Fall Prevention Program Characteristics and Experiences of Older Adults and Program Providers in Canada: A Thematic Content Analysis

Abstract

Objectives: To document the characteristics of fall prevention programs in specific regions in two Canadian provinces and to explore older adults’ and program providers’ experiences with these programs. Methods: Semi-structured interviews were conducted with 16 program providers/managers from 12 different programs. Ten semi-structured focus groups were conducted with 59 older adults. Data were analyzed using thematic content analysis. Results: Older adults reported functional and social benefits. Program providers identified barriers to program success, including cognitive impairment, frailty, and lack of motivation. The need for general attitudinal changes toward older adults’ needs and broader community changes were identified as important by the older adults. Discussion: Easily accessible information about fall prevention programs for older adults and no-cost, ongoing initiatives were critical. Health care providers play keys roles in disseminating information, facilitating referrals, and advocating for initiatives that best meet the needs of older adults in their communities.

Keywords

older adults program providers fall prevention programs perspectives and experiences thematic content analysis

Falls in community-dwelling older adults represent a major public health concern. According to Statistics Canada, falls account for 85% of hospitalizations due to injuries, with financial costs estimated at CAD $2 billion annually (Public Health Agency of Canada, 2014). The number of fall-related hospitalizations among community-dwelling older adults is over five times the number for older adults in residential care (Public Health Agency of Canada, 2014), and the average length of time older adults spent in hospitals because of falls was 10 days more than any other cause of admission (Public Health Agency of Canada, 2014). These statistics highlight the increased strain on the health care system that could potentially be addressed by effective fall prevention programs. In addition to the monetary costs, falls have unfavorable physical and mental health consequences for older adults, including fear of falling, reduced mobility and function, increased dependence, and depression (Li, Fisher, Harmer, Mcauley, & Wilson, 2003; Ruthig, Chipperfield, Newall, Perry, & Hall, 2007; Terroso, Rosa, Marques, & Simoes, 2013). Considering the population is aging (Public Health Agency of Canada, 2014), addressing falls and fall-related issues in older adults through effective programs is imperative.

The World Health Organization’s (WHO) “Active Ageing” framework outlines a fall prevention strategy for older adults. The framework posits that various determinants such as access to health services, physical environment, and personal, social and economic factors influence older adult’s health and quality of life (WHO, 2008). Viewing older adults as a heterogeneous population with varying range of function, the framework suggests public health policy measures such as age-friendly communities and health promotion initiatives to enhance participation (WHO, 2008). Community fall prevention programs are such initiatives that can promote healthy lifestyles to limit decline in older adults’ functional capacity. These programs can utilize single, multifactorial, or multiple-component intervention approaches to address falls risk (Hopewell et al., 2018). A single-component approach addresses a single factor to limit fall risk, for example, a program focused primarily on exercise (Hopewell et al., 2018). A multifactorial approach tailors the intervention to participants’ needs based on an individual risk assessment. The intervention can include a combination of interventions such as group-based exercises, medication review, home modifications, and dietary supplementation (Hopewell et al., 2018). A multicomponent intervention approach toward fall prevention offers a combination of fixed interventions to all participants, for example, exercise and medication review (Hopewell et al., 2018). Some research has suggested that a multifactorial approach may be more effective compared with single intervention programs for older adults with a history of falling (Costello & Edelstein, 2008; Day, 2013). However, several systematic reviews suggest that single intervention exercise programs may be more cost-effective in a community setting and achieve comparable outcomes with multifactorial interventions (Campbell & Robertson, 2007; Gillespie et al., 2012). Regardless of whether single intervention exercise programs, multifactorial, or multiple-component fall prevention programs are most effective for community-dwelling older adults, a crucial intervention is exercise (Sherrington, Tiedemann, Fairhall, Close, & Lord, 2011; Sherrington et al., 2008). The effectiveness of exercise as a single-component intervention has been established as a critical aspect of multiple-component intervention programs (Hopewell et al., 2018).

Effectiveness of interventions is reliant on older adults’ uptake of and adherence to these programs. Previous research suggests that the uptake of community fall prevention interventions is determined by the participant’s perception of intervention’s effectiveness, future risk of falls, future risk of self-injury, and limited physical mobility. Among these factors, perception of the effectiveness of the interventions had the strongest link with intent to access fall prevention interventions (Hill, Day, & Haines, 2014). Adherence to exercise programs in older adults with a history of falling has also been a concern; thus, older adult’s perspectives regarding motivators, barriers, and facilitators to program attendance and participation are crucial (Nyman & Victor, 2011). Drawing on older adults’ perspectives and experiences can assist with development and delivery of fall prevention programs, so they better align with older adult needs, which in turn may increase uptake and adherence. In addition to older adults, it is imperative to also garner input from the program managers and providers who are involved in developing and delivering fall prevention programs. However, there is a current lack of research exploring program providers’ experiences with and perspectives of fall prevention program development, delivery, implementation, and sustainability.

Research exploring the perspectives of older adults participating in community-based fall prevention programs is limited, and to our knowledge, research conducted in the Canadian context is lacking. A qualitative study conducted in the United Kingdom examined perspectives of older adults who received fall prevention interventions (Dickinson et al., 2011). Factors identified as promoting older adult participation included knowledge of the program, accessibility, appropriate design, qualities of health care professionals, and beneficial outcomes (Dickinson et al., 2011). Lack of knowledge and perceived benefits, and personal barriers such as language barriers, health issues, and lack of time, were found to hinder participation (Dickinson et al., 2011). Research conducted in the Australian context explored views of older adults attending a community fall prevention program (Ballinger & Clemson, 2006). Study participants noted several beneficial outcomes including a positive social experience, reduced pain, and increased confidence (Ballinger & Clemson, 2006).

The effectiveness of community programming is not merely dependent on program adherence and program attendees’ reported facilitators and barriers. Additional factors such as the milieu impinge upon the effectiveness of programs and therefore it is important to understand program implementation in the context of the environment and overarching health care system (Durlak & Dupre, 2008). For example, in Canada, program design and implementation may be affected by factors such as climatic features, sparsely populated regions, and health care system differences. A previous qualitative study exploring beliefs of older adults regarding physical activity living in Saskatchewan reported that adverse weather conditions limited their performance due to intrinsic fear of falling and extrinsic limitations imposed by concerned family members on older adult mobility (Schmidt, Rempel, Murray, McHugh, & Vallance, 2016). These weather conditions and their associated impacts can include attendance and uptake of fall prevention programs. Furthermore, Canada is a sparsely populated country which may also impact older adults’ access to community programming. Differences in health care systems and prioritization of health care funds toward prevention initiatives can translate into differences in wait times, barriers in accessibility and availability of programs. These system factors can also potentially influence how fall prevention programs are designed, implemented, and understood by program providers and the older adults themselves. Although these milieu factors are important considerations, there is a current lack of published research that has focused specifically on the Canadian context.

Canadian health care is coordinated by provincial and territorial governments and spending priorities are determined at the provincial level. In Ontario, 14 Local Health Integration Network (LHIN) units are responsible for planning, integrating, and funding various health care services and centers in their respective regions, including fall prevention programs. At the time of data collection (December 2016 to March 2017), Saskatchewan was transitioning from 13 regional health authorities to one province-wide health authority. This, along with government funding cuts and regional reprioritization strategies, resulted in plans to either stop or reduce support to many community-based programs for the remainder of 2017 and beyond.

Objectives

The study objectives were to (a) comprehensively document the characteristics of fall prevention programs in specific regions in two Canadian provinces and (b) explore older adults’ and program providers’ views and experiences with fall prevention initiatives.

Methods

We used qualitative data collection methods, for example, interviews and focus groups, and qualitative data analysis methods, for example, thematic content analysis, to address our study objectives.

Sample

To identify potential fall prevention programs for older adults, we conducted an Internet search and consulted with health care professionals and academic faculty in both provinces. We identified a total of 12 fall prevention programs with program providers and managers who were interested in participating in the study; nine in Southern Ontario (Hamilton-Halton, Greater Toronto, and Niagara) and three in Saskatoon, SK. In Southern Ontario, 37.5% of all the identified programs were interviewed, whereas in Saskatoon, a representative from all identified programs was interviewed. We consulted with the program providers and managers to identify potential older adult participants. We purposively sampled participants to achieve maximum variation. For instance, in Ontario, we recruited participants from a variety of settings, for example, hospitals, community health centers, retirement homes, and community centers. Sixteen program providers and managers from the 12 programs agreed to participate and were selected based on their current involvement in planning, supervising, or coordinating fall prevention programs. In Saskatoon, the limited number of programs permitted comprehensive sampling. In Southern Ontario, where the population base is much larger, typical case sampling was used. Fifty-nine older adults residing in Southern Ontario (n = 24) and Saskatoon (n = 35) who were completing or had recently completed a fall prevention program agreed to participate.

Data Collection

Program coordinators and managers were interviewed individually, and interviews were audiotaped and transcribed verbatim. In Saskatchewan, when possible, interviews were scheduled to take place in person at the program site or in the manager’s office; however, some interviews took place by telephone to accommodate interviewees’ requests. In Ontario, all interviews took place over the telephone to accommodate program coordinator’s and manager’s requests. Using a semi-structured interview guide, participants were asked to describe program development, program logistics, perceived barriers and facilitators, desired outcomes, and perceived effectiveness. Sociodemographic data, specifically age, sex, education, training in fall prevention, and current employment information, were also collected using a standardized demographic data collection questionnaire.

Focus groups were held with older adult program participants and were also audiotaped and transcribed verbatim. When possible, focus groups with program participants were scheduled in the same location as where the program was offered for convenience of the participants. Using a semi-structured focus group question guide, participants were asked to describe their recruitment into the program, their reasons for attending, program elements and logistics, the strengths and limitations of the program, their goals and achievements resulting from the program, as well as perceived barriers and facilitators. Sociodemographic data, specifically age, sex, education, perceived level of social support, and marital, financial, and health status, were also collected using a standardized demographic data collection questionnaire.

A $15 honorarium was provided to both the program provider and older adult participants. As well, in Ontario, transportation costs was also reimbursed for the older adult participants.

Ethical considerations

Ethical approval was received from the Hamilton Integrated Research Ethics Board (#2182) and the University of Saskatchewan Behavioural Research Ethics Board (#16-393). Operational approval was obtained from the Saskatoon Health Region. Research participants provided written consent to participate in digitally audio-recorded interviews and focus groups.

Data Analysis

Thematic content analysis, a method used for identifying, analyzing, organizing, describing, and reporting themes, was used to analyze the data (Braun & Clarke, 2006). Research team members worked independently as a first step. Transcripts were read multiple times to establish initial impressions, and initial impressions were then discussed among all team members. Each member of the team then proceeded with line-by-line coding of transcripts. Codes were then refined and classified into themes, and relevant quotations were identified for each theme. At each site, the working pair of team members discussed these findings and resolved any discrepancies collaboratively. Then, all research team members met to discuss the findings and to arrive at consensus on a final coding structure.

Results

Older adult participants were predominantly females (79.2% Ontario, 88.6% Saskatchewan), with a mean age of 81.6 years (SD = 7.9, Ontario) and 78.6 years (SD = 7.9, Saskatchewan). The majority of the participants had completed grade school and were retired at the time of study participation. The average number of self-reported health conditions was 1.8, with some variations between the two provinces. The sample from Ontario reported a higher number of health conditions (n = 2.7) compared with the Saskatchewan sample (n = 1.2). A majority of the Ontario participants reported living in a house, whereas the majority of Saskatchewan participants reported their living condition as “Other.” Participants who reported their living condition as “Other” were residing in supportive housing, wellness suite, retirement homes, or a senior’s complex.

Program provider participants ranged from 27 to 58 years of age and the vast majority were female (93.7%). Over 80% had a bachelor’s degree, and time in current role ranged from 1 to 18.5 years. Job titles were variable and included: Coordinator or Program Director (n = 4); Senior Fitness Specialist (n = 1); Community Senior Worker (n = 1); Health Professional Designation, for example, Seniors Outreach Nurse or Registered Nurse (n = 2), Physiotherapist or Senior Physiotherapist (n = 6), Occupational Therapist (n = 1), and Senior Recreation Therapist (n = 1). Half of the program providers had formal fall prevention training, but less than 20% had previous experience working with a fall prevention initiative prior to their current role.

Included Ontario fall prevention programs were 6 weeks (n = 3), 8 weeks (n = 1), 9 weeks (n = 1), or 12 weeks (n = 4) in duration and were offered in a variety of settings, including hospitals (n = 2), retirement homes (n = 1), community centers (n = 2), community health centers (n = 2), seniors centers (n = 1), and family health teams (n = 1). Just over half (55.6%) were offered twice per week, and two programs were offered once a week and two programs were offered 3 times per week. Over three quarters of the programs (n = 7, 77.8%) were 1 hr in length. Two programs were 1.5 hr in length and two programs were 2 hr in length.

Only three fall prevention programs were identified in Saskatoon, and all were included in this study. The first was a 1-day clinic in which older adults were assessed and received a personalized plan to reduce fall risk, formulated from contributions from each health professional on the team with older adult input. The older adult was expected to implement the recommendations within the next 6 months, assisted by 1- and 3-month follow-up telephone calls from the program coordinator. The second was an intensive 12-week program focused on education and exercise tailored to prevent falls and reduce fall-related injuries. It was led by a registered health professional, with the assistance of student volunteers. The third was a continuous program focused on exercise and to a lesser extent, education. This program had over 110 locations (rural and urban), often in seniors’ housing complexes. Each location was led by volunteer older adults who were provided with initial and ongoing training.

Overall, 33% of programs offered medication review and 83.3% (n = 10) offered formal fall prevention education, in addition to exercise sessions, which were provided by 91.6% (n = 11) of the programs. Formal fall prevention education sessions covered a variety of topics including home safety, vision care, medication management, nutrition, winter safety, emergency response to falls, energy conservation, bone health, sleep hygiene, footwear, and mobility aids. These education sessions were led by occupational therapists (n = 3, 30%), registered nurses (n = 2, 20%), physiotherapists (n = 2, 20%), kinesiologists (n = 1, 10%), community service workers (n = 1, 10%), and peer volunteers (n = 1, 10%). Some programs also sought the expertise of other professionals such as chiropodists, dieticians, and health promoters to lead some education sessions. Exercise sessions ranged from ½ to 2 hr per week and included stretching, balance exercises, strengthening exercises, and cardiovascular/aerobic exercises. These exercise sessions were led by physiotherapists (n = 5, 45.4%), kinesiologists (n = 1, 9.1%), registered nurses (n = 4, 36.3%), peer volunteers (n = 1, 9.1%), and community service workers (n = 1, 9.1%). A large majority of the programs conducted both before (intake) and after (discharge) assessments (n = 10, 83.3%). Outcome measures included Timed Up and Go Test (TUG), Berg Balance Scale, Falls Efficacy Scale, self-reported number of falls, Patient Health Questionnaire for Depression, Six-Minute Walk Test, 30-Second Sit to Stand test, Tandem Stance test, Falls Behavioural Scale, and Fall Risk for Older People in the Community Screen. One of the most common outcome measures used by program providers was the TUG (n = 9, 75%). Ongoing programs generally administered assessments periodically to record improvements and made decisions regarding discharge from the program accordingly.

Themes

Main themes that emerged were categorized into three levels: personal, program, and system (health care) levels. See Table 1 for main themes, subthemes, and representative quotes.

Table 1.

Themes, Subthemes, and Representative Quotes.

Personal level
Outcomes	Improved function Increased awareness of surroundings Proactive attention to health Social benefits	“I know it helped me because . . . cleaning the mirror in the bathroom I could never reach the top. And now I can reach the top and clean the mirror . . .” (P3, FG5) “Well I think I’m always careful not to have scatter rugs around and things like that you know.” (P1, FG1) “You’re more careful watching what you’re doing when you are walking . . . you don’t go out in your bedroom slippers.” (P2, FG6) “. . . I was driving . . . it was sunny and I had sunglasses on. And I realized I couldn’t really see as clearly as I wanted . . . So I’m going for another eye appointment . . . I think I’m more aware I need to take care of everything. So that my balance isn’t compromised.” (P3, FG3) “. . . you are just by yourself. It’s depressing. When you . . . come down here twice a week you break out of this atmosphere you know. It helps.” (P1, FG1) “It also makes you know that you are not alone. There are other people in the same situation.” (P5, FG2)
Enablers of program attendance and progress	Goals Preventing falls Improving function Motivators Desire to remain independent Support and encouragement from instructors Enjoyment	“they want to prevent the next one so again there is a little bit of that negative incentive of not falling again.” (I8) “they know that if they don’t come to class . . . they will suffer joint pain or whatever pain and they know that after they come to the class they will feel better.” (I10) “We just all want to be more independent.” (P3, FG5) “We walk in that door and it’s group motivation. I get energized from the group as well as XXX our instructor.” (P4, FG2) “Yeah so that would be one motivation like for them to be able to see their friends . . . their classmates and kind of share the same interests, oh we’re in the same class together, we are here for the same goal . . .” (I10) “I like the socializing afterwards, that’s why I come.” (P6, FG9)
Barriers to program attendance and progress	Cognitive impairment Frailty Conflicting commitments Inclement weather Transportation issues Lack of motivation	. “. . . person with cognitive decline is not going to be learning these exercises they are going to have to be prompted every single time.” (I8) “. . . those who are really frail that they can’t even really benefit . . . I guess they have other medical issues especially . . . even mildly cognitive impairment has a significant impact on attending, . . . also the education they can’t really practice at home when they are cognitively impaired. They are very forgetful so they don’t remember what we told them and so they ended up falling again.” (I5) “if my children have birthday or some important days I don’t come.” (FG4, P6) “. . . I cancelled . . . I had to go to the doctors.” (P2, FG1) “. . . they have home care service too so they have personal support worker (PSW) going to their homes and the class coincides with the time that the PSW comes and they can’t come.” (I5) “if it’s bad weather you either stay home or you take the bus.” (P3, FG2) “summer time then we would have a waitlist because they like to come out . . . in the winter time the waitlist is shorter, or we may not have waitlist . . . they don’t want to . . . it’s dangerous, they like to stay within the building. (I5) “we’ve heard complaints of really having a hard time to come because they can’t arrange the transportation.” (I5) “I always remind them to try to do a little bit at home or whatever and a lot of the times the answer is no, they don’t . . . when they are on their own or whatever either they are not motivated, or they just don’t do it, they’d rather be watching TV.” (I10)
Program level
Program-level outcomes	Improved confidence Improved function Improvement in medical conditions Social benefits Increased awareness of surroundings	“. . . numbers may not show like a lot of improvement it may stay the same . . . talking to the participants they really find themselves like more confident in doing things at home.” (I5) “. . . her strength improved, her endurance improved, her confidence improved . . . she was able to . . . walk around her block which she hadn’t been able to do in a couple of years . . .” (I2) “. . . have really increased their strength, endurance and/or balance as well.” (I1) “. . . one woman said her blood pressure was the best it’s been . . . her doctor said I don’t know what the heck you are doing but your blood pressure is incredible and so much better, and she said I go to exercise and falls class . . .” (I2) “a lot of our clients might be quite socially isolated . . . it’s really neat to see them . . . get to know each other and some neat friendships have kind of been formed . . . they kind of hold each other accountable in that way.” (I11) “. . . a lot of clients who have told us that, you know I used to rush around, I used to get up really quickly. I’d lose my balance, I would get dizzy and they’ve said I’ve changed that so when I get up I move slowly. So I’m not rushing. Those types of things” (I11).
Program determinants of success	Availability of appropriate exercise equipment Free service provision Professionalism, knowledge, and experience (staff) Impact of program location Small class sizes	“The layout of the building is pretty good for the exercises because they have wall bars . . . They’re very much built in to the exercises” (FG1, P2) “Yep and we get to do the weight lifting . . . the elastic bands. We have balls and we have noodles . . . We try to work all of the different muscle groups” (FG10, P6) “how lucky am I to be able to come twice a week . . . and it’s free? You know? And it’s good.” (FG5, P3). “You get the impression they really care for you as a person . . . they’re not doing it for . . . just a job” (FG4, P5). “we call them if they don’t show up um I think just them knowing . . . they genuinely feel that sense of like connection that we are kind of watching and we do care about them . . . sense of community is one thing.” (I2). “So some of our clients will even walk to the center for the session . . . they were really strategic on where they placed our building so that people could get to us easily.” (I11) “it’s a pretty good location. Because it’s in again the retirement complex . . .” (I12) “. . . we have small classes, so they can pay attention to the individuals . . . if they see someone who needs a little more attention they would focus on that person.” (FG4, P5) “because it’s a smaller size so they will sit in a circle . . . we can see that they provide a lot of peer support because it’s a smaller size.” (I6)
Barriers to program attendance and success	Lack of staffing Lack of space Need for consistent fall prevention program services	“. . . even if we could keep up with the referrals we don’t have the staffing to provide enough exercise classes . . .” (I7) “. . . I wish I could get a helper and that I could take more people cause that is the only reason why we don’t . . .” (I2) “I don’t think it’s big enough for the fall prevention class, . . . we are trying to you know do more walking within the space but then the space is not big enough . . .” (I5) “. . . we have space issues as well . . .” (I8) “. . . 70% of the clients would like to continue . . . if we have a waitlist then at the end of the three months they will have to graduate no matter because we need to enroll the new clients.” (I5) “. . . a lot of the seniors they are not able to graduate from the class . . . they keep repeating that 12 week falls prevention class. So that’s the one difficulty that we have is that it’s really hard for a senior to be able to gain that strength and be like okay well I’m able to do you know a general exercise class now.” (I10)
System level
System determinants of success	Post–fall prevention program referral	“The therapist tries to link them up with community-based programs . . . we also try to link them up to one of the community-based programs upon leaving . . .” (I7)
Barriers to program success	Lack of awareness of fall prevention programs Programs undervalued by funders Need for attitude change toward seniors	“I guess it’s mainly the lack of publicity for it . . . We really knew nothing about them until Dr. XXX recommended XXX to go.” (P3, FG1) “. . . I don’t think enough is shared about the actual successes that the program . . . we are doing really great things and I don’t think people maybe you know it’s a little bit frustrating to hear that the XXX, I mean that might not be true, but that the XXX only cares about the numbers, cause when you are in it and you see the difference . . .” (I2) “It takes elderly people longer to cross the street and I think that spreads in to you know XXX drivers and whatnot . . . there is a growing awareness . . . there should be more education around it . . . there should be education with bus drivers, with making the lights longer when you cross the streets. And I think there is a growing awareness of that because of the aging population. (P3, FG3)

Personal-level outcomes

Older adult participants expressed a range of beneficial outcomes as a result of program attendance: improved function, increased awareness of surroundings, proactive attention to health, and social benefits. These positive outcomes were perceived to be influenced positively or negatively by several enablers and barriers to attendance and progress.

Enablers of program attendance and progress

Participants attributed enablers of their program attendance and progress to two main factors: personal goals and motivators. Reported personal goals for attending the fall prevention program included preventing falls and improving function. Although the majority of the older adult participants had been referred to a fall prevention program by a health care professional, motivators to follow through with the referral or to continue to attend the program included: the desire to remain independent, support and encouragement from instructors, and enjoyment.

Barriers to program attendance and progress

Both program providers and older adults discussed a number of barriers impinging on attendance and progress in the program. Program providers expressed their concern that cognitive impairment reduced some participants’ capacity to fully benefit from the program services, due to inability to retain or recall educational information and to engage in the exercises at home independently. Program providers also felt that older adults with frailty could not fully benefit from the program due to multiple comorbidities and health issues. From the older adults’ perspectives, barriers to attendance included conflicting commitments and transportation barriers. Most of the older adults prioritized medical appointments and family commitments as these arose. Program managers corroborated this information, noting that medical or home care appointments sometimes overlapped with the program schedule, resulting in non-attendance. Older adults also faced issues with transportation, for example, cost, travel time, lack of reliability, and coordination issues associated with accessible transportation services. Older adults reported accessible transportation as inconvenient because they had to book pick-up times in advance. Both older adults and program providers noted decreased attendance associated with inclement weather and older adults raised concerns regarding safety during “harsh winter days.” Older adult participants also identified lack of motivation as affecting attendance or at-home implementation of program recommendations. Participants reported lack of motivation when performing exercises alone at home and attributed such behavior to laziness and other distractions at home such as television. Older adult participants also reported not feeling confident in their abilities to engage in activities independently at home.

Program-level outcomes

Program providers observed several beneficial outcomes as a result of program attendance, including: improved confidence, improved function, improvement in medical conditions, social benefits, and increased awareness of surroundings.

Enablers of program attendance and success

Both program providers and older adults identified various factors that facilitated program sustainability and success: frequency and length of program preference (older adults), access to appropriate exercise equipment, free service provision, professionalism, knowledge and experience of staff, program location, and small class sizes. Older adults who participated in 6-week programs felt the length of program was not sufficient, and very few participants preferred classes once per week. Older adults indicated programs offered twice per week as most appropriate. Overall, the older adults preferred 30- to 45-min sessions, no more than 2 times per week and no less than 8 weeks in total duration, although this did vary somewhat among participants. The majority of the older adults believed they had access to appropriate exercise equipment, and they appreciated being able to use exercise equipment if they were attending an ongoing program. However, older adults attending time-limited programs expressed concern of not being able to use the equipment (e.g., NuStep machines and weights) after program completion. These individuals appreciated exercises that did not rely on specific “gym-type” equipment.

All of the fall prevention programs were offered free of charge and both the older adults and program providers recognized that eliminating the barrier of cost improved program attendance. Program attendees greatly valued this free service, and some indicated they would not have attended if they had to pay. Another theme identified from the older adult data was the staff professionalism, knowledge, and experience. Older adults believed program providers understood their limitations, but also encouraged them to reach their goals. Impact of program location was also identified as a theme. For example, programs offered at community health centers or multidisciplinary centers had the advantage of receiving referrals for older adults who visited the facility for other services. Once the fall prevention program was completed, older adults could connect with other services at the centers. Older adults who attended a hospital-based program noted they felt safer being at the hospital and knowing they would receive immediate assistance in emergency situations. Participants who attended fall prevention programs within their retirement home facility recognized the benefits of not having to manage transportation and weather barriers. Program providers noted that participants benefited more from group sessions with a small class size. Small class size allowed for more attention from the instructor, more opportunities to try more challenging exercises, and enhanced safety. Instructors were able to individualize and modify exercises, as they were better able to attend to participants with different levels of ability. With a small class size, participants also benefited from opportunity to interact with their peers at a more personal level, thereby enhancing the overall experience. It was noted that small class sizes very mostly a result of lack of space available to support a larger group or lack of staffing to ensure adequate supervision.

Barriers to program attendance and success

Program providers shared concerns regarding the lack of staffing, lack of space and the need for consistent fall prevention program services instead of time-limited programs. Lack of staffing and lack of space limited the ability to provide services to meet the demands of referrals. This led to the formation of waitlists and required administrative time to manage. Program providers recognized that older adults require consistent fall prevention program services rather than time-limited program as older adults may regress and not retain gains made upon discharge.

System-level determinants of program success

Enablers of program success

A common theme was related to the post–fall prevention program referral process initiated by the program providers. Program providers expressed the importance of continued fall prevention interventions to sustain positive outcomes and therefore tried to link the older adult participants with other community-based exercise programs after a time-limited fall prevention program was completed. Some programs providers allowed continued attendance even after the individuals had utilized their allotted time at the program.

Barriers to program success

A common concern raised by program providers was the lack of awareness of fall prevention programs among older adults. Program providers attributed the lack of awareness to inadequate promotion or advertising, due to insufficient program funding. One program provider used her private funds to advertise the program in the local community. This program provider noticed increased attendance at the time and believed if funders allocated separate funding for advertising and promotion, the program would be better attended. Program attendees generally learned about a program through their physicians or other health care professionals and felt the primary care providers should be more proactive in learning about these services and recommending them. Program providers believed that prevention is typically undervalued by funders and thus is subjected to budget cuts. Program providers felt they had to be solicitous to prove the value of program and to be creative to garner resources. It was acknowledged that the burden of falls prevention success cannot be borne only by older adults and service providers but is also a social burden. Older adults, particularly those living in an urban setting, discussed the need for attitude changes toward seniors to promote “senior friendly” communities. Older adults discussed the need for improvements in city bus services, enhanced understanding from younger individuals, and sidewalk traffic safety. Older adults felt that bus drivers leave bus stops too soon, which presents a fall risk for older adults if they are not properly seated. It was also noted that bus drivers need to advocate for disability seating as some individuals do not vacate seats for older adults and the hand holds in the buses are too high to reach. Older adults also felt that younger individuals do not pay heed to them on pathways and sidewalks causing them to lose their balance. In addition, some also discussed the need for longer pedestrian walk signals to allow for adequate time to cross the road.

Discussion

As with research on older adults’ perceptions of fall prevention programs in the United Kingdom and Australia (Ballinger & Clemson, 2006; Dickinson et al., 2011), several beneficial program outcomes were identified in this study. These included socialization and increased confidence. Both program providers and older adult participants identified various factors that either facilitated or hindered the delivery of fall prevention programs for older adults at personal, program and system levels. Having an understanding, these factors can assist program providers in developing and delivering programs that are aligned and well-adapted to the care needs of older adults in their community and presenting relevant information to health care decision makers. It is evident that both program providers and older adult participants feel there is too little awareness of fall prevention initiatives in the community in the two regions included in this study. Several older adults expressed that they were unaware that these services were available to them and that they were free of charge. These findings are similar to those identified in previous research (e.g., Dickinson et al., 2011).

The need for effective advertising, promotion, and dissemination of information regarding fall prevention services to the public in general and health care providers specifically is crucial. This could be facilitated if fall prevention program budgets included allocation for advertising, to promote awareness of programs in the community. Family physicians and other community-based health care professionals serve a pivotal role in disseminating information to older adults who are unaware that such services even exist. Community nurses, occupational therapists, and physiotherapists are all well equipped to identify fall risks in older adults and initiating referral process to fall prevention services (Unsworth, 2003). By identifying those at risk of falls, health care professionals can assist older adults with navigating the system to find a fall prevention program that is most likely to be of benefit (Lawson, Zaluski, Petrie, Arnold, Basran & Dal Bello-Haas, 2013). Accessible locations of fall prevention program venues were identified as enhancing program attendance and participation, a finding previously reported by Dickinson et al. (2011). Although none of the included programs provided transportation services, some program providers suggested that the provision of transportation would allow for an increased number of older adults accessing these services.

Several program providers referred older adults to community exercise programs upon program completion. Although exercise is an effective fall prevention intervention, community exercise programs may not be specific to fall prevention and may not be able to meet the needs of older adults who are frail or have multiple comorbidities, health concerns, or cognitive impairment. A program provider indicated that community exercise programs typically serve about 30 to 40 participants per session, versus 10 to 20 participants in targeted fall prevention programs for older adults. Frail older adults with increased risk of falls need specialized attention that may be lacking in the community exercise programs. Although older adults with high care needs and increased falls risk may excel in community exercise programs with smaller participant-to-instructor ratios and instructors with specialized knowledge about older adults, some program providers believed community-based exercise programs may be too intense for frail older adults. This may explain the hesitation of some program providers to “graduate” participants from a fall prevention program and refer them to a community exercise program. This also highlights the need for exercise programs that are well-adapted to the needs of frail older adults requiring ongoing interventions. With some ongoing programs not “graduating” participants due to safety concerns, this may lead to fewer spots for new participants to engage in fall prevention program services. An ongoing peer-led fall prevention program offered in Saskatchewan seems to address these concerns. The program trains peer leaders to exercise safely, which includes education regarding basic anatomy and rationale behind various types of exercises. The classes are led by these peer leaders at convenient locations such as community centers, churches, seniors’ centers, or apartment buildings. The program provides ongoing services without the need to graduate seniors because it is not heavily reliant on health care professionals as the peer leaders are trained to offer the classes independently and receive ongoing supports and continuing education from Saskatchewan Health Authority. Some differences in characteristics of participants between the two provinces were noted, for example, the difference in mean ages and reported health conditions. Participants in Ontario were representative of an older group that may explain the higher number of reported health conditions.

Older adult participants also identified several system elements. The notion that fall prevention goes well beyond offering fall prevention classes was identified. Older adults suggested the need for a broader community-level awareness and strategy development to address older adult fall risk and prevention.

Limitations

This study has some limitations. First, a majority of the older adult participants were females. Our sample is reflective of the longer life expectancy for females compared with males and that females tend to engage in more health-seeking behaviors than males (Mackenzie, Gekoski, & Knox, 2006; Nabalamba & Millar, 2007). Regardless, our findings do not offer specific insight into male older adults’ perspectives toward fall prevention programs. Second, the only eligibility criterion to participate in the study was previous or current attendance in a fall prevention program for older adults. One of the Ontario focus groups consisted of participants who had attended a program 8 months prior to study participation. This may have introduced recall bias, although we did not notice any significant differences in themes when we compared with participants who were currently attending or had more recently attended a program.

Conclusion

The need for widespread awareness, including at the broader community level, of fall prevention initiatives for older adults is evident from the accounts of both program providers and program attendees. Health care providers play an important role in identifying potential fall risk in older adults and assisting with systems navigation. Additional strategies to ensure programs target older adults whose needs may exceed what typically can be addressed in community-based exercise programs are critical. The findings provide thought-provoking considerations for program providers, funders, and communities regarding resource allocation that would be barriers to attendance and participation in fall prevention programs.

Footnotes

Acknowledgements

The authors thank the older adults and program providers who participated in our study.

Declaration of Conflicting Interests

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

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Saskatchewan Health Research Foundation.

ORCID iDs

Humna Malik

Fiona Fick

Paulette V. Hunter

Sharon Kaasalainen

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