Fall Prevention: The 3Es, Promising Practices, & Evidence-Based Interventions

November is Fall Prevention Month in Canada. In Canada, almost 150,000 people, aged 65 and older, were hospitalized for injuries between 2017 and 2018. The majority of injuries were caused by falls, and every year, it is estimated 1 in 3 seniors aged 65 years and older are likely to fall at least once. Falls are a result of a combination of multiple risk factors and therefore requires a multi-pronged public health approach. The Public Health Insight Podcast examines promising practices and evidence-based interventions across the areas of falls risk assessments, the 3Es of injury prevention (i.e., engineering, education, and enforcement), exercise programs, the role of healthcare providers, community, and supportive policies. Is there more we should be doing to address falls or should we be more focused on creating an environment for seniors to maintain their independence?

References for Our Discussion 

• American Public Health Association (APHA) | Nation’s Health: Preventing senior falls requires community approach: CDC resources help health workers create programs that work

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Transcript

[00:00:00] Leshawn: Hey, Public Health Insight listeners. It's Leshawn here with a quick update. Public Health Insight is proud to sponsor Moving Beyond Repair a student led conference hosted by Dalla Lana School of Public Health at the University of Toronto. Over three days from November 12th to 14th, you can explore upstream approaches to public health emergencies, engage with experts in public health, and listen to emerging student research. Not only will you have full access to the webinars sessions, but you will also be able to attend interactive workshops and small-scale social networking events. On top of that tickets are free. So if you're interested in registering for the conference, please check out our episode description for more details. Thank you. 

[00:00:43] Sully: Public health is a population-based field of science focused on preventing disease and promoting health. Every week, you will be engaging in interactive discussions and analyses of the latest public health issues affecting you and your communities all around the [00:01:00] world. This is the Public Health Insight podcast.

[00:01:04] Ben: Hello everyone. My name is Ben and I'm here with Linda, Gordon, and Leshawn. Before we move on its important to note that the views expressed in this podcast are our own and do not represent any of the organizations we work for or affiliated with. 

[00:01:17] So we looked at the issue from a 30,000 foot lens in our previous episode, and it's clear that falls are a serious issue. In this episode, we will move the conversation to what public health interventions have been implemented thus far as well as critically analyzing any shortcomings. We'll be using interventions in specific countries as case studies for our analysis. 

[00:01:38] So I wanted to open up to you guys, what are arenas of action for public health interventions and fall prevention? And how can we apply them? 

[00:01:45] Linda: We mentioned in the previous episode that it's a multifactorial issue. So I think in this case, it's a strength because that means there are different ways we can intervene. 

[00:01:54] Ben: So what you're saying is that because even the causes of falls are multifactorial, [00:02:00] that the solutions are multifactorial as well. So we don't have to think of one silver bullet, but instead multiple places where we can put pressure on to help find the solution. 

[00:02:09] Linda: Exactly. And there are opportunities for like a whole of community approach to address these issues. 

[00:02:14] Ben: So Leshawn, in our previous episode, you've made some great points regarding modification and resources.

[00:02:20] So what do you think are some policies or interventions that we can go into home assessment and modification? 

[00:02:26] Leshawn: That's a very important area that you can kind of, um, act upon, um, in terms of prevention. So patients with a history of falls can benefit from, you know, specialists that come in and, you know, assess, um, living conditions or the environment to see where they can improve or prevent a potential, um, fall from occurring.

[00:02:48] So these are things like we mentioned in the previous episodes, like considering using handrails and stairs, Where you have maps that are non-slip maybe using indoor shoes with [00:03:00] grips and considering different areas of the house and making small improvements in those areas to prevent a fall. 

[00:03:08] Gordon: I think Ben, you mentioned, um, us needing to take a 30,000 foot view on the issue of fall prevention, right?

[00:03:17] In the practice of injury prevention, there's kind of a three E's guiding principle. Which is, um, engineering, enforcement, and education. And then there's discussion about adding a fourth E to the equation, which is equity, as we discussed, um, there's some inequities in the way falls are distributed. So that's why that's being discussed.

[00:03:37] So Leshawn kind of touched on the engineering side of things, you know, the home modifications. Um, there's also room for, education, which is what we're doing now. Like, did you know that fall was a public health issue? Do you know that falls are preventable? Do you know what resources are out there to prevent falls?

[00:03:56] Do you know what the risk factors are for falls? Did you even know that, you know, [00:04:00] um, maybe you're, you're you are sick if you're an elderly person or you have a grandmother who's sick, who started a new medication, are you aware that that medication could increase the risk of her falls? Right. So this is, these are some of the educational pieces that goes into the three E's of injury prevention. 

[00:04:17] Leshawn: And like even going off the education bit, as an individual, as an elderly person, like how, how do you fall properly? Like there are steps and best practices to know what to do when you're, when you're about to fall and there are steps and best practices on what to do in regards to how to get up after you have fallen. Right. So there's different steps you can take and education plays a big role in that as well.

[00:04:44] Ben: What can we focus on in terms of community engagement? Because as we know, education has to come from the community, is there any specific interventions that we could include? Is that the goal of it to identify people? Or is it the goal to make sure that we can refer them to [00:05:00] local resources? Is it both? Like, for example, home visitation programs, is there a training of individuals and communities with appropriate pediatric or geriatric medical care that should know, Hey, if a fall occurs, this is what happens in relation to children. This is what happens in relation to older adults. Um, is it simply, you know, you don't have to go into a really intense falls prevention program, if it's not available, is it simply making sure that an older adult is joining an exercise program, such as Tai Chi, where, you know, you focus a lot of stable stability and balance. And is it that simple? Like, is the evidence there or is it more, we need a combination of all these things? 

[00:05:43] Leshawn: Yeah. That's a, that's a great point. And I would definitely say a combination is probably best that touches at different levels. Right? You want to touch at the individual, the community level policy level, the more levels you hit?

[00:05:54] I think the more successful potential interventions would be, but, um, based on some of the [00:06:00] readings I went through, there was a really cool initiative. Basically the intervention involved individuals who are 65 years or older, um, they were trained by their local community center on, you know, best practices of, um, how to prevent falls, um, doing exercise during watching TV during commercial breaks, um, cooking, cleaning, gardening, just as strengthen and exercise, um, your, your muscles and these individuals who are trained on this would go out into the community and train individuals who needed the help in the community. And, you know, they would kind of pass on the knowledge and teach them.

[00:06:39] Gordon: Um, I wanted to, um, bring up, um, this tool that's available for people who are 55, 60, 65 plus or older or caregivers to those people, or even, you know, grandchildren, um, children of those people. And it's called a Falls Risk Assessment tool. And there's various versions of it out there. [00:07:00] And in most cases, um, if you get it from a credible resource, the questions have been validated.

[00:07:06] Um, so what this tool essentially measures, it asks you, it's kind of like a questionnaire. It asks you, what is your age? What is your history of falls? And there's like a point scoring system. And at the end of the questions, you tally up all the points and the falls risk assessment tool will tell you if you're a low, moderate, or high risk for experiencing a fall.

[00:07:27] So when you think of community-based initiatives, this is not something you would need a healthcare provider for to start that conversation. What you would, what you would do is you'd have, um, if you're having something like a fall prevention clinic, for example, you would have people. And I know, um, in Windsor, um, our health units involved with the, um, Windsor Essex county fall prevention coalition.

[00:07:50] Um, and they, a lot of times they have fall prevention clinics at the mall because seniors tend to frequent the malls, right? So they give out these Falls Risk [00:08:00] Assessment tools. They can answer the questions. And then basically this will flag the person. And this is especially important for a lot of times for people who don't think they're at risk of falling, because, if you've fallen before, it's likely that you'll take it seriously as a personal fall and follow up with your health care provider. But this one, this kind of allows the person to go, oh, wow. Um, you know, it says I haven't fallen yet, but I, um, this tool says I'm, I'm at a high risk for falling. Um, given that my age, my medication history and stuff like that, cognition and mobility, and maybe I should start having this conversation with my healthcare provider to make sure the medications I'm taking are safe for me. Uh, to seeing what can be done in my home environment, like grab bars in the shower and near the toilet, to prevent a fall from occurring. And this is important because we know that the most powerful predictor of a fall is a previous history of a fall. Right. So we want to catch people before their first fall event because the risk [00:09:00] just keeps going up after the first time you fall. 

[00:09:02] Ben: Yeah. And that's a great point that you made regarding the healthcare workers, because right now clinicians are the primary stakeholders in terms of screening falls because they work directly with the population. So they'll take a history and there'll be like, did you have any recent falls? Are you experiencing any of these comorbidities that may lead to a fall? 

[00:09:20] So when we only have one aspect that is screening, it's difficult to figure out from the data, what is actually happening. Like there's a lot of preemptive stuff that we should do that, like you mentioned, and also it shouldn't only just be focused on physicians, screening for falls. It should also be the pharmacists who are looking at the medication and be like, oh, I can see that this certain prescription may have these side effects.

[00:09:44] This is a red flag. We should be monitoring this. Or if there's physiotherapists also involved, you know, they're very great at coming to those home visits that Leshawn described in community engagement, where they go and they teach people how to strengthen their muscles, have better balance, et [00:10:00] cetera. So I feel like it's very much a allied health care worker approach instead of just physicians. 

[00:10:05] Gordon: I totally agree with that. But when you even think about from the perspective of the clinician and the Falls Risk Assessment tool, the great thing about it is that it's not, like I said, it's independently validated. It doesn't require, um, a medical brain to interpret it.

[00:10:21] It's it's algorithmic. Um, it's like, yeah. Based on your responses, you should be concerned about falling and losing your independence. So this kind of empowers the community because now the community has a tool to go around and say, Hey, this is a very important tool to, you know, provide education of your risk of falling. And then here's some action steps you can take, if this tool has told you that you're a moderate or high risk of falling. 

[00:10:47] Linda: And even something, you know, cause once you do that assessment and you're like, okay, I'm at risk of falling, now what do I do that could make someone worry. But even something like creating an action plan, if you or someone in your family is an elderly [00:11:00] person who lives alone, you know, okay, someone can check on them in case they do have a fall and no one is around or who do they call or what do they do? So unfortunately, the way our prevention is set up, a lot of it is based on the individual people to create a plan for themselves. 

[00:11:16] Gordon: Yeah. Yeah. And you know what, like even just putting everything together.

[00:11:20] So typically like we discussed the healthcare provider comes in when something already has happened. Right. So you go to the healthcare, you go to your doctor, not because you're worried about getting the flu. You go to the doctor because you have the flu. Right. So we want to, as a community empower it in such a way where there doesn't have to be as much of a burden on the healthcare system.

[00:11:46] So when you think of, um, things like even funding community programs, there are a lot of healthy aging programs in communities that often are the first to go when there's some budget deficits, you know, whether it's in the city [00:12:00] or the provincial level. And when we don't think of kind of the fallout with, you know, the financial burden of falls, because maybe if you're in decision-making and stuff, you're not aware of how important fall prevention is because you're not personally touched by it. Fall related injuries and deaths, um, cost Canada about almost $7 billion a year. So when we, when you think of it, that way, there should be more of an urgency to kind of fund and support community initiatives that are set up for the very purposes of fall prevention. 

[00:12:31] Linda: Yes, Gordon, I agree with everything that you were saying. Um, but even if there aren't explicit fall prevention programs, things like mall walking programs or, um, areas where perhaps elderly can get together and be more active. Um, those things indirectly do aid in fall prevention. So when people can make a prevention plan for themselves and understand, okay, this is what I have available within my community. How do I utilize what resources [00:13:00] exist within my community? Even if maybe there is a lack of funding, how can we still use what we have to reduce the risk of falling? 

[00:13:08] Gordon: Yeah. And to the point of, I hear what you're saying about, um, even if it's not as part of a fall prevention program, but I think the problem with that is the evidence suggests that, um, these components individually don't have a positive, not even as much, there was no difference, really, if you compare it to someone who wasn't engaged in a program. All the success of programs involved, all the kind of E's of injury prevention, three E's that I touched on. So I know it's difficult. You know what you're saying is, okay, if you don't have all the money to do all the things, do you just not do anything or you try to do something.

[00:13:48] So I hear, I hear you on that, but I think. We got to kind of get people to recognize that because falls is a multifaceted approach, um, that you have to try your best to have [00:14:00] multifaceted interventions as well. 

[00:14:01] Ben: Right. 

[00:14:02] Leshawn: So I guess when we're talking about multifaceted interventions, do we have any examples of any sort of policy interventions that have been done in this kind of area?

[00:14:12] Ben: I'm glad that you mentioned that because Switzerland did a national campaign to reduce, um, their fall related injuries in 2000 by the Swiss Federal Injury Prevention Agency. And what they focused on was long-term care facilities. And this specifically focused on using hip protectors and exercise program and environmental adaptations as a multi-factorial approach. So hip protectors covers the whole internal factors of why an individual would fall, right? Whether it's due to stability, medication, et cetera. The exercise program worked on, again, internal factors, but there was also, the environmental adaptations where modifying the home, so that covers more external factors. So it's bridging all of those together in your approach that seems to have the best [00:15:00] evidence for effective falls prevention, because one of the caveats to exercise that critics have mentioned is that how are you going to get older individuals to exercise if they're already weak and they don't have the capacity to? Are you putting them at risk? And then obviously means that you would modify the exercise, but it's a good point in the terms of should this, if this preventative measure, which is meant to be beneficial is causing you harm or risk, is it really beneficial? So that's why I think you just cover your bases with other aspects of the intervention 

[00:15:30] Gordon: Yeah and because public health research is so tough as opposed to something like a randomized controlled trial and a drug where you can like tease out, okay, this was 10% effective. With public health you need to kind of throw everything at it and see if that's effective because the individual impact of one is so small that you can't even measure it. So that's why sometimes you have to have multiple interventions to see the cumulative effect, rather than trying to tease out the effect per component. 

[00:15:57] Ben: Yeah, and I'm glad you mentioned that as well, because [00:16:00] you just kind of have to look at the scenarios that are existing in our world, and then try and figure out from the data, what comparisons that you can make.

[00:16:07] So in Norway, an interesting thing happened where basically two different cities approached the falls prevention in two different ways. One did a community-based intervention and one didn't. And basically what the intervention was is that they removed environmental hazards in homes and they promoted safe outdoor footwear in winter.

[00:16:26] Just those two things, right. The rates of fracture from falls did not decline in residential care settings, but they decreased 26% in the community. And there was also a 17% reduction in hospital admission rates for fall fracture patients from the community. So just those two things, we have a great reduction. 

[00:16:45] Gordon: But then, you know what that shows to, um, not to make things even more complicated.

[00:16:50] So in addition to it being multifaceted is like, what is your target population? 

[00:16:54] Ben: Exactly.

[00:16:55] Gordon: We discussed about half of the falls that occur, occur [00:17:00] in people's own homes. So, right. So something like a home modification and stuff like that can help to address that 50% of people who fall in their homes, that those home modifications won't impact people who fall in residential care facilities, because the language is a bit different in that it's not a home.

[00:17:18] So you'd have to kind of tailor your approach to where the kind of target population is. So if it is it's seniors, living in care facilities is seniors living at home? Is it seniors in community dwelling? So if it's a community dwelling, then something like a sidewalk is important. Um, for if you're living in a care facility on a private property, then the sidewalk and stuff becomes less important.

[00:17:43] Right? So you won't see an effect there. So just, I think sometimes at public health we try to have a big effect on the population level, but sometimes you almost have to pick up subpopulation and kind of implement something there to get the best effect. 

[00:17:58] Ben: Yeah. And especially if you don't [00:18:00] have the resources of funding, you'd have to go for the low-hanging fruit, 

[00:18:02] Linda: but then success in those areas you could use for buy-in for more funding for also, so. Start small, I guess if that's all you have. 

[00:18:12] Gordon: I think you just come to the conclusion on public health just never has any money, man. 

[00:18:16] Ben: Yeah, basically.

[00:18:19] Gordon: Yeah. So what role does kind of medical innovation have to play in terms of fall prevention and preventing fall related injuries and what role does even something like technology have in preventing those?

[00:18:32] Leshawn: Yeah, just off the top of my head, I just, um, something that comes to mind is the apple watch and one of the new, I guess, maybe not new anymore, but they have a feature in that apple watch that can detect when someone falls. And if, I guess they're not responsive after a certain amount of time after the apple watch detecting that the person is, uh, fallen it'll kind of call for emergency contact.

[00:18:59] Gordon: Yeah. And, um, [00:19:00] that's a good point because I don't think we mentioned in this episode, oftentimes I'm not sure of the exact percentage. But a lot of times, the reason why people who fall in their homes are disproportionately affected are because sometimes they live alone.

[00:19:16] Leshawn: Live alone, yeah. 

[00:19:16] Gordon: And if you fall and you don't, you don't have any access to the phone to call for medical assistance or emergency assistance. Then you're talking about an hour or two, maybe even 10 hours from the fall event. So that significantly decreases your chances of survival when you do get medical help. So that's one of the, you know, while a watch might not prevent a fall from happening, a watch might be able to, um, decrease the mortality rate due to falls because people can get medical care sooner.

[00:19:49] Linda: Do you know, if we have any type of national or even in your provinces, like a provincial, um, strategy per se, because here, I know, like in Alberta Health Services and [00:20:00] Injury Prevention, we do have a fall prevention focus, but all of it is very much on the individual, uh, reduce risk factors in your environment. It's not much of like, what are we as a government, as a province doing. 

[00:20:12] Leshawn: Yeah, that's an interesting point. I was watching a webinar by Loop, which is kind of a fall prevention community of practice organization. Yeah. And, um, basically their approach to this was kind of incorporating fall prevention into social policy. So an example of that would be, um, if you're looking at targeting children and youth, um, you would have maybe, um, enhanced home visiting programs where an individual who's trained in this comes in talks and talks to the parents and the children about hazards and how to prevent falls, or it can be in the form of a provincial child benefit where, um, financial assistance is offered to lower-income families.

[00:20:56] And this could be used, like I mentioned, in the previous episode, um, for, [00:21:00] uh, child gates to prevent them falling down stairs, et cetera, or even policies that are targeted towards elderly individuals. So income supplements and senior benefits. So, um, financial assistance from these types of policies can go and contribute to some of these devices that we're talking about for fall prevention.

[00:21:19] Gordon: That's a good place to end, and Leshawn popped off for a minute there. Yeah. I know I showed up to the party better late than never. 

[00:21:26] Ben: Fashionably late. 

[00:21:27] Leshawn: Let's go. 

[00:21:28] Ben: So in this episode, we discussed interventions that can be used for fall prevention, as well as highlighted some cases where community action has been proved to be successful. 

[00:21:38] Falls are a complex and serious issue as we've discussed. So November is fall prevention month in Canada, and we hope that you can use this episode and the knowledge within it to inform and take care of those who may be at risk of falls in your community. 

[00:21:52] Gordon: Shout out to the Canadian Fall Prevention Curriculum, shout out to Loop.

[00:21:58] Leshawn: That's hilarious. Life [00:22:00] lit apple watch apple sponsor us. Right? Let's go 

[00:22:03] Gordon: parachute, parachute, shout out to parachute for duty zero vision zero dementia episode. Yup. You got to get lit. You know, Linda's calling you out. You need to get involved with fall prevention too. If you're not, 

[00:22:15] Linda: No no, not calling them out, calling us out. We should do it. 

[00:22:21] Sully: Thank you for listening to the Public Health Insight podcast, your go to space for informative conversations, inspiring community action. If you enjoy our content and would like to stay up to date, follow us on Instagram, Facebook, Twitter, and LinkedIn, to learn more about our community initiatives and how you can support us visit our website at: ThePublicHealthInsight.com 

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