Stepping on - A multifaceted program reducing the rate of falls
Falling in older age is not uncommon and unfortunately it can have devastating consequences, not just the immediate effects of an injury, but loss of confidence and the capacity to do less. For some it starts a downward trajectory that can lead to having to give up living at home and move into a care environment. Lindy Clemson, Professor in Ageing and Occupational Therapy at The University of Sydney, shares her groundbreaking work with Stepping On, a program which has had international reach
Falls can be a marker for underlying deterioration such as weakness and loss of balance, or an untreated cataract, or a mix of medications that may cause drowsiness. Rushing and not paying attention to the environment can contribute to a fall. A frailer person may fall at home tripping on a rug: weak ankles and hips as well as an unsafe mat could contribute.
A more active person may fall trying to use a ladder cleaning leaves off the gutter. Perhaps it is time they asked for assistance. There may be underlying dizziness that needs to be discussed with their GP. A cataract maybe causing difficulty seeing and they have not realised their vision is now a hazard.
Falls can have complex underlying factors but the good news is that something can be done.
There is strong evidence, supported by the most recent Cochrane Review of community interventions for falls (Gillespie et el., 2013), that balance and strength training, home safety conducting using occupational therapy approaches, and medication reviews are effective. Multi-faceted programs need to include those known evidence based strategies. Stepping On is a multifaceted program proven to be effective in reducing the rate of falls in a large randomised trial which we published in the Journal of the American Geriatrics Society in 2004.
A neighbour, who was not aware of my work or what I did, told me recently that her father had fallen and, ‘unlike him’, he had become fearful of going out, was very concerned about falling in the supermarket and she was worried as he was deteriorating. Then someone encouraged him to attend a program called Stepping On and ‘it changed his life.’ He was so enthusiastic about it and now was getting out and about and re-gaining his strength and confidence. While I am committed to conducting quality randomised trials to test whether an intervention is effective or not, and to engaging in meta-analysis to better understand over time what does work, it is these spontaneous and unexpected personal stories that truly make it all worthwhile.
We designed Stepping On to be evidence based, to use what we know about falls prevention but to do this in a group situation where the older person takes control and learns to apply safety strategies into their everyday lives. The program uses concepts of cognitive-behavioural learning, a decision making model to assist people moving from the injury experience to exploring potential causes, weighing up their alternatives and moving onto tackling barriers and following through. There is a variety of learning opportunities which are facilitated by trained Stepping On leaders – using the group process, storytelling and brainstorming techniques. Experts are invited to provide the evidence on specific topics such as coping with low vision, pedestrian safety, medication management which are presented in ways that participants can make informed choices with specific homework to help follow through.
For example, participants learn how to do home based balance and strength training but they also understand why they need to do this to protect from slips, trips and falls. They also learn very practical safety strategies, defensive walking and safety tips for catching the bus, that help them be more aware as they move about their community.
When we conducted our trial, we used part of the last session for each participant to share what they had got out of the program and we recorded these in our Stepping On manual.
Nancy had been forced, when her husband died, to move from a large house in a well-to-do suburb to a small housing commission house in a new area and a fall during this move had hugely disrupted her life and self-esteem. She worked hard at Stepping On, and the following comment captured some of her renewed philosophy to life.
“We all have our abilities and disabilities. As we get older the disabilities become more obvious. You lose some sight, some hearing and maybe your balance is worse. But what you have done is focus on our abilities. No one else has done that.” Nancy
People’s stories vary but their capacity to learn and change in positive ways is very evident in these brief personal testimonials.
“I never cross the street now unless its at a crossing. I take the longer route, its good exercise.” Betty
“I’ve had some near falls but you have a quicker recovery and your muscles don’t collapse.” Herbert
“I feel more confident and I’m going out more.” Marie
“It’s made me more aware, just so much more aware; of the buses, of my place; of making it brighter inside, getting rid of leaves outside, of everything.” Roleena
The work by Dr Meryl Lovarini in her in-depth focussed interviews and subsequent development of a model for sustainability of programs over time demonstrated the importance of management support, the need for the program to be a good fit with organisational values, the importance of skills and beliefs of the health professionals and staff involved and the overall crucial way that networking serves to enable sustainability, particularly when at different times some conditions are not being adequately met (Lovarini, 2012). We know from evidence the importance that training and mentorship plays to ensure the programs have longevity and are conducted with fidelity, maintaining the key features that make them work.
NSW Health has been supporting the roll out of Stepping On across the state. Professor Jane Mahoney, University of Madison, Wisconsin introduced Stepping On to the US. In a translational project between 2008 and 2011 there were 253 programs conducted across the state with various buy-in from different counties. They provide training to leaders and training to trainers for the whole of the US. Currently Stepping On is one of three programs supported by the US Centres for Disease Control, Injury branch, along with Otago and Tai Chi, offering a variety of evidence based programs for different levels of risk and that fit within their health system.
Megan Swann, co-developer of the program, continues to run Stepping On programs and is involved in training Stepping On leaders in Australia via Royal Rehabilitation College at Ryde. In the last six months Megan has conducted 21 workshops in the Sydney and country areas of NSW, three of these for CALD facilitators. She reports a shift in the questions in that leaders no longer need an explanation that Stepping On is evidence based and that generally management support has shifted from uncertainty of reasons to implement falls prevention to enthusiasm for their staff to implement the program. Networking is encouraged in their local areas, facilitated by Stepping On co-ordinators. Training is now interstate, with workshops recently conducted in Melbourne. She also offers fidelity checks and mentorship.
Stepping On handouts are now translated into 12 different languages, also available from Sydney University Press along with the Stepping On manual. ‘Staying Power, tips and tools to keep you on your feet’, is a booklet we wrote from Stepping On that captures key points and is useful for relatives, caregivers and participants.
[caption id="attachment_6095" align="alignleft" width="181"] Lindy Clemson is Professor in Ageing and Occupational Therapy at the University of Sydney.[/caption]
“There is strong evidence, supported by the most recent Cochrane Review of community interventions for falls (Gillespie et el., 2013), that balance and strength training, home safety conducting using occupational therapy approaches, and medication reviews are effective. Multi-faceted programs need to include those known evidence based strategies.”
The following are papers on falls prevention she has co-authored:
Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Sherrington, C., Gates, S., Clemson, L. M., & Lamb, S. E. (2012). Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 9, CD007146.
Clemson, L., & Swann, M. (2008). Stepping On: building confidence and reducing falls. A community based program for older people. (2nd ed.). Camperdown, NSW: Sydney University Press.
Clemson, L., & Swann-Williams, M. (2010). Staying power: Tips and tools to keep you on your feet. Sydney University Press.
Lovarini, M. P. (2012). Sustainability of a community-based falls prevention program: A grounded theory. PhD thesis, The University of Sydney.
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