Introduction
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.
Conclusion
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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