Tuesday, May 13, 2014

Strength and Flexibility: A Critique of the Matter of Balance Methodology as a Public Health Intervention– Molly Sass

You trip. You fall. Your hands fly forward and you catch yourself. What would have happened if you hit the ground? Falling has been deemed one of the most important public health concerns of the senior population (1) but should not be considered an inevitable part of aging (2). Health can decline for any number of reasons; one result of weakening muscles and loss of balance and stability can be falls. This is a major cause of concern for older adults, as one in three people over the age of 65 falls every year (1).  There are physical, mental and emotional consequences for individuals as well as larger financial consequences. In the United States, $30 billion dollars were spent in fall related injuries and over 20,000 people died in 2012 as a result of a fall (1).
Older adults are a fast growing segment of the population, and by 2020 there will be nearly 60 million people over the age of 65, or an anticipated 20% of the population (3). Rarely does anyone in a demographic group share a uniform opinion, so it is not surprising that seniors have many different views of and feelings toward falling. As the number of people in this age bracket increases, so will the disparity in their individual opinions. Fighting external and internalized ageism, many older adults will not seek out services that could help them live independent, healthier lives with a better quality of life.
The “Matter of Balance” (MOB) curriculum is an evidence based program that works to improve participants’ comfort in increasing physical activity and talking about their fear of falling (4). It is targeted at older adults who are concerned about falling and works to assuage their fears while providing tools to prevent falls and targeted exercises to strengthen stabilizing muscle groups (5). Additionally, the program is intended to help participants view falls as preventable and not accept that falls are an inevitable part of aging  (5). It is one of a series of programs that has been used to increase balance and strength in older adults (6,7,8).
MOB has a multifaceted approach to fall prevention: education, physical exercise and discussion. Participants complete eight weeks of classes where they learn how to see falls as controllable and discuss ways to make adaptations to the home to decrease fall risk. Simple exercises target specific muscles to improve balance and strength in legs, hips and torso and increases coordination and physical endurance (volunteer manual). Classes are held for eight to fourteen people (5), a group setting that is essential for a successful program for older adults (9). The program is often led by volunteers (10), which was shown by Healy et al. (2008) to be as successful as a professional instructors (11).
The Matter of Balance program advertises that it is geared towards older adults who live in the community, rather than an assisted living facility or nursing home (12). The intended participants include individuals who have a fear of falling, have fallen in the past, limit their activities because of their fear of falling, would like to improve their physical well-being through exercise, or are over the age of 60 (5). The current marketing advertises outcomes for participants will include learning to “view falls as controllable,” set achievable goals, make alterations to their home, and improve their balance through strength and balance exercises (5). MOB is effective at reducing participants’ fear of falling (4,5,10), but it does not necessarily significantly lower the rate of falls in the general older adult population (4).
            While there are many positive elements to this falls prevention course, there are several challenges the program faces. The overall impact of the health intervention program could be strengthened by considering alternative frameworks for developing, implementing, and marketing the program. The first weakness in the program that program misses a large portion of the target population because of the law of small numbers and optimistic bias. Secondly, it follows the health belief model and does not account for many outside factors that impact older adults. Lastly, the program is advertised to older adults who fear falling, rather than attempting to reach the broader older adult population with a more comprehensive marketing campaign.
Critique Argument 1: Optimistic Bias and Law of Small Numbers
            The primary detraction to the Matter of Balance program is the effect of the law of small numbers and optimistic bias. The law of small numbers refers to people’s ability to accept what is true for a small sample as representative of what holds true for an entire population (13). Optimistic bias states that individuals overestimate the amount of good things that will happen to them and underestimate the number of bad things that will happen to them (14). In this case, it means that older adults will underestimate their risk of falling because people in their social network have not had a problem with falls.
            People tend to gather information from a small sample around themselves, but they may lose a greater sense of context if they believe that their risk for an activity is different from a general statistic (14). While people of all ages generally maintain an optimistic bias, older adults tend to have an even more favorable view of their outcomes (15). For example, a 68-year-old may live in the community, work full time, be physically active and have a network of friends who fit a similar description. This individual may not have a fear of falling, or even identify with the description of ‘older adult’ and will not internalize the risk that one in three Americans over the age of 65 fall each year. Yet this statistic is one of the main selling points of the MOB program.
            One in three adults over 65 fall each year, yet Kumar et al. (2014) found that only one in five older adults reported a fear of falling (16). More people fall than fear falling, so an approach that only targets those with a concern of falling misses a significant portion of the ultimate target population if the end goal is reducing falls nationwide. This discrepancy highlights the need to shift the marketing of a falls prevention program to all older adults, even those who do not have a fear of falling. This discrepancy also points out the lack of perceived personal risk, or an optimistic bias.
Critique Argument 2: Health Belief Model
            A second challenge the Matter of Balance program faces is that it is modeled on the health belief model. The health belief model (HBM) was developed in the 1950s and uses a cognitive model to explain how individuals weigh perceived costs and benefits of a particular action (17). This theory’s basic premise is that intention leads to behavior given the individual’s perceived susceptibility and the perceived severity of the concern at hand. It also incorporates the perceived costs of the desired action, including the perceived barriers to action (17,18). Applied to a fall prevention program, it presumes that if individuals perceive their susceptibility and severity to be critical enough to warrant action, an individual given the information to improve their health will do so. There are two components necessary for the Health Behavior Model to be successful. First, individuals need to have an accurate perception of their severity and susceptibility. Secondly, individuals must rationally weight the benefits of action with the perceived any costs.
            From the statistics of enrollment in Administration on Aging supported programs between 2006 and 2010 it would appear, according to HBM, that the perceived benefits do not outweigh the perceived costs. Only 27,000 out of 40 million adults over 65 enrolled in a fall prevention program, despite the often cited statistic that one in three older adults fall annually (1,19). According to HBM, there was not a great perceived sense of severity or susceptibility (18).
The HBM does not factor in many barriers that factor into an individual’s decision to participate in a MOB program. In many research studies, mostly active, community-dwelling adults were recruited for the program (20); for these individuals, perceived barriers may be low. However, there are many individuals who also live in the community but may face a number of obstacles for participation, including linguistic or physical limitations or cognitive impairment (21).
However, the model does not account for outside forces that may limit participation: inconvenient times, inaccessible locations, and many other factors. Other factors that impact an older adult’s decision to take part in a specific balance program must be considered along with their perceived susceptibility and severity.
            The HBM assumes that when an individual believes they can gain from a program, he or she will participate in that program. This is a flawed model for intervention programs that require a series of decisions over time, because the participant must perceive a benefit at every step of the program. The MOB program was designed as an educational tool that builds on making behavioral changes over eight weeks. Participants are given a workbook and follow the leader through discussions and expected to complete the exercises at home. The HBM requires each step of this process to confer a perceived benefit, which is unlikely given a long-term program.
            The HBM states that an individual will react according to their level of fear when given information conveying their susceptibility to a given risk (17). Using HBM to structure the MOB program does not work because individuals who are acutely afraid of falling may reduce their level of activity in response to the information. Individuals who are less afraid of falling are more mobile and more likely to participate in the intervention.
Critique Argument 3: Advertising Theory
            On the homepage for A Matter of Balance the word ‘fall’ appears six times in 120 words (5). This marketing highlights an older adult’s insecurities and vulnerabilities. The program is marketed towards people with a fear of falling; falls are not a positive label and maintain a negative connotation (21). This method of advertising may not appeal to the entirety of the intended target population, all adults over the age of 65.
The main principle of Advertising Theory is that a marketing campaign with underlying core values will resonate with the target audience and sell the product. Advertising theory demonstrates that a promise, support and strong underlying core values can sell any product if the core values are strong enough and the support is convincing. The support must be appealing to the target audience and can include stories and images. Core values such as maintaining independence, strength, social connections, and fun among friends would better resonate with any population, and especially the older population that can be portrayed as dependent, having limited mobility and activity, and as isolated individuals. Positively framing the concept of being older can have a much stronger selling power (22).
Advertising theory has been used successfully in other public health campaigns. For example, advertising theory was instrumental in the ‘truth’ campaign in Florida in 1998 to 2000 that reduced youth use of cigarettes (23,24). This campaign worked to shift the youth attitude around smoking and tobacco products, restrict the availability of tobacco products, by engaging the target population (youth) in developing education and prevention programs (23). The marketing campaign for the ‘truth’ campaign resonated with youth because it appealed to their sense of independence and rebellion (24). The overall campaign was successful in lowering rates of cigarette use among teenagers (23).
An additional flaw in the marketing of the MOB program is that it targets any individual “over the age of 65” who identifies with a fear of falling. While we addressed the issue of fear as a negative connotation, the fact that ‘65’ is used as a reference can also be a detriment to the marketing of this program. The target population spans 30 years or more and includes a diverse group of people: some who are still working, some who are retired, some live alone, some are community-dwelling, some lead active lifestyles, some who are increasingly isolated as friends and family pass away. There cannot be a single marketing strategy for such a diverse population (25).
A fall prevention, multicomponent program should be marketed towards groups according to their circumstances and psychosocial situations and not by age bracket (25). Baby boomers (adults born between 1946 and 1964) are constantly influencing and influenced by the social system as well as the culture (25). A program intended to improve the well-being of a complicated and diverse target population should better reflect the needs, desires and expectations of that group. 
Proposed Intervention
As Matter of Balance uses a multifaceted approach to falls prevention, an intervention must be comprehensive to address the complex issues for the target population. In November 2013 the City of Newton Department of Senior Services hosted a Matter of Balance program. Sixteen people enrolled in the program yet only two people remained at the end the six weeks. An alternative intervention will reach a broader population and better retain participants.
The intervention I propose would suggest a pilot program on the local level in the City of Newton that would work with primary care physicians (PCPs) to better incorporate balance assessment and fall history into an annual physical, identify local social network nodes, use an alternative marketing plan, and adapt balance and fitness classes to fulfill the needs of the local community.
Defense of Intervention Section 1: Combating Optimistic Bias and the Law of Small Numbers
While many adults may know the statistic “one in three adults over the age of 65 falls each year” this will not impact an individual’s decision making; decisions are often not made rationally (24). To confront the optimistic bias from individuals who do not estimate their risk of a fall to be as high as the national statistic, my alternative intervention would require all PCPs to ask patients annually about their fall history and complete a basic balance assessment. This component of the intervention would be a way to reach many adults over 65, who on average see a PCP two to three times a year (26). Establishing a baseline measurement for strength and balance would allow a doctor to monitor the effect of changing medications on balance, and other health conditions that impact strength, flexibility, and endurance. The existing recommendation for general practitioners is to complete a fall history assessment every six or twelve months (27,28). However, a small number of older adults are asked about their fall history by their primary care doctor (29). My proposed intervention would begin on a localized level, working with a local hospital to encourage and monitor doctor’s practices.
Doctors have a well-rounded sense of their patients; they see a patient over many years and develop a professional relationship with the patient. This relationship with a person of authority might improve a patient’s compliance with any health or wellness recommendation.  By charting and monitoring a slight change in a patient’s mobility and balance, a PCP would have the evidence to show the patient and engage in a discussion about the increasing risk of falls.  Once a PCP identifies a significant change in the patient’s balance, he or she would refer the patient to a local fitness or balance program. The older adult would not have to identify their fear of falling; the monitoring and guidance from a PCP would counter the patient’s optimistic bias.
Defense of Intervention Section 2: Social Theory Analysis
The most present flaw of the health belief model in the Matter of Balance program is that it does not account for external forces that influence an individual’s actions. The proposed intervention would shift away from the HBM and acknowledge the diversity of the population and myriad barriers that influence different segments of the target population.
To better reach the end goal of reducing the number of falls in the over 65 population in the United States, programs should rely more on a social networking theory. Social network analysis incorporates an examination of factors outside of the individual: relationships, organizations, community (30). The program will target the level of the local social network, which are often underrepresented in large scale implementation (31). A fitness programs could incorporate social networking theory by identifying pivotal community members and building individualized support. As the social pressure increases, more individuals would join, not only for the changing social norm (i.e. all people in a particular neighborhood, house of worship, social group, etc.) but with the expectation that it is a structured hour of socialization.
The alternative intervention would develop an individualized plan for a particular community, a method that is more effective than formulaic group models (6). Programs are effective when they are adaptable and appropriately respond to the needs of a particular community (32). For example, programs that provide transportation remove a barrier that many community-dwelling older adults face. A locally based program would identify the specific barriers faced by residents. Additionally, programs held in familiar spaces within the community may be more appealing to local residents (21). By recognizing the needs of the community a program intended to reduce the rate of falls among older adults will more effectively reach the target population.
A strength of the current MOB program is the social component: a weekly gathering at a scheduled time for individuals who may feel isolated. However, the program comes to an end and the group disbands. The proposed intervention would provide an ongoing fitness program. Many of the programs facilitated through studies (4,20) last just three, six, eight, or sixteen weeks. By offering year-round opportunities program participants would be held accountable by the group and less emphasis would be placed on completing the exercises at home.  
Defense of Intervention Section 3: Advertising Theory Alterative
Successful marketing appeals to the desires and values of the target population. The proposed intervention would highlight the positive elements of maintaining one’s independence. The current MOB program is marketed as a program about ‘fall prevention’ which immediately elicits a negative image about older adults. A shift in language will better appeal to the target population if it reinforces the core values that resonate: sense of independence, vitality and strength (21).
            An important element of a successful campaign is the involvement of the target population. An advertising campaign would need to begin with a planning session with adults over the age of 60 and work to gain their insight (24). It is important to establish goals driven with the input of the target population (23). The goal of the program would be to reduce number of falls and frequency of falls in adults over the age of 65, indirectly lowering medical costs and the number of injuries and fatalities among older adults. In the Florida “truth” campaign, youth contributions strengthened the validity and direction of the targeted message (23).
Creating an advertising campaign incorporating positive core values will improve the message of the falls prevention public health intervention and reach a broader audience. A positive message told from older adults’ individual stories will communicate the benefits of the program and illustrate the promised independence. By focusing on the active components of the program and highlight the fun, social component, the marketing campaign will sell those aspirations to the target population. 
Incorporating an advertising campaign of celebrities ranging from persons in their 50s, 60s, 70s, 80s, and 90s could have a positive impact on the campaign in multiple ways. By highlighting specific stories from a range of people, this public health concern becomes more tangible and relatable to distinct demographics. AARP sells their cause through targeting different segments of the large older adult population with three separate bi-monthly issues (33). The magazines contain much of the same information while incorporating some different articles and ads (33). A younger actor, Antonio Banderas, may be more relatable and attractive to people in their 50s – 70s, whereas Angela Lansbury may be more appealing to people 70 and above. This marketing appeal to the target population strengthens their brand and builds a positive cultural image of older adults and active aging.
            The Matter of Balance program provides a wonderful opportunity for older adults to decrease their risk of falling. However, an intervention incorporating alternative marketing strategy, a local focus, and leadership from primary care practitioners will better support the goal to reduce the number of falls among adults over the age of 65 in the United States. Falling can have a lasting impact on a person’s mental and physical health (1). With these changes there is potential for a broader reaching public health intervention to reduce falls, and the societal impact of falls, in the United States.


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