Can an evidence-based fall prevention program be translated for use in culturally diverse communities?

David A.Sleet,Grant T.Baldwin

Centers for Disease Control and Prevention,Atlanta,GA 30341,USA

Commentary

Can an evidence-based fall prevention program be translated for use in culturally diverse communities?

David A.Sleet*,Grant T.Baldwin

Centers for Disease Control and Prevention,Atlanta,GA 30341,USA

Older adult falls are a significant public health problem,but one that is amenable to preventive interventions.1,2Despite the progress made in identifying risk factors,developing efficacious health-related interventions,and promoting evidence based programs in the community,much work remains before these strategies are broadly available and effectively used to reduce fall-related injuries.3As New ton and Scott-Findlay4have pointed out,the translation of basic scientific know ledge into clinical studies,and the transformation of clinical studies into improvements in health services and public health practices,remain major obstacles to widespread adoption.

Donaldson and Finch5have shown the feasibility of applying implementation science to sports injury prevention, and Li et al.6,7demonstrated how an exercise and balance program(Tai Ji Quan)can successfully be translated into a community program and implemented in either community or clinical settings.Equally important was the fact that Li and his colleagues showed that program fidelity and adherence to their intervention was maintained,at least over the short term,to prevent older adult falls.Manson et al.8showed positive results in taking a Tai Ji Quan program to low-income older adults,concluding that“non-(Tai Ji Quan)culturally related ethnic groups did not experience a barrier to participation in an older low-socioeconomic population sample”.However,the sample consisted of only 56 participants who were recruited into a 16-week program,and no attempt was made to translate the findings to the wider multi-ethnic community through the use of existing stakeholders.

The articleImplementing an evidence-based Tai Ji Quan program in a multicultural setting:A pilot dissemination project9by Fink and Houston in this special issue ofJournal of Sport and Health Scienceextends these findings and takes the next step.Specifically,the authors demonstrate that it is possible to scale up an effective health-related fall prevention program in a community of older adults with differing cultural backgrounds,provided that the intervention meets three criteria:

(1)Native language:The intervention must be translated and delivered to participants in their native language.It is also important for program leaders to be bilingual.

(2)Community organization engagement:The intervention must be implemented by a broadly imbedded community organization such as an Area Agency on Aging.

(3)Program fidelity:The intervention must be delivered with fidelity to specified research-tested protocols.

The work by Fink and Houston9shows that interventions proven effective using randomized control trials require additional adaptation and translation for use outside the research setting,but by adhering to these three elements a community-based organization can successfully implement a Tai Ji Quan program even in a multicultural setting.

Another important component of this program was the use of community-level infrastructures and delivery systems.In the study,the Minnesota Area Agency on Aging served in a coordinating role to help community-level organizations such as the Lao Advancement Organization of America and the Korean Service Center implement the program.Other community groups with wide reach,such as public health departments,community-based health associations,faith-based organizations,and aging services providers or senior centers,were also instrumental in achieving participation and community uptake.This“system integration” is essential for widespread adoption and sustainability.

The Minnesota program also demonstrated the importance of“know ledge brokers”to bridge the gap between know ledge generated from research and applications of know ledge to community programs involving older adults from different cultural backgrounds and languages.Local community organizations served as know ledge brokers to:

·provide resources such as technical assistance,training, incentives,and peer support;

·link program developers with bilingual program leaders;

·translate program materials into relevant native languages of participants.

Sleet et al.10have highlighted the importance of following the rigorous public health model in older adult fall prevention programs,in which a lynchpin to successfully reducing older adult falls is the utilization of RCT-tested interventions in program delivery.The Tai Ji Quan program used by Fink and Houston9meets these criteria,and its multi-ethnic applicability makes it especially appealing.

It is equally important for rigorous falls screening to occur within healthcare provider settings to triage and refer older adults to an appropriate community-based program like Tai Ji Quan.The Centers for Disease Control and Prevention developed the Stopping Elderly Accidents,Deaths,and Injuries toolkit to foster this screening,treatment,and referral.11Among the many benefits of this approach is that it can help integrate clinical medicine and public health and assure improved patient outcomes.It can also provide substantial cost savings to society.

In evaluating the impact of efforts to translate,disseminate, and implement evidence-based fall prevention programs,more attention to research models such as RE-AIM12,13might be considered.RE-AIM can help measure a program’s reach in the target population,efficacy and effectiveness of the implementation/dissemination strategies,extent of the adoption by the target audience,consistency and fidelity of intervention delivery,and elements necessary for maintenance. Glasgow and colleagues14have already demonstrated that REAIM can be used successfully in a low-income community for weight loss and hypertension self-management.

Translation research like this can also help identify characteristics of the implementation process that are critical to assure uptake,adoption,and maintenance of fall prevention behaviors embedded in programs such as Tai Ji Quan.This is an encouraging step forward.

Disclaim er

The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

1.Centers for Disease Control and Prevention.Preventing falls:how to develop community-based fall prevention programs.Available at:http://www.cdc.gov/homeandrecreationalsafety/Falls/community_preventfalls.html[accessed 01.11.2013].

2.Centers for Disease Control and Prevention.A CDC compendium of effective community-based interventions:what works for community dwelling older adults,2nd edition.Available at:http://www.cdc.gov/homeandrecreationalsafety/pdf/cdc_falls_compendium_lowres.pdf[accessed 01.11.2013].

3.Noonan RK,Sleet DA,Stevens JA.Closing the gap:a research agenda to accelerate the adoption and effective use of proven older adult fall prevention strategies.J Saf Res2011;42:427—30.

4.New ton MS,Scott-Findlay S.Taking stock of current societal,political, and academic stakeholders in the Canadian healthcare know ledge translation agenda.Implementation Sci2007;2:32.http://dx.doi.org/10.1186/ 1748-5908-2-32.

5.Donaldson A,Finch C.Applying implementation science to sports injury prevention.Br J Sports Med2013;47:473—5.

6.Li F,Harmer P,Glasgow R,Mack KA,Sleet D,Fisher KJ,et al.Translation of an effective Tai Chi intervention into a community-based falls prevention program.Am J P Health2008;98:1195—8.

7.Li F,Harmer P,Stock R,Fitzgerald K,Stevens J,Gladieus M,et al. Implementing an evidence-based fall prevention program in an outpatient clinical setting.J Am Geriatr Soc2013;61:2142—9.

8.Manson J,Ritvo P,Ardern C,Weir P,Baker J,Jamnik V,et al.Tai Chi’s effects on health-related fitness of low income older adults.Can J Aging2013;32:270—7.

9.Fink D,Houston K.Implementing an evidence-based Tai Ji Quan program in a multicultural setting:a pilot dissemination project.J Sport Health Sci2014;3:27—31.

10.Sleet DA,Moffett DB,Stevens J.CDC’s research portfolio in older adult fall prevention:a review of progress,1985—2005,and future research directions.J Saf Res2008;39:259—67.

11.Stevens JA,Phelan EA.Development of STEADI:a fall prevention resource for healthcare providers.Health Promot Pract2013;14:706—14.

12.Gaglio B,Shoup JA,Glasgow RE.The RE-AIM framework:a systematic review of use over time.Am J Public Health2013;103:e38—46.

13.Shubert TE,Altpeter M,Busby-Whitehead J.Using the RE-AIM framework to translate a research-based falls prevention intervention into a community-based program:lessons learned.JSaf Res2011;42:509—16.

14.Glasgow RE,Askew S,Purcell P,Levine E,Warner ET,Stange KC,et al. Use of RE-AIM to address health inequities:application in a low-income community health center-based weight loss and hypertension self management program.Transl Beh Med Pract2013;3:200—10.

Received 9 November 2013;revised 18 November 2013;accepted 19 November 2013

*Corresponding author.

E-mail address:dds6@cdc.gov(D.A.Sleet)

Peer review under responsibility of Shanghai University of Sport

2095-2546/$-see front matter CopyrightⒸ2014,Shanghai University of Sport.Production and hosting by Elsevier B.V.A ll rights reserved. http://dx.doi.org/10.1016/j.jshs.2013.11.001