The evaluation of a strength and balance exercise program for falls prevention in community primary care

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ABSTRACT

We aimed to evaluate a strength and balance program delivered in the community. There is little

evidence of implementation of evidence based exercise in practice.

The program was a step-down model, designed to encourage long-term exercise in community

classes. The program consisted of a fully-funded referral only evidence-based 12-week strength and

balance (Community Otago) class, followed by an evidence-based continuous open-access

community strength and balance class (Active Always). The program was offered to 1) patients after

formal falls rehabilitation (Falls and Fracture service) 2) patients after falls rehabilitation in

intermediate care 3) patients referred by GPs who were not eligible for rehabilitation (preventative

measure). Outcome evaluation used descriptive statistics to report changes in function, confidence in

balance, hospital attendance/admission for falls/fractures and transition to community classes. Focus

groups established participant experience/satisfaction. Seventy-nine participants were included, aged

56 to 96, 53 (67%) were women. 63.3% of patients transitioned to Active Always classes,

demonstrating improvement in maintenance. Follow-up scores from baseline attendance at Falls and

Fracture service to 12-weeks follow-up (24 weeks) in Community Otago showed the majority of

patients improved their function (Timed up and Go), confidence (ConfBal) and lowered their falls risk

(Tinetti). Follow-up of participants from Community Otago baseline to the end of 12-weeks showed

improvement in function and confidence, but only a third of participants lowered their falls risk.

Focus groups data suggests continuity of delivery, the role of the instructor, health professional, social

and physical outcomes were essential for maintenance. A supportive environment can be created

which encourages older adults’ continued participation in group-based strength and balance, helping

the delivery of evidence-based practice.

Key Words: Practice, older adults, maintenance

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INTRODUCTION

Falls are an important public health issue. About 45% of people aged over 80 who live in the

community fall each year (DH, 2009). This has implications in terms of independence,

quality of life and also cost to the health service (DH, 2009). Evidence-based strength and

balance exercise is one of the few single interventions proven to be effective in reducing falls

(Gillespie et al, 2012). The Otago and Falls Management Exercise program (FaME) are the

two main evidence-based exercise interventions which have been shown to be effective in

reducing falls and preventing deaths from falls (Robertson, Devlin, Gardner, and Campbell,

2001; Sherrington et al, 2011; Skelton, Dinan, Campbell, and Rutherford, 2005). They have

also been found to be cost-effective interventions (Davis et al, 2009).

Nyman and Victor (2011) found that in trials, overall adherence to evidence-based strength

and balance programs is poor. However, group based delivery of these programs has been

shown to more effective in promoting long-term adherence than home based exercise (IIiffle

et al, 2015). Community based falls rehabilitation projects in Rotherham (North of England)

have shown that patients followed up in the community six months after rehabilitation,

deteriorate back to their pre-rehabilitation state (increased falls risk and reduced function).

This is due to a lack of maintenance of physiotherapy set exercise and a lack of community-

based exercise classes (Hawley, 2009). Therefore, it is important that we successfully engage

and maintain older adults in evidence-based exercise both as a preventative measure, during

and after falls rehabilitation.

Older adults’ attitudes have been identified as paramount in understanding their uptake and

adherence to exercise classes (Hawley-Hague et al, 2014). Self-efficacy (the belief that an

older person can successfully carry out the exercises) can be a particularly important factor

when assessing older adults’ attitudes in relation to exercise uptake and adherence (Hawley-

Hague et al, 2014; Yardley, Donovan-Hall, Francis, and Todd, 2007) and interventions which

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are designed to strengthen self-efficacy have been used successfully to increase older

peoples’ exercise (Lee, Arthur, and Avis, 2008). Group cohesion, instructor characteristics

and continuity of delivery have been found to relate to both attendance and adherence to

classes (Estabrooks et al, 2004; Hawley-Hague et al, 2014).

There have been few studies which have looked at the delivery of evidence-based programs

for falls prevention in practice (De Groot, and Fagerstrom, 2001, Hedley, Suckley, Robinson,

and Dawson, 2010) and none that we are aware of that examine programs designed to

promote transfer from falls rehabilitation to community exercise programs. The aim of this

intervention was to create an environment which could support older adults to adhere to

strength and balance classes (Hawley-Hague et al, 2014; Yardley, Donovan-Hall, Francis,

and Todd 2007). This evaluation aimed to use routinely collected data from service provision

and qualitative feedback from patients to establish whether a community based evidence-

based strength and balance exercise program was successful in improving outcomes for

patients and in helping transition to long-term community exercise classes. This provides an

insight into the delivery of evidence-based exercise in practice, something currently lacking

in the existing literature.

METHODS

Subjects

Inclusion Criteria for the Intervention

Referral sources. Patients were referred to the program from either (Figure 1): 1)

Rehabilitation services from the Falls and Fracture service or Rotherham Intermediate Care

Centre where they had already received 12 weeks of strength and balance training (alongside

multi-factorial risk assessment and intervention); or 2) Primary Care Teams (GPs) where GPs

identified patients who did not meet the criteria for falls rehabilitation of three or more on the

Falls Risk Assessment Tool (FRAT) (Nandy et al, 2004), but still had strength and balance

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issues. These participants had to have stable medical conditions and be either unsteady on

their feet or unable to get out of a chair without arms (indication of lack of strength). The GP

could also refer patients if they had been in numerous rehabilitation settings and discharged,

but required an exercise class to support them to maintain their exercises (had a FRAT score

of three or more but had been through rehabilitation services already).

Inclusion Criteria for the Evaluation

We aimed to examine quantitative data on all of the older people who were attending one of

the classes at the eight different community venues (all available classes) at the time of data

collection. All participants were over the age of 50 (to target those at risk of falls but also

those who could benefit from strength and balance training to improve bone health) and

entered the program between November 2011 and December 2012.

For the focus groups we purposively sampled Community Otago groups which were running

at the start of the qualitative data collection period. We approached groups which were well

established (N=3) so that we could collect feedback from participants who had been attending

for some time (participants had been attending for at least six weeks). We approached Active

Always classes (n=2), which had been set up as part of the new intervention where there was

a good representation of participants who had transitioned from Community Otago to the

Active Always class. The program was delivered by two different instructors and we

included classes delivered by both instructors. Qualitative data was collected from groups

until data saturation was reached.

Intervention/Program

The proposed intervention was delivered through a collaborate approach between health and

social care. The intervention was commissioned by the NHS Clinical Commissioning Group

(CCG), managed by Leisure Services within Rotherham Council and overseen by Rotherham

Public Health.

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The intervention consisted of: 1) Community Otago: 12 week strength and balance program

delivered by an exercise instructor. The program was referral only (as outlined above), free of

charge, offered locally to the patients home, in the same community venue (where possible)

as their rehabilitation (no transport offered, although instructors did engage with community

transport on the patients behalf); and 2) Active Always: The same instructor then provided a

community-based class (the participant could attend indefinitely) afterwards in the same

venue on the same day (with a charge), in the hope that this would increase long-term

maintenance (also managed by Rotherham Council). This was intended to promote the

transition from health services to community provision (Figure 1).

All instructors delivering the program had to have at least a level three older adult

qualification (the level seen as safe for delivery to older adults by health services in the UK)

and have either the accredited Otago (Campbell et al, 1997; Later Life Training, 2014) or

Postural Stability Instructor (PSI) qualification (Later Life Training, 2014a; Skelton et al,

2005).

The strength and balance class was offered once a week, tailored to individual’s needs and

was progressive. Home exercise a further twice a week was encouraged outside of the class

and Otago home exercise booklets were handed out with specific exercises highlighted for

each individual. Weights, increased sets of strength exercises and peak strain (holding the

exercise at full range of movement for five seconds) were used to progress strength exercise

(per evidence based protocol) in all classes, therabands were used where instructors

incorporated the FaME program. Increasing the challenge of the exercises, reducing support

(hand-holds) and vestibular and proprioceptive challenges (eyes closed, uneven surfaces)

were used to progress balance exercises. Tailoring included adapting the number of exercises

(some participants may carry out more sets than others) and asking some participants to carry

some of the exercises out seated (e.g. use a theraband to work the hip muscles rather than

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standing side leg-raise). The exercise class was delivered for 60-75 minutes followed by 20-

30 minutes of ‘social time’ to give opportunity for social support and improve group

cohesion, class members were offered refreshments.

It was proposed that the Community Otago program would strengthen self-efficacy by

promoting confidence in the classes through referral by a health professional but also through

the delivery of the same evidence-based exercises (the same exercises carried out in

rehabilitation). The program also sought to strengthen group cohesion through delivery of

the classes in the same venues and delivered by the same instructor. This enabled participants

to stay together as a group and maintain confidence in the quality of instruction.

Evaluation

This evaluation took a mixed methods approach, collating existing quantitative outcome data

(collected by the Falls and Fracture service and exercise instructors as part of standard service

delivery) and public health data. Qualitative feedback from participants was collected by the

researcher through five focus groups. The use of qualitative and quantitative approaches

enables us to triangulate findings, provide a broader picture of the outcomes and impact of

the intervention. There is growing recognition that significant advances in health care are

made when both qualitative and quantitative methods of enquiry are used (Johnson, and

Onwuegbuzie, 2004). Because this was a pragmatic evaluation based on routinely collected

data, we do not have full follow-up data (3 months post intervention) for all participants.

Measures

Function (Including Strength and Balance) and Confidence

For the sample of patients who had been referred from the Falls and Fracture service we

looked at data collected from baseline with the Falls and Fracture service to 12 week follow-

up assessment for Community Otago (24 weeks). For all participants we looked at data

collected from baseline to 12 week follow-up at Community Otago.

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To assess improvements in physical function and confidence the Timed Get up and Go

(Mathias et al, 1986) and ConfBal (Simpson, Worsfold, Fisher, and Valentine, 2009) were

used. These assessment tools where chosen to mimic the ones used by the Falls and Fracture

service. The Falls and Fracture service also used the Tinetti tool (Tinetti, Williams, and

Mayewski, 1986) to assess falls risk with their patients who were also re-assessed during

their time attending Community Otago.

Falls and Fractures

Public Health data (Health Episode Statistics) were used to assess attendance at

A&E/admission for fracture/admission for falls. This was collected three months prior to

rehabilitation for those who had attended the Falls and Fracture service before attending

Community Otago and three months prior to Community Otago for those referred from the

GP and RICS (as there was a time lapse between rehabilitation at RICS and referral

onwards). For those participants who attended the Falls and Fracture service the intervention

period was classed as the whole 24 weeks (attendance at falls rehabilitation and Community

Otago), for those referred by GP and RICS (classed as attending only Community Otago) the

intervention period was classed as 12 weeks. Falls (W00 to W19) and Fractures were based

on International Classification of Diseases (ICD) (WHO, 2002) codes.

Transition

The ultimate success of the pathway was measured by looking at participants’ transition from

‘Community Otago’ to the Active Always community exerciseclasses. The program aimed

to keep participants exercising in group based strength and balance (non-adherence defined as

drop-out from classes).

Focus Groups

Focus groups were carried out by the researcher with both Community Otago and Active

Always classes. The focus groups were held after the classes during the coffee and social

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time and the instructors were asked to leave the room. We assessed the barriers and

motivators to initial attendance, transition between the different types of classes and

satisfaction with the program, asking open-ended questions to elicit broad discussion (Table

1).

Analysis

Quantitative data analysis included descriptive statistics (presenting means and standard

deviations) because of the small sample size and loss to follow-up, using IBM SPSS Statistics

V20. As this was service evaluation and we included all available participant data at the time

of data collection, a sample size or power calculation was not carried out. All quantitative

data (apart from transition data) must be considered with caution due to small sample size

and loss to follow-up.

Follow-up focus groups were analysed using thematic analysis (Braun and Clarke, 2006).

Data from the Community Otago and Active Always classes were coded together, but

similarities and differences were examined as part of the analysis. The research generated

categories and explanations directly from the data rather than based on previously set aims

and objectives, reducing risk of bias (Braun and Clarke, 2006). QSR International's NVivo 10

qualitative data analysis software was used to analyse the data. The validity of the analysis

was checked by returning to the data once themes had been identified and also through the

use of a second researcher who checked samples of analysis. The study was given approval

by NHS Research Governance who decided that ethical approval was not required as the

study was classed as service evaluation.

RESULTS

Quantitative Results

During the evaluation period one hundred and ninty-six people went through the program

between (November 2010 to May 2013). However, N=79 participants are included in this

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evaluation as participants who entered the program between November and December 2012

(with some follow-up data). Twenty patients only had data on whether they transferred to

Active Always and had no other follow-up data. Fifty-three (67%) were women, only 2

(2.5%) were of non-white ethnic origin; ages ranged from 56 to 96. Forty-six patients

(58.2%) were referred from rehabilitation services, with 40 (50.6%) patients referred from the

Falls and Fracture service, 6 (7.6%) from RICC and 33 (41.8%) referred by the GP. As there

was a delay in referral from RICCs (patients had finished their rehabilitation sometime before

being referred onto Community Otago), falls and fracture data for patients from RICC’s and

GP’s were analysed together. Quantitative data analysis was based on the extraction of

existing data and there was a significant loss to follow-up, therefore findings should be

considered with caution.

Transition

There was a good level of transition of patients into long-term group exercise with 50

(63.3%) participants attending Active Always classes. Twenty-four (30.4%) participants did

not continue to attend group exercise (some participants did report home exercise), five

(6.3%) participants were still attending Community Otago at the time of data collection so we

did not have transition data for them.

Function

Timed Get Up And Go Times (TGUG)

Assessment times from baseline with the Falls and Fracture service to follow-up at

Community Otago (32.58 seconds ±17.13 v’s 26.04 seconds ±13.78) and for baseline at

Community Otago to follow-up, indicate an improvement in function (27.81 seconds ±13.75

v’s 23.71 seconds ±12.49). Several participants TGUG times increased (table 2), but this is

thought to relate to ill-health (self-reported) and the fact that on follow-up one participant no

longer needed to use a walking aid (and therefore their time increased).

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Confidence in Balance (ConfBal)

Assessment scores from baseline with the Falls and Fracture service to follow-up at

Community Otago (21.67 ±5.02 v’s 19.93 ±4.75) and for baseline at Community Otago to

follow-up (19.30 ±4.73 v’s 18.57 ±4.52) indicate overall an improvement in confidence in

balance. However, a small number of patients did show a decline in their confidence (Table

2).

Falls and Fractures

Tinetti

The Tinetti was only taken for those who attended Falls and Fracture service. Follow-up

scores for baseline with the Falls and Fracture service and follow-up at Community Otago

(16.21 ±3.74 v’s 20.75 ±5.75) indicate overall an improvement in falls risk. Data from

baseline at Community Otago to follow-up shows mixed results, approximately a third

reduced their falls risk, and a third maintained the same level of falls risk and a third

declined. However, on average the mean score for the group improved between baseline and

follow-up (17.61 ±4.70 v’s 20.11 ±5.00).

Public Health/Hospital Episodes Data

There was a reduction in falls admissions, attendance at A and E and admission for fractures

over the period that participants attended the intervention (table 3). However, numbers of

recorded falls and fracture were very small in this population before attending the service.

Those referred by the Falls and Fracture Service seem to have had more falls prior to

intervention.

Focus groups

During the focus groups we explored class participants’ experiences of the Community Otago

program (from three groups) and also why they continued to attend. We also carried out focus

groups with two cohorts who had attended the Community Otago classes but had now

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transferred into Active Always community classes held on the same day so that we could

discuss transition. There were N=28 participants from three Community Otago group and

two Active Always groups, of which 9 participants were men and 19 women. All eligible

participants, (participants who were attending or had attended Community Otago) who were

present when the researcher attended were interviewed apart from seven participants who had

to leave as soon as the class had finished (due to transport arrangements). The mean age was

81.2 (Range 70 to 91). Participants’ responses focused on motivation to attend (uptake) and

the subthemes: similarity; alternative; health professionals; fear; and transport. They also

focused on maintenance of exercise (adherence) in the classes and the subthemes: improved

physical outcomes; social units; self-management; and instructor/staffing ratio.

Motivation to Attend

When asked about their reasons for coming to the group and what motivated them to attend,

for those who had already been through falls rehabilitation it was reassurance of similarity.

They knew that it would be the same program of exercises that they had already been

carrying out:

“I went to falls unit before and this is a continuation of that. Continuation after falls

group” (Community Otago group 1, F2).

For the transfer from community Otago to long-term maintenance in an Active Always class

it was about the similarity of being in the same venue and often a lot of the same group

members which made participants feel more reassured and comfortable, this often led to

additional social events:

“Well I think you look forward to it each week don’t you, meeting up and having your

dinner with your friends” (Active Always group 1, M3).

Participants within this group chose to have lunch at the venue after the class had finished.

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For those who were referred directly to Community Otago and had not attended a previous

rehabilitation program (were new to the exercises), they often liked it as an alternative to falls

rehabilitation as they did not identify themselves as fallers:

“I said I don’t know whether I’m clumsy or what, but I’m not actually, I don’t think

I’m actually ready for going to falls group and then they invited us to this”

(Community Otago group 3, F3).

The Community Otago class seemed to be more acceptable and had a better fit with their

sense of identity than falls rehabilitation.

Motivation to attend was often linked to the health professional making the referral:

“…and the young lady there she said to me, she said I don’t want it to stop, she said I

want you to go to this class, are you willing?” (Community Otago group 1, F1).

Here the health professional suggested the participant could maintain their exercises by

attending a Community Otago class. Motivation to attend could also be related to an existing

relationship that had been established with the instructor:

“XXX (instructor) got us into the falls, and then when we’d done that, we went to the

falls and to XXX” (Active Always group 2, M1)

This relationship helped the transfer through from rehabilitation into long-term maintenance.

Participants were asked about what the barriers were to attending the classes and if there was

anything which could be improved. Participants said one of the major barriers was fear, and

this is why others had not attended:

“she said, ‘I wouldn’t go if I was you’. So I said why? She said ‘she’d been to a

class…and she said it was walking round this room doing these exercises, she said

there were no chairs’, she said ‘I felt as though I just had to sit down now and again,

and she said it was just too much for me” (Community Otago group 3, F1).

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This lady was talking about her neighbour who had actually experienced a general older

adults class aimed at quite fit older adults and this had then put her off attending any future

type of exercise class. The other major issue was transport:

“Yeah, I only live over the top of the hill. I can probably see where I come from but I

can’t get there…transport used to pick me up then…and it was nice and easy”

(Community Otago group 2, F4). 

This was particularly seen as a barrier if they had attended a rehabilitation group which

previously provided transport and then had to try and find their own way to the follow-up

class (particularly for the transition to the Active Always class where they would have to pay

to both attend the class and the transport to get there).

Adherence and Maintenance

Participants said that they adhered to the classes and moved into maintenance because of the

improved physical outcomes they felt, for example:

“I can now get upstairs and sleep in my own bed for the first time in years!”

(Community Otago group 3, F1).

“My knee, well, they were thinking oh you’re going to have to have an operation, but

it’s much, much better” (Community Otago group 3, F2).

There were also positive mental outcomes which were achieved:

“It has lifted my spirits, I suffer from depression and it really helps” (Active Always

Group 1, M3).

The groups did not only see outcomes in terms of their physical and mental well-being but

also in terms of social opportunities and building new social networks. They bonded as

social units especially as a lot of them went through the pathway together. This was

particularly the case for one group where there were quite a few gentlemen who bonded:

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“We’re all in a similar predicament aren’t we? We’re the same I think. We’ve got to

that stage” (Active Always Group 1, M1).

“Well there’s only me and wife, and I tell her I’m going up youth club” (Active

Always Group 1, M2).

These gentlemen established themselves as a close group of friends who always sat together

both in the class and during refreshments afterwards, they shared their improvements with

each other and encouraged each other to attend.

Participants other key motivation was a sense of pride in self-management;

“Yeah, because you keep going, you can hold your head up, if you don’t then you

might as well just...” (Community Otago Group 3, F4)

and also a determination to continue to be independent and a fear of what will happen if they

lose independence:

“have you been in a home and seen them, they just sit there don’t they?” (Community

Otago Group 3, F1).

The role of the instructor in maintenance of the group was found to be very important by the

participants both in terms of facilitating outcomes and in terms of the close relationship and

bond established. Participants felt confident that the instructors supported them and would

not push them beyond their capabilities;

“she goes over things, she insists that you mustn’t hurt yourself or that sort of thing,

don’t overdo it, but we’ve just enjoyed it” (Active Always Group 2, F2),

that they were being closely monitored:

“she encourages you, she watches everything” (Active Always Group 2, F3).

They also have noticed how the instructors adapt the exercises to individual need:

“Like for xxx and xxx when they can’t do every exercise as we do, then they’ve said

well you do this” (Community Otago, Group 3, F5).

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Participants felt that the instructors were more than just instructors. They were an important

part of the group:

“I feel as though she’s one of the group” (Community Otago, Group 3, M1). 

The only issue raised by the participants about the classes was the instructor to participant

ratio. This was only raised by those who had previously attended falls rehabilitation where

there were at least two members of staff to eight patients. One gentleman said:

“She’s got a problem with having a group on her own, whereas we’ve come from a

falls group that had numerous assistants…she’s doing it on her own which must be a

burden” (Community Otago Group 2, M2).

Some participants felt that the instructor was not as attentive as she could have been and this

was because of the numbers of people in the class.

DISCUSSION

The Community Otago program in Rotherham was found to be generally successful in

supporting older adults to transfer to long-term community exercise provision and in helping

them to maintain outcomes.

The 63.3% of participants transferring to the community based Active Always classes

indicates an improvement on transitions prior to the program. Although we do not have

directly comparable data from before the Community Otago program was introduced. Verbal

feedback from health professionals and instructors of the Active Always program suggests

that previous to the program being put into place an average of two to three patients a year

would transfer from rehabilitation into the long-term community based Active Always

classes. The Community Otago program accepted referrals from general practice and it could

be argued that the transition rate increased because the pathway accepted participants at

lower falls risk. However, the transfer rate of patients from the Falls and Fracture Service (via

Community Otago) into Active Always classes was 65%, which is in fact higher than for the

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total sample.

Although quantitative data can only be seen as exploratory, it does indicate that there were

improvements for most participants in function and confidence. A reduction in the level of

falls risk between baseline and follow-up at Community Otago was not achieved by all

participants, with approximately a third of those referred from the Falls and Fracture service

showing an improved Tinetti score and a only third maintaining their score in their

assessment. However, between baseline with the Falls and Fracture service and follow-up

assessment at Community Otago patients falls risk did reduce. This suggests that although

Community Otago may have assisted in maintaining a reduced falls risk, it did not continue

to reduce falls risk for everyone. Hospital data also gives an indication of a reduction in falls

but this data must be considered with caution. However, we know that a reduction in falls

and falls risk takes a longer period of time to be achieved (a dose of 50 hours) than functional

outcome measures (Sherrington et al, 2011), and therefore it is possible that on further

follow-up more participants may have continued to reduce their falls risk. Improved

outcomes and the role of the instructor have been found to assist in attendance and adherence

to classes (Hawley-Hague et al, 2014) and were cited by participants as important factors in

the focus groups carried out as part of this evaluation. Self-management of their own

conditions and promoting their own independence was a key outcome for most participants

(Hawley, 2009; Robinson, Newton, Jones, and Dawson, 2014).

Qualitative feedback from participants gives us some insight into the reasons for transition.

Transfer between the Falls and Fracture service and Community Otago was aided by health

professionals and the referral system. The role of referral and encouragement by health

professionals (and therefore social influence) in the transfer from rehabilitation to

maintenance has been reported as important in previous qualitative studies (Horne, Skelton,

Speed, and Todd, 2010; Yardley, Donovan-Hall, Francis, and Todd, 2007). Our qualitative

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data indicates that communication between different parts of the rehabilitation pathway was

essential for older adults to feel confident in the class and the instructor and confident in their

own ability to carry out the exercises (self-efficacy/PBC), this is also supported by previous

research (Hawley-Hague et al, 2016). Communication is essential for participant satisfaction

(smooth transfer from different classes/clear knowledge of participants’ conditions and

medications and their capabilities and current exercise program) and needs to be continually

monitored and improved (Hawley-Hague, Horne, Skelton, and Todd, 2016).

Common barriers cited in the literature, fear of the unknown (particularly caused by previous

negative experiences) and transport issues (Franco et al, 2015) did still occur for some

participants and this explains why not all participants transferred into either Community

Otago or Active Always. For the Active Always classes the combination of transport costs

and the fee to attend the class were seen by some participants as too much to pay. However,

the location of the classes within people’s local communities and the role of health

professionals in referring patients did help to alleviate some of these barriers. A recent study

with exercise instructors suggest that the barrier is more about older adults willingness to pay

(attitudes) than the actual cost (Hawley-Hague et al, 2016)

For longer term maintenance of exercise (in particular transfer to an Active Always class) it

was the achievement of positive outcomes, both physical and social. The findings of the

qualitative focus groups indicate that the fact that participants could continue to stay as part

of the same group with the same exercise instructor increased confidence, positive attitudes

and likelihood of maintenance of group exercise. Social support and the role of the group

have repeatedly been found to be associated with continuation of exercise (Estabrooks et al,

2004; Hawley-Hague et al, 2014; Oka, King, and Young, 1995) and the program was

specifically designed to strengthen this. Person-centred delivery (Stathi, Mckenna, and Fox,

2010) and being sensitive to individual need has been stated previously as important

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instructor attributes related to adherence, and was something that participants involved in this

program felt was important.

For some older adults, attending the Community Otago program (promoted as a strength and

balance class) was more attractive and relevant to their identity than attending a ‘falls group’.

This echoes previous research and recommendations on how to promote exercise for falls

prevention to older adults, that we should emphasise the positive things older adults can do

for themselves to promote independence and not mention the ‘falls’ word (Hawley, 2009;

Yardley, Donovan-Hall, Francis, and Todd, 2006, 2007). This is specifically relevant to

older adults who are referred through primary care rather than falls rehabilitation.

Some participants did express a concern about the staff to person ratio. As a ‘step-down’

model from rehabilitation, the same amount of staffing should not be required as participants

should be more physically able and have started to improve their function. However, in

response to this feedback the program now has both an instructor and an assistant (Otago

exercise trained) for each class as an increased safety measure and also to promote participant

confidence and support.

Limitations

A large number of the people attending the pathway during the evaluation period may not be

classed as high risk fallers (had not had previous admissions for falls recorded three months

before intervention). However, we also know from self-reported data that participants

requiring strength and balance intervention have often had non-injurious falls which are not

identified and therefore reflected in the statistics. Some of the participants were the lower risk

patients referred by general practice (Falls Risk Assessment Tool score of less than three and

no fracture, Nandy et al, 2004).

As participants entered the program at different times and within different cohorts, full data

for all participants entering the program has not been provided and there was significant loss

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to follow-up. Quantitative data was collected and reported on by the clinicians within the falls

and fracture service and by the instructors delivering the program as part of routine service

reporting rather than being collected specifically for evaluation purposes. This means that

data for some of the analysis is only available on a sub-sample of participants, and therefore

findings should be considered exploratory. However, this evaluation aimed to provide a

snapshot picture of a pragmatic real-life evidence into practice program. It provides us with

an understanding of the types of data that can be collected routinely by falls prevention

services and also the issues with loss to follow-up when relying on staff delivering services to

report data.

For practical reasons we did not try and recruit participants who had failed to attend the

Active Always class after the Community Otago program to ask them to participate in the

focus groups, so we were unable to establish why they did not attend. However, some of the

participants included in the Community Otago focus groups did not go on to attend an Active

Always class, the major barrier to this was the combination of the costs to attend the class and

transport, even though the class was located very near to them.

CONCLUSION

We know that strength and balance programs are successful in clinical trials. However, there

is very little evidence on their success when delivered in practice. This evaluation gives us

an insight into the elements required to support successful transition from rehabilitation into

maintenance in evidence-based community exercise classes. With an ageing population and

continued challenges to resources, it is important that interventions to prevent falls and

promote healthy active ageing are successful, maintaining older adults in the community

independently for as long as possible. This evaluation suggests that a supportive environment

can be created which encourages older adults continued participation in strength and balance

exercises. We suggest that good communication and well trained experienced staff are

21

important in achieving this. Further research is required to further establish the effectiveness

of the proposed ‘step-down’ model using a larger sample. However, the evaluation helps us

to understand the practical implications of delivering the evidence base in practice and the

issues with pragmatic data collection.

22

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