n'balance: a community-based fall-prevention intervention with older adults—lessons learned

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N'Balance: A Community-Based Fall-Prevention Intervention With OlderAdults—Lessons LearnedCatherine M. Headley a , Laura L. Payne b & M. Jean Keller ca Department of Exercise and Sport Science , Judson University ,Elgin , ILb Department of Recreation, Sport and Tourism , University of Illinoisat Urbana-Champaign , Champaign , ILc Department of Kinesiology, Health Promotion and RecreationStudies , University of North Texas , Denton , TXPublished online: 13 Mar 2013.

To cite this article: Catherine M. Headley , Laura L. Payne & M. Jean Keller (2013) N'Balance: ACommunity-Based Fall-Prevention Intervention With Older Adults—Lessons Learned, Activities,Adaptation & Aging, 37:1, 47-62, DOI: 10.1080/01924788.2012.760139

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Activities, Adaptation & Aging, 37:47–62, 2013Copyright © Taylor & Francis Group, LLCISSN: 0192-4788 print/1544-4368 onlineDOI: 10.1080/01924788.2012.760139

N’Balance: A Community-BasedFall-Prevention Intervention With Older

Adults—Lessons Learned

CATHERINE M. HEADLEYDepartment of Exercise and Sport Science, Judson University, Elgin, IL

LAURA L. PAYNEDepartment of Recreation, Sport and Tourism, University of Illinois

at Urbana-Champaign, Champaign, IL

M. JEAN KELLERDepartment of Kinesiology, Health Promotion and Recreation Studies, University of North

Texas, Denton, TX

An examination of a community-based fall-prevention interven-tion, N’Balance, for adults age 55 and older was completed.N’Balance is a multidimensional intervention. A quasi-experimen-tal intervention trial with a control group, using two sites, wasthe research design. This 6-week intervention met twice weeklyfor 50 minutes and included pre- and post-tests of physical andpsychosocial aspects. Results indicated that N’Balance was asso-ciated with improved balance, a reduction in the fear of falling,and approached significance with leisure self-efficacy. The RE-AIMmodel was used with this intervention to explore its reach, effi-cacy, adoption, implementation, and maintenance in communityrecreation settings.

KEYWORDS fall prevention, N’Balance, older adults, balance,self-efficacy, RE-AIM

Falls are the leading cause of injury deaths, are a major cause of severenonfatal injuries, and are the most common cause of hospitalizations among

Received 07 January 2012; accepted 12 May 2012.Address correspondence to Catherine M. Headley, Department of Exercise and

Sport Science, Judson University, 1151 North State Street, Elgin, IL 60123. E-mail:[email protected]

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48 C. M. Headley et al.

adults age 65 and older (Centers for Disease Control and Prevention [CDC],2010). One out of three older adults falls each year with 20%–30% sufferingserious injuries (Hausdorff, Rios, & Edelber, 2001). Sedentary older adultsmay have reduced mobility and physical activity, which increases their riskof falls. Falling may be defined as an incident that results in a person comingto rest inadvertently from a higher to a lower level (Vellas, Garry, Wayne,Baumgartner, & Albarede, 1992).

Falls have public health implications that directly impact older adults,their caregivers, spouses, friends, family, health care organizations, andcommunity-based recreation programs. To reduce the risk and incidence offalling, public health professionals are emphasizing proactive and preventiveholistic health-promotion approaches, including fall-prevention interven-tions. There are numerous ways older adults can reduce their fall risk,decrease fall-related injuries, and improve their physical and emotionalhealth (National Prevention Council, 2011). Also, it is well known that physi-cal activity is important throughout the life span. Remaining physically activeno matter the setting is important for public health.

Community-based programs and interventions with older adults havebecome more prevalent. Yet, relatively little research focuses on how bestto conduct studies and implement programs for community-based recreationprograms. This may be due to insufficient evidence related to the effective-ness of fall-prevention programs or to a lack of training and education relatedto fall prevention by community-based recreation professionals. This studyexamined a fall-prevention program titled N’Balance, and used the RE-AIMmodel to better understand issues that might affect its reach, efficacy, adop-tion, implementation, and maintenance in community recreation settings.

THE IMPORTANCE OF FALL-PREVENTION PROGRAMS

Older adults often fall because of impaired balance due to changes inthe functioning of the body’s sensory systems (i.e., vestibular, visual, orsomatosensory) or chronic diseases that occur with aging. Additionally,extrinsic risk factors are those elements that are external to individualsand include environmental hazards such as poor lighting or wet surfaces,which may cause older adults to fall (Keller, 2009). Another often over-looked extrinsic risk factor for falls among older people is medication, bothprescribed and over the counter. Older adults who take four or more pre-scription drugs have a greater risk of falling than those who take fewer (Todd& Skelton, 2004). Another concern is that later life is associated with highincidences of and susceptibility to injuries, particularly fall-related injuries.Falling is an indicator of undetected illnesses, and numerous falls predict adecline in physical abilities (Carter, Kannus, & Kahn, 2001; CDC, 2010; U.S.Department of Health and Human Services, Office of Disease Preventionand Health Promotion, 2011). According to the Centers for Disease Control

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N’Balance Fall-Prevention Intervention 49

and Prevention (CDC, 2010), more than one-third of adults age 65 and olderfall each year and 20%–30% of these individuals experience traumas suchas hip or head injuries. Falling can reduce one’s independence and increasethe likelihood of premature death (CDC, 2010). Falls not only cause physicalharm, they also present an immense societal economic burden. This includesvisits to emergency rooms, stays in hospitals, time in nursing homes, as wellas support from home health care and physical rehabilitation services (CDC,2010).

Specific psychosocial factors, such as high self-esteem and confidence,are known to be important determinants of successful aging and reducepotential risks leading to injuries among older adults (Andresen et al., 2006;Peel, McClure, & Hendrikz, 2007). Low self-efficacy was found to increasethe risk of falls, primarily due to the fear of falling, which leads to reducedor discontinued involvement in valued physically active leisure activities.The “fear of falling is strongly associated with future falls, even among peo-ple who have not fallen recently” (Stevens, 2002, p. 10). Fear of falling isalso associated with self-imposed restrictions on social and physical activ-ities, which impact quality of life (Aminzadeh & Edwards, 2001; Brouwer,Musselman, & Culham, 2004; Fletcher & Hirdes, 2004; Martin, Hart, Spector,Doyle, & Harari, 2005; Tennstedt et al., 1998; Tennstedt, Lawrence, & Kasten,2001). For example, Fletcher and Hirdes (2004) found that 41% of individualsreceiving home care services would not consider going outside due to fearof falling. Fear of falling can also negatively affect older adults’ quality oflife because being fearful can prevent people from engaging in valued andmeaningful leisure activities.

Having briefly discussed the risk factors associated with falls and theimpacts of fall among older adults, it is apparent there is a need for fall-prevention interventions. The need is greatest among older adults who residein community environments, and fall-prevention programs should supportolder adults’ physical and psychosocial needs using a holistic approach.Interestingly, older adults who maintain engagement in physical, social, andrecreational activities experience added health benefits including reductionin fear of falling and falls (CDC, 2010). In physically based fall-preventioninterventions, such as N’ Balance, older adults’ prior successes can be used toenhance their expectations and perceptions of self-efficacy. Social modelingcan also be utilized to include observations of others and positive feedbackamong peers. When older adults experience support for engaging in physi-cal activities, their self-efficacy broadens, they gain confidence, and they aremore likely to adhere to an activity (Rowe & Kahn, 1998).

N’BALANCE FALL-PREVENTION PROGRAM

N’Balance, a community-based fall-prevention intervention, was created asan instructor training (i.e., train the trainer) program for professionals in

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recreation, exercise science, and other allied health and social service per-sonnel who work with older adults and is based on a scientifically basedfall-prevention program titled FallProof!, which targets physical therapists,occupational therapists, and other health care professionals. FallProof! wasdeveloped at the California State University–Fullerton Center for SuccessfulAging and is licensed nationally through Human Kinetics.

The intervention groups participated in the N’Balance program in gym-nasiums or dining areas two times a week for 50 minutes during a 6-weekperiod. Each class began with a 5–10 minute warm-up while sitting in chairs,and participants were given three reminders for appropriate posture: focuseyes forward, put shoulders in the back pocket, and lift feet off the ground.Reminders were reiterated a minimum of two times per session.

The program curriculum itself entailed activities critical to balance witha focus on center of gravity and activity progressions. Progression in theexercises provided challenges to the sensory systems (vestibular, visual, andsomatosensory). Gaze-stabilization activities included eye and head move-ments that were used during warm-up and cooldown periods. The warm-upwas followed by center-of-gravity work in both sitting and standing posi-tions, such as holding posture; lifting arms, legs, and trunk; and hip actions.Center-of-gravity exercises required the participants to be seated, standing,and moving. The level of challenge increased as participants became com-fortable on the chair by using a dyna-disc followed by using a stability ball.Moving center-of-gravity exercises (e.g., sit-to-stand, heel and toe raises,and leg movements) and weight shifting were routine and were used toimprove the vestibular, visual, and somatosensory systems that focused onimproving postural control. Changes of surface activities were completed tochallenge the somatosensory system. Activities challenging gait were com-prised of walking, change-of-surface activities, knee raises, and four-cornerstepping. Obstacle-course activities tested the three systems and consisted ofhurdles, ladders, 6-inch steps, and walking the gauntlet. The list of poten-tial activities and exercises are available from the Consortium for OlderAdult Wellness (COAW) N’Balance program (Christine Katzenmeyer, personalcommunication, June 17, 2009). The N’Balance program was implementedwith community-dwelling older adults. The evaluation framework RE-AIM(Glasgow, Vogt, & Boles, 1999) was used to share the research and theintervention’s effectiveness in various environments.

THE RE-AIM EVALUATION MODEL OF PLACINGRESEARCH INTO PRACTICE

RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) isan evaluative framework adapted from the concept of diffusion of innovationin consumer behavior research applied to community health education and

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health-promotion programs (Glasgow et al., 1999; Glasgow, McKay, Piette,& Reynolds, 2001). The first concept in RE-AIM is reach, which considersthe percentage of potential participants who are exposed to an interventionand how representative they are of the population. The second concept iseffectiveness,which is concerned with both the intended or positive impactsof an intervention on targeted outcomes and the possible negative or unin-tended consequences of the intervention on quality of life and nontargetedoutcomes. Adoption is the participation rate and representativeness of boththe settings in which an intervention is conducted (community) and theintervention agents who deliver the intervention (e.g., activity profession-als, health educators). The fourth concept is implementation, which is theextent to which an intervention is delivered consistently considering dif-ferent participants and staff and differences over time. The final conceptin the RE-AIM framework is maintenance, which includes both individualand setting levels. The individual level includes evaluating the long-termresults of an intervention (minimum of 6 months following the previousintervention) by following all participants (including dropouts) that beganthe program. At the setting level, maintenance refers to the program becom-ing embedded in the organization and sustained for the long term. Thisstudy demonstrates the importance of N’Balance, a community-based fall-prevention intervention, as a means of improving physical and psychosocialoutcomes among older adults using the RE-AIM model to explore lessonslearned.

METHODS

A community-based intervention study was implemented with a controlgroup and treatment group and conducted in the Midwestern region ofthe United States. The study was approved through an institutional reviewboard. Participants were recruited from residential and senior communitiesand were randomly assigned to either the intervention or control group.Participants were older than age 65 and self-reported being sedentary orinvolved in low to moderate physical activity programs. All participants livedindependently and had no self-reported neurological or musculoskeletaldiagnosis (e.g., Parkinson’s disease) that put them at a greater risk for imbal-ance and falls. Individuals volunteering for the study underwent initial pretestscreening and assessments to: (a) examine participants’ fall-risks, (b) targetintervention strategies, (c) assist in motivating participants, (d) offer tech-niques to provide feedback, and (e) gather baseline data to document theeffects of the intervention (McDowell, 2006). Exclusionary criteria adoptedfor this study were non-English speaking, nonambulatory, and currently notreceiving physical therapy. These criteria were adopted to minimize the riskof participant falls, possible confounding effects, and resource limitations.

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TABLE 1 Description of Subjects’ Characteristics

Overall Sample % (N ) Intervention Group % (N ) Control Group % (N )

GenderFemale 74 (37) 77 (20) 71 (17)Male 26 (13) 23 (6) 29 (7)Total 100 (50) 100 (26) 100 (24)

Marital StatusSingle 2 (1) 2 (1) 4 (1)Married 34 (17) 23 (6) 46 (11)Divorced 4 (4) 2 (1) 4 (1)Widow/widower 60 (30) 73 (19) 46 (11)Total 100 (50) 100 (26) 100 (24)

Age (Years)70–75 4 (2) 4 (1) 4 (1)76–80 16 (8) 24 (6) 8 (2)81–85 38 (19) 36 (9) 41 (10)86–90 26 (13) 20 (5) 33 (8)91–95 10 (5) 12 (3) 8 (2)96–100 4 (2) 4 (1) 4 (1)No answer (age) (1) (1) 0 (0)Total 50 100 (26) 100 (24)

The intervention and control groups met on the same schedule (twice aweek for 50 minutes), for 6 weeks. Pretest and post-test assessments utiliz-ing duplicate procedures were administered to groups by trained field staff.A small incentive ($20 gift card) was provided to all participants to completethe study.

The total final sample included 50 individuals (intervention = 26, con-trol = 24). The sample ranged in age from 73 to 97 with a mean age of 84.51.There were more females (74%) than males, which was a higher percentagethan the county census statistic of 59% (U.S. Census Bureau, 2009). Sixtypercent of participants were widow/widowers, 34% were married, 4% weredivorced, and 2% were single. The groups were somewhat similar in terms ofgender (intervention = 77% vs. control = 71% female). A larger proportionof individuals in the control group were married (46%) than in the interven-tion group (23%). See Table 1 for a summary of the study’s sample. Althoughrace, ethnicity, education, and socioeconomic status were not surveyed, therespondents were Caucasian and resided in middle-income communities.

ASSESSMENT MEASURES

A series of physical and psychosocial assessments and questionnaires wereadministered to each participant. Assessments of physical functioning (i.e.,lower body strength, agility, gait, balance, posture) and psychosocial con-structs (fear of falling and balance self-efficacy) were completed as pretests

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and post-tests. A leisure self-efficacy questionnaire was created to addressthis study’s question in the absence of available measures. Physical assess-ments included: 8-Foot “Up and Go” (α > .95); 30-second chair stand (r= .78) (Rikli & Jones, 2001); 50-foot gait analysis (α > .90 for comfort-able speed and α >.91 for maximum speed) (Bohannon, 1997; Hills, Byrne,Wearing, & Armstrong, 2006); Modified Clinical Test of Sensory Interactionin Balance (M-CTSIB; Shumway-Cook & Horak, 1986); Fullerton AdvancedBalance Scale (FAB; α >.96) (Rose, Lucchese, & Wiersma, 2006); and posturalanalysis (piloted; http://sl.wellnessone.net/PDF/SR.Posture.pdf). Two itemsfrom the M-CTSIB overlap with items in the FAB (eyes closed, solid surface;eyes closed, soft surface). To control this overlap, 8 of the 10 items from theFAB were used to calculate a composite score, with a higher score indicat-ing better balance. The Cronbach’s alpha for this slightly revised scale wasacceptable at .82. Also, measures of lower body strength, agility, gait, andbalance were valid and reliable.

Participants were also asked to complete the 18-item Balance EfficacyScale (BES) developed for FallProof! (Rose, 2003) as it is part of the program.This scale assessed respondents’ self-confidence and balance while engagingin daily routine tasks (e.g., getting up out of a chair using hands, gettingup out of a chair not using hands, getting out of bed without losing yourbalance, stand on one leg [with support] while putting on a pair of trouserswithout losing your balance). Confidence levels were rated on a scale from0 to 10 for a variety of activities of daily living. A composite score wascalculated by averaging the total of the item responses. Participants scoringless than 5 on the BES were labeled as having low self-confidence. Thisscale has undergone confirmatory analysis and has been used primarily atthe Center of Successful Aging, California State University–Fullerton. Internalconsistency has been demonstrated with an alpha coefficient of .95. Gunterand colleagues (2003) tested and retested the BES twice with 15 subjects ina 2-week period and obtained a test-retest correlation of .88.

An additional question was included to determine individuals’ percep-tions of how their fear of falling had limited their participation in activities.The question was worded as follows: “In the last 12 months, to what extenthave you limited your activities because you were afraid you would fall?”and used a 4-point Likert-type response where 3 = not at all, 2 = somewhat,1 = mostly, and 0 = very much.

Items were developed and included in the questionnaire that measuredthe person’s perception of his or her abilities to participate in active leisureactivities. This set of questions was utilized to examine changes in leisurebehavior that occurred as a function of the N’Balance program intervention.Participants were asked to mark the active leisure activities they felt theycould do and whether they would actually engage in them. They were thenasked to rate how confident they were about doing each one of the listedactivities using a 5-point scale.

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To consider changes that may occur in perceptions of leisure-relatedfear of falling and participation in leisure activities, respondents were alsoasked two questions about their participation in active leisure activities onthe pretests and post-tests. The first question was worded: “During yourleisure time, how physically active do you generally like to be?” with a5-point Likert-type response scale. A second question was worded: “Howmuch of your leisure time do you generally spend being physically active?”Participants responded using the same 10-point scale as in the BES (Lachmanet al., 1998).

The control group was led by the researcher and met immediately afterthe intervention group in the activity space. Lifelong learning educationalactivities were provided in absence of the fall-prevention intervention. Whenparticipants arrived at the activity center, they engaged in different sessionseach week, including “If They Could See Me Now” karaoke, “Cruisin’ the7 Seas” travel series, “If I Knew Then What I Know Now” trivia, book reviews,and “Scamproofing Your Life” programs. The control group met for the sameduration (50 minute) sessions, two times per week, during the same 6 weeksas the intervention groups.

To enable comparison of the intervention and control groups, all partic-ipants attended and were actively involved in group sessions. Adherence forboth groups was measured by taking attendance at each session. Individualswho participated in fewer than 50% of the sessions were excluded from dataanalysis.

RESULTS

Independent sample t tests using the conservative two-tailed significancelevel were conducted for all variables of interest in this study, with no signif-icant differences indicated between the control and intervention groups onany of the physical or psychosocial measures at the pretest session. Thus,indicating groups were reasonably matched.

The measure of lower body strength (chair stand) did not produce astatistically significant group main effect (.92) or group-by-time interaction(.81). Agility, as measured by the 8-Foot “Up and Go,” was not statisticallysignificant (.68 group by time). Gait was assessed using the 50-foot preferredand fast speed with no significant group-by-time effect (.27). Posture wasmeasured by a visual test. Nonsignificant group main effect improved acrosstime for both groups (.25). Notably, over time, both groups improved on thephysical assessments.

Balance was evaluated using the M-CTSIB and the FAB. There was a sig-nificant main effect for time for the M-CTSIB (.03). There was no statisticallysignificant group-by-time interaction (.29). The FAB detected a significantmain effect for time (.00) and group-by-time interaction (.00; see Table 2).The cell means indicated improvement in balance for the intervention group

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TABLE 2a Analysis of Variance Summary Table for Balance (FAB)

SS df F P

Groups 54.97 1 .57 .45Time 363.71 1 38.32 .00Group by time 106.67 1 11.24 .00Error 4618.24 48

p ≤ .05.

TABLE 2b

Cell Means for Balance (FAB)

Groups Pretest (N = 50) Post-test (N = 50) Overall Mean

Intervention (N = 26) 19.00 24.88 (21.94)Control (N = 24) 19.58 21.33 (20.46)

(19.28) (23.18)

Note: Balance was scored on a 4-point Likert-type scale where 0 = unable to, 1 = able to completeactivity at a minimum, 2 = able to do activity better, 3 = able to do the activity independently and fully.

TABLE 3a Analysis of Variance Summary Table for Fear of Falling

SS df F P

Groups .60 1 .47 .50Time .21 1 .76 .39Group by time 1.17 1 4.29 .04Error 62.29 48

p ≤ .05.

TABLE 3b

Cell Means for Fear of Falling



(1.76) (1.86)

Note: Fear of falling was measured on a 4-point Likert-type scale where 3 = not at all, 2 = somewhat, 1 =mostly, and 0 = very much.

(pretest x = 19.00, post-test x = 24.88, for an overall mean of 21.94) acrosstime as significantly greater than that of the control group (pretest x = 19.58,post-test x = 23.18, for an overall mean of 20.46).

The BES (assessed self-confidence during daily routine tasks) indicateda significant main effect for time for both groups (.00). In terms of fearof falling, significant group-by-time effect interaction (.04) suggests that theintervention group (pretest x = 1.73, post-test x = 2.04, for an overall meanof 1.89; control group, pretest x = 1.79, post-test x = 1.67, for an overallmean of 1.73) reduced their fear of falling (see Table 3).

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TABLE 4a Analysis of Variance Summary Table for Leisure Self-Efficacy

SS df F P

Groups 1,085.86 1 1.75 .19Time 150.81 1 2.92 .09Group by time 194.02 1 3.76 .06Error 86.86 48

p ≤ .05.

TABLE 4b

Cell Means for Leisure Self-Efficacy



(62.98) (65.55)

Note: Leisure self-efficacy was measured with a 5-point Likert-type scale where 0 = can’t do at all, 1= can do a little, 2 = can do somewhat, 3 = can do mostly, and 4 = can do entirely. Higher scoresindicated higher perceived ability to engage in physically active leisure activities.

Findings indicated that improvements in balance and fear of fallingoccurred as a function of participation in a 6-week (12 class) N’Balanceintervention. Although only approaching significance, findings also suggesta trend that participation in N’Balance is associated with an increase in leisureself-efficacy (see Table 4). However, it is important to note that in this studymany physical assessments did not indicate that N’Balance decreased par-ticipants’ risk for falls. Reasons for the lack of statistically significant changeover time within treatment group are discussed in the following section.

FINDINGS RELATIVE TO RE-AIM

Using the RE-AIM method to review this study of N’Balance fall-preventionintervention, a variety of lessons learned will be shared. The findings of thisstudy suggest that increased participation in N’Balance may improve leisureefficacy, balance efficacy, and fear of falling for older adults. The RE-AIMframework may be particularly useful in relating the findings to the processof planning and implementing community-based fall-prevention programs inrecreation settings. The anticipated effects and unintended consequences arenoted using the RE-AIM framework.

Reach considers the percentage of potential participants exposed to anintervention and how representative they are of a population. Recruitmentwas located in two settings: a gated community and a retirement commu-nity. By being delivered in community settings, N’Balance has the potentialto reach a larger percentage of eligible participants than similar video and

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home-based fall-prevention interventions, which lack the group experience(Close et al., 1999; Tennstedt et al., 1998; Tinetti et al., 1994). This studyincluded 50 participants (74% female; 26% male). The demographic profile ofthe participants was homogenous regarding race and ethnicity. N’Balance hasbeen implemented extensively in Colorado, but little data exist on the repre-sentativeness of the population served (i.e., race, ethnicity, age). N’Balancemust be tested with more diverse populations to better understand its effi-cacy and effectiveness. Judging by the high interest in the study among olderparticipants, there was a demand for this program among older adults. Also,attendance in N’Balance was 86%, indicating that this program appears tohave a high adherence rate (Vrantsidis et al., 2009). The control group had aparticipation rate of 78% during the same time period.

Effectiveness concerns both the positive impacts of an intervention ontargeted outcomes and the possible unintended consequences of the inter-vention on quality of life and nontargeted outcomes. This 6-week study didnot find substantial evidence that N’Balance impacts older adults’ physicalfunctioning or perception of ability to participate in active leisure, but itdid show a significant interactive effect on participants’ fear of falling andbalance.

Numerous factors may have impacted the ability to detect change overtime in the physical and psychosocial measures. First, the timeframe for theintervention was only twice per week for 6 weeks. This was minimal timeto enable changes in physiological parameters (e.g., lower body strength,agility, and gait), which take more time. Moreover, the control-group partic-ipants often arrived early and observed the intervention group’s N’Balanceactivities. It is therefore plausible that the control group was influenced bythis observation, perhaps practicing the skills themselves.

Adoption is the participation rate and representativeness of both thesettings in which an intervention is conducted (community) and the inter-vention agents who deliver the program (instructors). Currently, Coloradooffers N’Balance in community settings as part of the cadre of healthyaging programs offered to older adults. N’Balance has reached more than400 Colorado residents who may be at risk of falling (Downs-Karkos,2009). In Illinois, several rural locations, as well as the sites used in thisstudy, use N’Balance as a fall-prevention program. While all N’Balanceinstructors have been trained through the COAW in Colorado, limited dataexist on participation rates of trainers and their representativeness of thepopulation.

Several challenges were faced regarding program adoption, which likelyaffected intervention efficacy. Within a community, dynamics change andexperiences are often based on unforeseen circumstances, which may con-tribute to challenges such as those experienced in this study. Difficultiesarose finding organizations willing to adopt the program and allowingthe implementation of randomized controlled research trials. Understaffing

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and unwillingness to support and adopt the study impeded the reach ofthe intervention.

Implementation is the extent to which an intervention is delivered con-sistently across different components. Biannual N’Balance training is offeredexclusively through Colorado’s COAW, which fosters program fidelity regard-ing staff training, program content, and implementation strategies; yet, havingit in one place may limit access to training. In this study, implementation dif-fered between the two intervention groups due to setting characteristics.Residents in the gated community were not offered recreation programs.At the retirement community, a fitness director offered and assisted withclasses and programmatic aspects, such as marketing of the program, andserved as a liaison with the center.

Maintenance includes both individual and setting levels.Individualmaintenance of outcomes was not part of this study. However, it isan important aspect to consider. While there are no data regardingmaintenance, anecdotal evidence suggests that the effects of N’Balancelasted beyond the classes. Further study of individual maintenance (i.e.,postevaluation of intervention and control groups including dropouts) isneeded.

FUTURE RESEARCH AND IMPLICATIONS

The connection between RE-AIM and N’Balance should be extendedthrough additional research. McAuley and Blissmer (2000) suggested thatself-efficacy might be predictive in the adoption and maintenance stagesof vigorous physical activity, yet this needs to be examined more broadlyfor fall-prevention interventions. Also, it is unclear how a general senseof fear of falling (measured in this study, but not reported in this article)affects participation in valued leisure activities, which are important tooverall health and quality of life (Janke, Nimrod, & Kleiber, 2008; Mendesde Leon, Glass, & Berkman, 2003; Santiago & Coyle, 2004). Furthermore, thecurrent reach of N’Balance is limited to several states, and creating sites inother states to implement this community-based fall-prevention interventionwould extend its reach.

Community-based exercise programs had beneficial effects on physicalfunctioning with significant gains achieved during 4–8 months of participa-tion (Belza et al., 2006). This was a 6-week study, thus the time was limitedto demonstrate significant effects on physical functioning. Participants inthis N’Balance study had relatively high levels of adherence (86%), possi-bly due to the social support and group experience. Positive adherence ratestend to be higher in community settings than clinical settings (Rose, 2003).Community-based programs generally reach a larger population (McAuley& Blissmer, 2000). Therefore, translating fall-prevention programs such as

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N’Balance into community settings is one way to increase reach to an olderpopulation, potentially delaying or preventing falls.

It is important to learn how to effectively disseminate fall-preventionprograms to varied community settings in order to increase the reachof the programs. Integrating fall-prevention programs into recreation andleisure activity programs may increase program adoption among partici-pants (Hosseini & Hosseini, 2008). Additionally, strategies for promotingand implementing fall-prevention interventions must be supported and pri-oritized by the community to be successful. The National Cancer Institutesuggests that when communities are active and participate in the develop-ment of community programs, they are better positioned to evaluate andsolve their own social problems (National Cancer Institute, 2005, cited inHosseini & Hosseini, 2008).

Fall-prevention research could be integrated into programming strate-gies for all ages. According to Healthy People 2020, current fall-preventionstrategies are focused on adults older than 65; however, these strate-gies may be beneficial for all ages (U.S. Department of Health andHuman Services, Office of Disease Prevention and Health Promotion, 2011).Moreover, N’Balance could be adapted for individuals with disabilities whoare institutionalized or who are living in various types of community settings.

In summary, researchers suggest that fall-prevention programs shouldbe designed as multifactorial, multidimensional interventions and shouldinclude components of flexibility, balance, gait mobility, and strength(American Geriatrics Society, British Geriatrics Society, & American Academyof Orthopedic Surgeons Panel on Falls Prevention, 2001). While this studyexplored N’Balance in community settings, there is a need to explore theimpact of N’Balance in a variety of settings serving older adults. The resultsof this study indicate that N’Balance has the potential to be an interventionprogram that may have physical and psychosocial benefits for participants.Much more research and practice work is need to “build public awarenessabout preventing falls, promoting a fall-prevention program within the com-munity as well as educating older adults on best practices for preventingfalls” (Stevens & Sogolow, 2008, p. 43). This study, using the N’Balance fall-prevention program and the RE-AIM evaluation and dissemination process,hopefully will guide researchers and practitioners in the design, implementa-tion, study, and evaluation of fall-prevention interventions with older adults.

IMPLICATIONS FOR ACTIVITY PROFESSIONALS

Activity professionals as must seek more evidence-based practice interven-tions in order to support their work with older adults. Ideas and lessonslearned from this study hopefully will guide professionals in their futureefforts. Ongoing evaluation of programs and practices is essential to the

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activity profession. Understanding and applying the RE-AIM model to inter-ventions implemented by activity professionals in community settings willhelp demonstrate the reach, effectiveness, adoption, implementation, andmaintenance of programs. While there are challenges in conducting researchrelated to recreation-based programs with older adults in community set-tings, the lessons learned can improve the practice and profession. Moreand more, demonstrated outcomes are necessary to obtain the attention andfunding to support activity programs with older adults in all settings. Also,N’Balance may be appropriate for implementation in skilled nursing, reha-bilitation, assisted living, and other long-term health care settings and maypromote physical activity. Therefore, learning from each other’s experiencescan help activity professionals be more effective when planning and imple-menting interventions for health-promotion programs such as fall-preventionin a variety of settings.

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n'balance: a community-based fall-prevention intervention with older adults—lessons learned

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