discharge population, including participants who had a history of previous falls. Conclusion An educational intervention designed using the HBM improved older people’s awareness and knowledge of falls and falls prevention strategies and enhanced their self-efficacy to engage in falls preventive behaviours. Older people were at increased risk of falls after hospital discharge but had low levels of knowledge about how to reduce falls risk and low levels of engagement in exercise. Future research should develop and evaluate interventions that are specifically targeted to this population.