Views and Expectations of Community-Dwelling Thai Elderly in Reporting Falls to Their Primary Care Physicians

Abstract

Fall among older adults is a concern in Thailand. The challenge for primary care physicians is to deliver effective interventions potentially adhered to by older people. This research employed a mixed-methods design to understand factors leading to fall reporting by community-dwelling Thai elders and their expectations regarding fall prevention education. Participants (N = 305) who had fallen in the last year completed a questionnaire in the quantitative phase, and 50 of these were interviewed in-depth in the qualitative phase. Results revealed that only 39% reported their fall. Participants with comorbidities were 1.6 times more likely to report falling than those without (odds ratio = 1.61, confidence interval = [1.01, 2.58]). Post-fall pain (84%) was the strongest reason for reporting. Some participants believed that falling is an inevitable life event. It is crucial to encourage older adults to report falling, to provide targeted education, and to focus on improving the overall health status of older adults.

Keywords

behavioral science community-dwelling elderly fall prevention explanatory sequential mixed-methods study Thailand

Introduction

The aging population in Thailand has increased dramatically in proportion to the overall population from 10% in 2005 to 14% in 2015 (Institute for Population and Social Research, Mahidol University, 2006). Thailand now ranks second for the most aged country in Southeast Asia after Singapore (Institute for Population and Social Research, Mahidol University, 2006). It is projected that the proportion of aging population in Thailand will be nearly 30% by 2050 (Institute for Population and Social Research, Mahidol University, 2006). The older adults’ population in Thailand is associated with a high prevalence of falls; 30% to 40% of those above 65 years and up to 50% of those above 80 years experience a fall each year (Assantachai, Praditsuwan, Chatthanawaree, Pisalsarakij, & Thamlikitkul, 2003; Jittapunkul, NaSongkhla, & Chayovan, 1998). Falls seriously affect the physical, emotional, social, and functional health of older people and are clearly associated with reduced quality of life levels (Hartholt et al., 2011).

The World Health Organization (WHO) Innovative Care for Chronic Conditions (ICCC) provides a framework (WHO, 2005) to educate patients about the potentially deteriorating effects of their chronic diseases. The framework also includes information about the risks of falling for older adults and information about falls prevention programs. Using the ICCC guidelines, health care providers need to consider how fall prevention program can be implemented routinely in both medical and community settings. Prior study of an Asian minority group in the United Kingdom has shown that the responses of health care professionals to reported falls play a major role in the referral to and acceptance of interventions (Dickinson et al., 2011). These responses were proactive screening and case findings, giving prevention advice and facilitating older people’s access to fall prevention programs. Currently in Thailand, there is a national fall prevention guideline (National Thai Institutes of Geriatric and Gerontology, 2008) that recommends primary care physicians take a history of falls annually and provide guidance regarding fall assessments and prevention. The fall risk assessments include assessing disorders affecting balance and gait, the use of psychotropic drugs, depression, and poor vision. The guideline also provides multifactorial interventions such as home hazard assessment and modification, reducing or stopping psychotropic drugs, and group exercise. However, the translation of fall assessment and prevention guidelines into practice is difficult because of competing demands by other acute health care issues, a shortage of health care providers and, especially, a lack of understanding about the Thai elderly’s perceptions of the potentially negative effects of falling and their rationales for not reporting their falls. Qualitative studies, exclusively conducted in Western countries, have shown that the elderly see falls as being beyond their control and as something that will occur in the distant future (Clemson, Cusick, & Fozzard, 1999; Commonwealth of Australia, 2000; Yardley, Donovan-Hall, Francis, & Todd, 2006). Also, prevention is negatively associated with the desire for an independent life and seen as viewing the self as a “frail elderly” (Aminzadeh & Edwards, 1998; Ballinger & Payne, 2002).

The challenge, therefore, is for Thai primary care physicians to deliver effective and efficient interventions to older Thai people at risk for falls, and for these interventions to be adhered to by older adults. Consequently, it is important to understand how individuals are likely to perceive an elevated fall risk status and the health consequences of falls. Thus, the aims of this study were twofold: (a) to better understand the views and factors related to reporting falls to primary care physicians by community-dwelling Thai elders and (b) to understand the expectations of this population toward their primary care physicians regarding fall prevention. Employing an explanatory sequential mixed-methods design, this study focuses on addressing the above aims through survey of community-dwelling Thai older adults followed by in-depth interviews with selected participants (Creswell & Plano Clark, 2011).

Materials and Methods

An explanatory sequential mixed-methods design was used as a framework to collect and analyze data related to falls in populations of Thai older adults. Data collection occurred in two phases from February 2012 to August 2012, with collection of quantitative data in Phase 1 (February 2012-April 2012) and qualitative data in Phase 2 (May 2012-August 2012). In the quantitative phase, a correlation-cross-sectional design was used. Data collectors (registered nurses, health care volunteers, physical therapists, or environment health officials) who knew people in the community well surveyed elderly residents (≥60 years old) listed in the community census in five regions: Bangkok (capital city), Mae Hong Son (northern province), Kalasin (northeastern province), Nakornprathom (central province), and Surathanee (southern province). They approached 1,050 elderly residents aged ≥60 years at their houses or the elders’ clubs until they obtained 310 eligible participants. Five participants were excluded as they were not able to complete the interviews. In the qualitative phase, descriptive qualitative process was used. Participants were purposefully recruited from the 305 subjects in the quantitative phase to be interviewed in-depth by using maximum variation sampling technique (Sandelowski, 1995). To maximize the variation in the sample, the principle investigator (PI) reviewed all the answers from the open-ended questions part in the questionnaires packet and decided to sample by their fall experiences. This included reasons of reporting and not reporting the falls and expectations toward their primary care physicians. To ensure the heterogeneity of the sample, 50 participants were chosen based on their location (10 cases from each region), age, gender, education, number of falls, falling reporting status (yes vs. no), and number of comorbidity.

Participants

Participants in the communities (age ≥60 years old) were eligible for the study if they could communicate verbally in Thai, had experienced at least one fall within the past year (February to August, 2011-February to August, 2012), and agreed to participate in the study. A fall was defined as “an event that resulted in a person coming to rest unintentionally on the ground or other level and which does not occur as a result of an intrinsic event or overwhelming hazard” (Lamb, Jørstad-Stein, Hauer, & Becker, 2005, p.1619). Three hundred and five participants meeting these criteria were included in the quantitative phase. In the qualitative phase, 50 of these 305 participants (10 in each region) were interviewed in-depth by the PI. Most participants in the second phase preferred to be interviewed at home, whereas a few preferred to be interviewed at the local health center. Each participant was paid $10 for taking part in an in-depth interview.

The study protocol was approved by the Ethics Committee on Human Rights Related to Research Involving Human Subjects, Faculty of Medicine, Ramathibodi Hospital, Mahidol University. For data collection consistency, all data collectors were trained how to collect quantitative and open-ended data by one of the co-investigators in each province. Each data collector told participants about the study protocol, potential risks, and benefits of the study. No identifiable information was included in our results, and all participants had given informed written consent.

Sample Size

To ensure a sufficient sample size and power for quantitative data analysis, an online power analysis program G*Power 3.1 (Faul, Erdfelder, Buchner, & Lang, 2009) was used. Choosing a priori power analysis for logistic regression with a small effect size of 1.44, an alpha of .05, and a power of 0.80, a sample size of 297 was yielded. Therefore, 305 participants provided a sufficient statistical power in our study. A sample size of 50 in the qualitative phase was justified via literature review indicating that the interviewing of 20 to 50 participants in a descriptive qualitative study can lead to data saturation (Collins, Onwuegbuzie, & Jiao, 2007).

Tools and Data Analysis

In Phase 1, quantitative data were collected using a structured questionnaire packet (see Appendix) comprising separate questionnaires to collect data pertaining to demographics, health information, fall experience, and depression. Demographic questions asked about age, gender, marital status, educational level, religion, income, occupation before retirement, caregiver information, and accommodations. Health information questions addressed disease status, comorbidity defined as having more than or equal to two diseases as listed in Table 1, vision problems, dental problems, continuity of care with primary provider defined as “the patients’ experience of continuous caring relationship with an identified health care professional” and health care coverage. In addition, an open-ended question asked participants whether or not they reported falling to their primary care provider and their reason(s) for reporting or not reporting. Depression was measured by the 15-item Geriatric Depression Scale (GDS). In Phase 2, qualitative data were collected by the PI. Examples of qualitative questions included the following: “Did you tell your primary physician about your fall(s)?” “Why or why not?” “How has the fall experience(s) impacted your daily life?” “What would you like to learn about falls from your primary physician?” Tape recording and verbatim transcriptions were both done. Qualitative results were analyzed by content analysis (Creswell, 2007). The analysis involved reading field notes and transcripts and listening to the interviews to gain the general sense of the data. After several readings, which ensured immersion in the data, the PI and co-investigators underlined keywords. Data were coded independently by the first and second author, and then rigorously scrutinized by the research team. Themes were identified and categories were developed. Any disagreements were resolved through the discussion. Quantitative data were analyzed by using descriptive statistics and logistic regression analysis. Mean and standard deviation or median and range were used to describe continuous variables. Frequency and percentage were applied to categorical variables. Chi-square (χ²) was used to compare categorical demographic variables between the reporting falls group and underreporting falls group. Altogether, 14 variables were used in logistic regression analysis (see Table 2) as potential predictors of the dichotomous dependent variable: reporting of falls (yes or no). Using the GDS scores (Committee TTBF, 1994), participants were categorized into three groups: <5 (no possible depression), 5 to 9 (possible depression), and ≥10 (probable depression). All analyses were performed using STATA version 13 (StataCorp, 2013). A p value less than .05 was considered statistically significant.

Table 1.

Demographic and Health Characteristic of Falling Elderly Subjects.

Population characteristic	ParticipantsN = 305 (%)
Age (mean ± SD)	72 ± 7.9
Sex
Female	231 (74.5)
Male	79 (25.5)
Education
6 years of school	222 (71.6)
High school	26 (8.4)
Bachelor degree or higher	16 (5.1)
Illiteracy	46 (14.8)
Disease status
Hypertension	159 (52.1)
Diabetes	83 (27.2)
Dyslipidemia	78 (25.5)
Osteoarthritis	49 (16.1)
Osteoporosis	16 (5.2)
Cardiovascular disease	30 (9.8)
Neurological disease	14 (4.6)
Others	73 (27.5)
Comorbidity (≥two diseases)	154 (49.5)
Numbers of comorbidities (mean ± SD)	2.00 ± 1.2
Vision problem	138 (46.2)
Dental problems	121 (39.7)
Health care coverage
Government	72 (23.7)
Co-private and government	3 (1.0)
Social welfare	4 (1.3)
Universal	186 (60.9)
Social welfare for disability	23 (7.4)
Self-pay	3 (1.0)
Others	15 (4.7)

Table 2.

The Demographic and Clinical Characteristics of Community-Dwelling Elderly Who Report Falls Compared With Those Who Do Not Report Falls.

Characteristics	N (%)		p value
	Reporting fall	Underreporting fall
	n = 120 (%)	n = 185 (%)
Age (years)
60-69	42 (35.3)	79 (42.9)	.343
70-79	51 (42.8)	74 (40.2)
≥80	26 (21.8)	31 (16.8)
Gender
Male	31 (25.8)	46 (24.8)	.849
Female	89 (74.2)	139 (75.1)
Education
6 years of school	78 (65.0)	139 (75.1)	.217
High school	11 (9.2)	15 (8.1)
Bachelor degree or higher	9 (7.5)	7 (3.8)
Illiteracy	22 (18.3)	24 (12.9)
Hypertension
Yes	66 (56.4)	91 (49.4)	.239
No	51 (43.6)	93 (50.5)
Diabetes
Yes	39 (33.3)	44 (23.9)	.075
No	78 (66.6)	140 (76.1)
Hypercholesterolemia
Yes	28 (23.9)	50 (27.2)	.531
No	89 (76.1)	134 (72.8)
Cardiovascular disease
Yes	11 (9.2)	19 (10.3)	.752
No	109 (90.8)	166 (89.7)
Neurological disease
Yes	9 (7.7)	5 (2.7)	.046*
No	108 (92.3)	179 (97.3)
Degenerative joint
Yes	21 (17.9)	28 (15.2)	.532
No	96 (82.0)	156 (84.8)
Osteoporosis
Yes	9 (7.7)	7 (3.8)	.143
No	108 (92.3)	177 (96.2)
Other diseases
Yes	34 (29.1)	39 (21.2)	.121
No	83 (70.9)	145 (78.8)
Vision problems
Yes	50 (42.4)	88 (48.1)	.331
No	68 (57.6)	95 (51.9)
Geriatric Depression Scale (15 items)
<5	80 (66.6)	126 (68.1)	.882
5-9	29 (24.2)	45 (24.3)
≥10	11 (9.2)	14 (7.6)
Comorbid (≥2)
Yes	68 (58.1)	85 (46.2)	.044*
No	49 (41.9)	99 (53.8)

p < 0.05

Results

Quantitative Results

Demographic and health characteristics of 305 participants who had fallen within the past year are shown in Table 1. The average age was 72. Approximately three quarters (74%) were female and had finished grade school (72%). Almost all of their main caregivers (99%) were family members (children or spouses). Most participants had low annual income (US$400-US$600). The highest annual median income was found in Bangkok (US$4,000) and the lowest in the north and northeast of Thailand (US$400). Sixty-one percent had universal health care coverage, but less than half (44%) had continuity of care from their primary care doctors. Our participants fell outside more than inside their houses (56.3% vs. 44.7%). Most fall incidents occurred during participants’ routine activities, especially while they were walking inside or around the house (65.7%), and about 10% slipped and fell in the bathroom (see Figure 1).

Figure 1.

Activities and related causes occurring in falling events.

Based on the open-ended questions in the quantitative questionnaire, only 39% of our participants reported their fall to their primary care providers, and pain was found to be the most compelling reason for reporting (84%). Only 7.5% reported the falls because they were asked by their primary care doctors. For those who did not report their fall experience(s), their reasons included no symptom after the fall (80%), the fall was not related to their present illness (12%), and their physicians did not ask about their fall history (6%). More than 60% of falling elderly were aware of some consequences post falls (e.g., injuries, disabilities, and death).

The demographic and clinical characteristics of community-dwelling elderly who report falls have been compared in Table 2 with those who do not report. Most variables were similar between groups, except for neurological disease and comorbidity, which were significantly higher in reporting falls participants. Logistic regression analysis is shown in Table 3. Participants with comorbidities were 1.6 times more likely to tell about their falls than those without comorbidities (odds ratio [OR] = 1.61; p value = .044; 95% confidence interval [CI] = [1.01, 2.58]). Although not statistically significant, participants with neurological disorders were about 3 times more likely to report their fall experiences to their primary physicians than those without such disorders (OR = 2.98; p value = .056; 95% CI = [0.97, 9.13]).

Table 3.

Factors Associated With Reporting Falls: Simple Logistic Regression Analysis.

Factors	OR [95% CI]	p value
Age (years)
>80	1.30 [0.77, 2.17]	.325
70-79	1.58 [0.83, 2.99]	.164
60-69	1
Gender
Female	0.95 [0.56, 1.61]	.849
Male	1
Education
Illiteracy	0.71 [0.22, 2.24]	.562
6 years of school	0.44 [0.16, 1.12]	.113
High school	0.57 [1.62, 2.01]	.381
Bachelor degree or higher	1
Hypertension
Yes	1.32 [0.83, 2.11]	.240
No	1
Diabetes
Yes	1.59 [0.95, 2.66]	.076
No	1
Hypercholesterolemia
Yes	0.84 [0.49, 1.44]	.532
No	1
Cardiovascular disease
Yes	0.88 [0.40, 1.93]	.752
No	1
Neurological disease
Yes	2.98 [0.97, 9.13]	.056
No	1
Degenerative joint
Yes	1.22 [0.66, 2.27]	.532
No	1
Osteoporosis
Yes	2.11 [0.76, 5.82]	.151
No	1
Other diseases
Yes	1.52 [0.89, 2.60]	.122
No	1
Vision problems
Yes	0.79 [0.50, 1.27]	.332
No	1
Geriatric Depression Scale (15 items)
≥10	1.02 [0.59, 1.75]	.957
5-9	1.24 [0.54, 2.86]	.618
<5	1
Comorbidity (≥2)
Yes	1.61 [1.01, 2.58]	.044*
No	1

p < 0.05

Qualitative Results

Qualitative results indicated that most Thai elderly who experienced pain reported their fall incidences to their primary physicians and requested analgesic drugs from them. Pain after falling seems to have been the most important reason. Themes that emerged from our narratives have been described as below.

Why Thai Elderly Did Not Inform Their Primary Care Physicians About Their Falling

Even though some elderly sought help from their health care providers after falling, others did not. Two reasons for this emerged: (a) seeking help instead from folk healers or lay health volunteers and (b) a perceived insignificance of the fall or a perceived lack of connection between fall and health.

Seeking help from folk healer or lay health volunteer

Some Thai elderly, especially in rural areas, decided to get help from folk healers or lay health volunteers rather than from their primary physicians. This was largely due to the easier access to such healers or volunteers.

I went to see the health volunteer in the village and told him about my fall, and he gave me some anti-pain medication. It was an easy access. (A 74-year-old woman from a Southern province who did not report her fall to the primary physician, tripped on her cat and fell on the ground outside her house.)

Perception of self as insignificant and/or perceived lack of connection between fall and health

Some elderly said that they did not want to add a burden to their doctor, who they felt was already overloaded by other patients, and some perceived themselves as a lesser priority group. As falling was not part of a routine health assessment, some did not tell their primary physician and did not see a connection between their fall and their existing health condition:

I did not tell my doctor because he did not ask me about my fall, and I was doing OK when I saw him. I think my fall accident did not have anything to do with my COPD. (An 84-year-old woman who lived in Bangkok slipped and fell in the bathroom.)

Expectations Related to Falling

When asked what they expected related to falling prevention and treatment, most said that they had no expectations regarding fall prevention information. They did not see any benefits and believed that they had already received good care from their physicians in general. However, a few participants wanted to receive service through a mobile clinic in the village due to their limited means of transportation:

I didn’t tell my doctor because I just got a bit of pain, not much. I still could walk. I did not expect anything much from the doctor. He gave me free medicine that really helped me a lot. I think the doctors probably did not have much money, and they already had given us such great help. (A 70-year-old woman in the Northeast region experienced multiple falls while in the forest searching for vegetables and food for her meals.)

Actually, I want the doctors to see the more frail elderly in the village. As elderly, we cannot go to the hospital to see the doctors by ourselves. I’ve only seen health volunteers. (A 78-year-old man in the Northeast region fell in the bathroom without injuries. He did not tell his doctor.)

How the Falling Event Affected the Thai Elderlies’ Lives

The event of falling affected the participants’ lives in several ways. The most immediate effects were physical limitations from pain and injuries such as bone fractures. These problems were a significant factor in reporting falls to primary physicians to get pain medications and/or appropriate treatments. A longer term effect of falling involved both limitations of physical and social activities. Although a few participants wanted to keep exercising at home, they did not know how. This limitation stemmed from their decline of physical health and also from fear of falling by themselves or their family. Some elderly showed depressive symptoms:

I know that falling could cause disabilities. I am very afraid of falling again. My children don’t let me go anywhere and don’t let me work in the field. I feel very bad about myself. I don’t feel that I am a normal person. I feel hopeless . . . No one wants to talk to me . . . (A 65-year-old woman in Central Thailand did not report any of her falls to her doctor.)

Since my falls, I have lost some weight. I have lost my energy. I can’t clean my house or even pray as usual. I want to get stronger, and I have tried my best. Before falling, I liked to go to exercise with a group of my friends every day, but now I just can’t do it anymore. (A 78-year-old woman in Northern Thailand had multiple falls, mostly due to dizziness and vertigo.)

Elderly’s Perceptions About Falling and Fall Prevention

Most participants believed that falling is not preventable. They perceived falling as a part of life and a signal of aging and frailty. Still some participants tried what they could do to lessen their chances of falling:

I don’t know what caused my falls, but they were unavoidable. I knew I could be disabled, and I am actually afraid of falling again. I noticed that my body is shakier from getting old. I can’t do anything as agilely as I used to. I have used a cane to help me walk to the temple and have been more careful. When it rains, I take off my shoes and ask someone to help support me while I am walking. (A 72-year-old woman in Northern Thailand slipped and fell while picking vegetables in her garden. She broke her arm and was in a splint for 3 months.)

Discussion

Despite substantial evidence about the effectiveness of fall prevention intervention (Assantachai, Praditsuwan, Chatthanawaree, Pisalsarakij, & Thamlikitkul, 2002; Cusimano, Kwok, & Spadafora, 2008; Gates, Fisher, Cooke, Carter, & Lamb, 2008; Gillespie et al., 2009), there is still a gap between clinical guidelines and clinical practice. This gap is created by, for example, the lack of standardization and consistency in messages to health care providers, and the poorly understood human factors that affect adherence and compliance (Shubert, Smith, Prizer, & Ory, 2013). This explanatory sequential mixed-methods study quantitatively examined several predictors of reporting falls among Thai community-dwelling elderly and aimed to qualitatively describe their reasons for reporting their falls to their primary care providers—along with their views of the perceived impact of the fall on their daily life activities. Our study found that these elderly were likely to report falls when they experienced post-fall pain or injury. It was reported that most primary care physicians provided analgesic drugs. Based on logistic regression, Thai elderly were likely to report falls when they had comorbidity (≥2 diseases). These falling reports may have come out in conversation with their physicians about their comorbidities, thus an opportunity for reporting may have been provided in such a discussion that was not provided to participants without comorbidity. Most participants in this study did not expect to get information regarding fall prevention from their primary care providers, even though more than half knew the negative consequences of falling, including disabilities and/or death. This contradiction may be explained through our qualitative results revealing that some participants believed that falling is inevitable and, indeed, a normal occurrence in life during the aging period. Such a belief is also deeply embedded in Buddhist thought—the concept that nothing is immortal and that aging is unavoidable (Ross & Ross, 2008), so that falling can be considered a natural part of aging. In other cultural studies (Clemson et al., 1999; Commonwealth of Australia, 2000; Dickinson et al., 2011; Yardley et al., 2006), participants viewed falls as being beyond their personal control, but they expected the physicians to facilitate the access to fall prevention program. Considering the views and expectations of Thai elderly in reporting falls, health care providers should provide information on fall prevention and on the benefits of fall prevention to their overall health status, especially regarding the continuance of their independence life styles. This finding is useful to bridge the gap between clinical guidelines and clinical practice by improving the compliance of Thai elderly toward fall prevention program.

Education that falls can be preventable is key to fall prevention. This is in line with the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention for Fall Prevention Guideline (Stevens, 2010) which comprises five components: education, exercise, medical risk evaluation, vision assessment/referral and home modifications. Maintaining independence is a central life-enhancing goal and as such a fall prevention program can be tailored to meet difference individuals’ needs. This study revealed how falls affect Thai elderlies’ lives in multiple ways, including post-fall pain and injury resulting in physical limitations, social isolation, and depression. To improve their functional status, a health assessment with a tailored exercise program should be implemented. Recently, studies have been conducted using individual home-based exercise programs, and were found to reduce fall rates significantly (Day, 2011; Kuptniratsaikul et al., 2011; Mori et al., 2011; Thomas, Mackintosh, & Halbert, 2010; Yang et al., 2011). A future study on the effectiveness of tailored home-based exercise programs should be designed and conducted to examine how easily or practically such programs might be followed by the Thai elderly at home.

Based on the National Fall Prevention Guideline, primary care physicians should ask patients annually about falls and evaluate them for medical risk factors by assessing disorders affecting balance and gait, the use of psychotropic drugs, depression and poor vision. In reality, this guideline is not well followed by primary physicians as evidenced by the fact that only 7.5% of physicians asked their elderly patients about falls in our study. It is important that guidelines for fall screening and prevention in the community setting be implemented and evaluated. There is evidence to support the benefits of active training of health care professionals to implement fall prevention into clinical practices (Tinetti, Gordon, Sogolow, Lapin, & Bradley, 2006). In our study, many Thai elderly sought help from folk healers and volunteers, not only because of easier access, but also because they have trust in them. Thus, folk healers and volunteers should be recruited to be part of teams providing fall prevention education. In addition, fall prevention programs can be implemented not only in primary care settings, but also in other health care settings where falls and injuries are likely to be reported such as in an emergency department. Most Thai elderly in this study underreported falls to their primary care physicians and sought care only when they had pain or injuries. Hence, the emergency room could be the first place that the falling elderly patients would be seen by their health care system. Establishing strategies to increase awareness in emergency department settings, such as creating an age friendly environment or using audio-visual media about fall prevention, can improve coordination with primary care settings. Addressing primary care physicians’ beliefs and barriers related to fall prevention education should also be further studied for program sustainability.

The translation of guidelines into practice is very complex, and multi-faceted strategies are more likely to be successful. Systematic review (Goodwin, Jones-Hughes, Thompson-Coon, Boddy, & Stein, 2011) showed evidences that the implementation of falls prevention programs such as support for active training of health care professionals, the use of community awareness programs, and peer or lay volunteer delivered fall prevention programs can be effective. This study is the important first step in translating the Thai National guideline into practice. The results support the value of a more proactive approach by primary care physicians and other health care providers, including folk healers, in screening for falls and providing prevention information. It also documents the need to educate Thai elderly to report falls and follow prevention programs in line with the National guideline. In addition, recommendations in the Behavioral Change Wheel focusing on the Capability, Opportunity, and Motivation (COM-B) system should be applied to help prevent falling (Michie, van Stralen, & West, 2011). As proposed by Michie (Michie, 2014, p. 9), to successfully move guidelines into practice, “education, persuasion, incentivisation, coercion, training, restriction, environmental restructuring, modeling, and enablement” can all be potentially incorporated into “mass-media/marketing, legislation, fiscal policy, service provision, guideline development, regulation, and environmental/social planning” to meet that end. Ory et al. (2010) gave an example of the implementation and dissemination of an evidence-based program to prevent falls in Texas, which was widespread in the community for older adults to participate for successful aging by creating the partnerships and building community infrastructure. The findings demonstrated that training and delivery structures were necessary for the dissemination of the evidence-based programs.

One of the strengths of this study is the use of mixed methods. This design facilitated the ability to understand patients’ views and identify factors associated with patients’ reporting of fall events to their primary care physicians. The information obtained can be used to implement fall prevention programs more effectively by improving primary care physician responses to elderly patients who have fall experiences. This study also identified the important role that folk healers and lay volunteers play in health care. Their use in the dissemination can be included in strategies. Overall, understanding Thai elder’s beliefs can help to present fall prevention information more effectively. Our study has two clear limitations: First, although our community-dwelling elderly were enrolled from all five regions in Thailand, the sites were chosen based on personal connections that we had with health care providers in the areas. Thus, generalizability of the results could be limited. Future research will need to include more sites based on random sampling. Second, our results were based only on those elderly who had fallen. Future qualitative research should examine fall prevention practices from the elderly who have never fallen. Such a study can add significant information as to how falls can be prevented based on the overall target population. The ultimate goal should be the movement of guidelines into effective practice using comprehensive strategies such as those found in the COM-B model.

Conclusion

This study examined the views and expectations of community-dwelling Thai elderly about reporting falls to their primary care physicians. Results indicated the following: (a) It is critically important to educate the Thai elderly in order for them to report falls to their primary care providers; (b) fall prevention programs should help the elderly to understand that falling is an avoiding event and to learn the benefits of fall prevention for their overall health status; (c) the prevention programs should not be limited to the primary care providers, but include emergency room workers and folk healers; and (d) fall prevention programs should be tailored to meet individuals’ needs based on their beliefs about falls and their comorbid medical problems.

Footnotes

Acknowledgements

We are grateful to Professor Chatchalit Rattarasarn, the head of the Development Potentials of the Thai People Project, for his support. We also would like to acknowledge our statisticians (Dr. Sasivimol Rattanasiri and Nattawut Unwanatham) and participant recruiters (Dr. Pichit Suksabye, Dr. Phanlop Thappawong, Dr. Sirichai Namtassanee, Dr. Anupan Saramanee, Arunee Tangcharoenbumrungsuk, Srichan Kanhasali, and Prapatsorn Janpromma). Our thanks to Jirawadee Chumpol, the project investigator’s assistant researcher, for her effective project and data management; Ms. Chumpol for her help with part of the descriptive data analysis; Dussadee Maneesuwannarat, Suranya Wicuna for their help in general; the Thai People Project researchers and coordinators for their helpful funding management. Finally, we would like to thank Professor Emeritus Antonnette V. Graham who provided valuable feedback on the manuscript. The manuscript was edited by Professor Graham and Jeffrey Ross. We appreciate their help.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Development potentials of the Thai People Project, Mahidol University, Bangkok, Thailand. The funding source has no role in the study design, collection and analysis, writing of the manuscript, and in the decision to submit the manuscript for publication.

Author Biographies

Chitima Boongird, MD, the director of the comprehensive geriatric assessment clinic in Ramathibodi Hospital, is the principal investigator of this fall prevention project in the Thai community as funded by the Development Potentials of Thai People Project, Mahidol University, Thailand.

Ratchneewan Ross, PhD, associate professor and director of international programs, College of Nursing, Kent State University, is the co-investigator and a mixed-methods expert who has conducted various mixed-methods studies in different countries.

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