The issue and impact of elder falls  

According to the U.S. Centers for Disease Control and Prevention (CDC), falls are the leading cause of injuries and injury deaths for people 65 and older in the United States.¹ American Indian/Alaska Native (AI/AN) elders report the greatest percentage of falls (34.2%) of all races/ethnicities. Additionally, AI/AN elders are more likely to report a fall-related injury (16.8%) than whites (10.9%), Hispanics (10.7%), and blacks (7.8%).² Among all people 65 and older in the United States, approximately 20% of falls cause serious injuries such as broken bones or a head injury, potentially leading to loss of independence and quality of life.³ 

Elders who have fallen once may develop a fear of falling and, as a result, limit their activities and social engagements. This can result in further physical decline, depression, social isolation, and feelings of helplessness.  

Falls risk factors  

A range of modifiable risk factors can contribute to falls, including:  

• Muscle weakness, particularly in the lower body  
• Balance and gait problems  
• Type of medications and use of multiple medications  
• Vision and hearing problems  
• The presence of home or other environmental hazards⁴

AI/ANs experience a number of disparities that can potentially increase the risk and rate of falls and fall-related injuries. AI/ANs have a greater burden of chronic disease, along with a lower life expectancy.⁵ For example, more than 30% of AI/AN elders in 2012 reported at least one form of heart disease, while only 10.9% of non-Hispanic whites did in the same period.⁶ AI/ANs have the highest rate of Type 2 diabetes in the United States, and are over twice as likely to be diagnosed with Type 2 diabetes than non-Hispanic whites.⁷ Diabetic neuropathy can contribute to falling due to lack of feeling in the lower legs and feet. Diabetes can also increase the chance of having osteoporosis, leading to a higher risk of injuries and fractures from a fall. Furthermore, the higher rate of many other chronic illnesses in this population increases the risk of dying from a fall when one does occur.⁸

The Indian Health Service (IHS), U.S. Department of Health and Human Services, provides health and educational assistance to federally recognized tribes.⁹ However, since IHS serves less than half of the AI/AN population, AI/ANs may have less access to the healthcare system. This may make them less likely to visit a health care provider to receive needed care. Additionally, many AI/ANs live in rural settings, which can negatively affect their access to care. Access for American Indians in urban areas also can be limited since there are only 34 IHS funded urban clinics in the United States.^{10, 11}  

Environmental risk factors can contribute to falls. Tribal housing is seriously limited in many communities, and it is not uncommon to have multiple generations living in the same residence. Overcrowding in the home can cause tripping hazards due to excess belongings needed by multiple people. The homes of some elders may need to have improvements made to be safe. Safety concerns include insufficient lighting, difficulty accessing the home due to unsafe steps or entrances, tripping hazards within the home, unsafe bathrooms with no grab bars, insufficient plumbing, and lack of handrails on stairs. Occupational therapists or other trained professionals or volunteers can help with home safety assessments and home modification plans.  

Changing diets among AI/ANs have increased the risk of falls. Traditional diets consisted of healthy, nutrient rich, indigenous foods that were not overly processed and were usually roasted or boiled instead of fried. Moving away from the traditional diet has led to health conditions such as obesity, diabetes, and cardiovascular diseases, all of which can increase the risk of falls.^{12, 13}  

With an increased number of risk factors, including many that disproportionally affect the AI/AN population, research suggests the importance of evidence-based approaches to reduce various risk factors and prevent falls and injuries.  

Strategies for engaging AI/AN elders  

Assess your organizational readiness to serve tribal communities.  

Relationships with tribal communities are relationship-based and take more human capital than the relationships with other organizations. Assess to what extent your organization has sufficient human and financial resources for a long-term commitment before you initiate the relationship. Understand that tribal members may not have had positive interactions in the past with outside people or organizations that provided short-term, “flash in the pan” health promotion offerings.  

Identify the needs of tribal members.  

Involve tribal representatives, other key partners, and stakeholders in the planning, implementation, and evaluation phases of your program. Research public data about the prevalence of falls within the tribe with which you will be working (e.g., tribal health studies, state public health department or state unit on aging reports, Centers for Disease Control and Prevention data). Check to see if a tribal needs assessment has been conducted that could help determine which programs are a good fit.  

The National Resource Center for Native American Aging supports tribes in completing community needs assessments; however, the information about individual tribes is proprietary and not available unless the tribe chooses to share their information with you.  

Understand the tribe’s governmental and social structure.  

Recognize that tribes have a government to government relationship as a sovereign nation. There is no common or predictable form of government, and federally recognized tribes have their own Constitution. It is critical that you understand how the tribe is structured so that you can appropriately target your outreach efforts to decision makers. Does the tribe have departments or other entities that could assist with falls prevention efforts (e.g., a tribal aging unit [often called an “Elders” Program or a Title VI Program], health clinic, elderly or health advisory board, nutrition and/or health education department, tribal outreach department)? Where does the tribal population live and what is the geographic reach of the tribe (e.g., only on or beyond the reservation)?  

Leverage existing resources.  

Leverage existing resources to help with your efforts to engage tribal members in offering falls prevention programs.  

• Engage tribal health professionals, tribal clinics, health departments, area agencies on aging, technical assistance centers, or other agencies already serving or working with the community.  
• Reach out to occupational therapists, physical therapists, and pharmacists to provide valuable resources for engaging tribal members.  
• Ask about and collaborate with falls prevention and health promotion programs already being offered to the community.  
• Explore what other grants the tribe has received that support falls prevention or treatment. For example, the Indian Health Service Division of Diabetes Treatment and Prevention provides Special Diabetes Program for Indians (SDPI) grants. This funding provides support for evidence-based interventions in over 300 AI/AN communities in 35 states to treat and prevent diabetes. Falls prevention and treatment may not be part of the existing programs offered, but the SDSPI will likely provide collaborative partners and a population of elders and others to serve with programs you may have to offer.  

Ensure a culturally competent workforce.  

Assure that staff and volunteers who are not tribal members understand the tribal culture and are sensitive to their needs. Whenever possible, seek out tribal members from on or off reservation who are a good fit based on custom, knowledge, and the politics of the tribe. Engage clinics, health centers, or other medical services, as well as traditional healers.  

• Recognize that what has worked with one tribe will not necessarily work with another.  
• Ask questions about the best way to work in the community.  
• If you are not a tribal organization, approach the community with an open mind and an interest in and respect for the tribe’s culture.  
• Acknowledge and value the important role tribal elders play in their community as well-respected parents, grandparents, healers, and cultural leaders.  
• Expect that building relationships will take a long time. Expect resistance as part of the “getting to know you” process and go back again. Resistance can be used by tribal members to filter out individuals who are not really committed.  
• Accommodate the need for extended families to participate in falls prevention programs. For instance, an elder who takes care of grandchildren may need to bring the children to sessions.  

Establish champions and strong tribal community infrastructure.  

Identify key individuals who are known, respected, and influential within the community. Engage respected elders or other community leaders as program champions. Seek out health professionals, allied health professionals, Community Health Representatives (CHRs), tribal health promotion programs, and others already working with the tribe.  

Honor and build upon tribal history.  

Build upon traditional ways of life which include cultural activities to prevent injuries and falls. Exercise and a healthy diet are a natural part of Native American culture and history.  

• People sat on the ground, which builds hip muscles and flexibility. Walking and exercise were part of daily necessities like gathering food and transportation from place to place, so were built into the culture.  
• Traditional activities played into better balance, and traditional diets supported healthier living.  
• Walking is the favorite recreational activity for most Native American elders. One Tribal Administration for Community Living falls prevention grantee makes walking sticks as an incentive to participate in a falls prevention program; these walking sticks are valued since they are traditional and made from a special type of wood.  
• Relate programs to tribal culture when possible. For example, Tai Chi has become popular among some tribal organizations because elders can also relate some of their traditional and spiritual beliefs with Tai Chi philosophy and movements as shown in this video. 

Use culturally relevant marketing strategies and materials.  

Reach out with your message multiple times, since people generally do not act the first time they hear a message. Deliver your message in multiple ways by multiple people - through community or health center newsletters, group meetings, media sources, and word of mouth. Hearing from someone who has benefited from the program, or from a trusted member of the community, is a powerful motivator. Build upon other approaches that have been shown to be effective. For example, the Centers for Disease Control and Prevention’s “Spread the Word: Marketing Self-Management Education Through Ambassador Outreach” program is a model for training program graduates to serve as “ambassadors” to help recruit and enroll participants. Another approach that can be helpful with enrolling and retaining participants is to conduct an informational session before the program begins to increase understanding and acceptance of the falls prevention program.   

Target marketing materials to the AI/AN population.  

• Incorporate pictures of individuals from the community and/or images that are meaningful to the tribe.  
• Use appropriate language and reading level.  
• Use messages that resonate with the tribe. For example, in many tribal communities, it is rude to focus on yourself, rather than on the community. Self-help messages that focus on the individual should be reframed to focus on how fall self-efficacy can be used to support their family, be a more active parent or grandparent, and contribute to the community.  
• Include tribal members in developing and reviewing marketing materials.  

Look to traditional and non-traditional sources for marketing and referral.  

• Potential referral sources are grocery stores, pharmacies, senior centers, barber shops, beauty salons, physician offices, hospitals, and community-based organizations.  
• Local fire departments, emergency medical services, and ambulance services can help identify frequent fallers and are trusted referral sources.  
• Social media and newspaper articles can increase visibility of programs.  
• Many rural communities have a public access cable network that may be able to provide publicity. The Rural Farm District TV (RFDTV) is another potential partner.  
• Be flexible with your expectations for attendance. Sometimes the first workshop scheduled in a location is not as well attended as the ones that follow. Overbooking the first workshop, calling participants each week, reminding them of the workshop, and encouraging them to bring someone with them helps keep participants invested.  
• Some falls prevention tribal grantees have done program demonstrations at casinos. They have marketed their programs there and have targeted casino employees and their family members.  
• Include refreshments at gatherings and a gift of some sort for successful participation.  
• Make completion of the classes a community event by inviting members of the tribal council, health staff, or social services program to come to honor the participants.  

Be flexible, while assuring program fidelity.  

Minor adaptations may be made to programs to increase receptiveness among AI/ANs, while assuring that the program fidelity is maintained. If you plan to make adaptations to the program, you should check with the program developer to assure that the program fidelity is not compromised.  

• Conduct sessions seated in a circle, like a traditional “talking circle.”  
• Use culturally appropriate words to include traditions which may be part of the community you are working in. Rather than exercise, suggest culturally appropriate activities that would be recognized as their own such as fishing and hunting, gathering foods, pulling bark, etc.  
• Refer to traditional foods used in the community.  
• Use a talking stick or other item to designate speakers/discussants.¹⁴
• Be flexible about starting sessions late if transportation issues arise, and postpone sessions when there is a death in the tribe.  
• When working with the elders, it is important that they participate in cultural events. Do not inadvertently schedule a class during a cultural event. If you do, reschedule whenever possible.  

Minimize barriers and provide incentives to increase program participation and retention.  

• Coordinate with meals or nutrition programs to provide healthy snacks for breaks or meals before or after the program.  
• Identify resources to provide childcare and respite care.  
• Coordinate with partners to provide transportation. Access is a significant barrier/issue among tribal elders.  
• Hold the programs at times and locations that are convenient to potential participants. Places where tribal members typically congregate with accessible transportation are ideal.  
• Consider tribal holidays and other cultural events. Some sessions may need to be rescheduled if many participants will be observing holidays or special observances of their tribe.  
• Offer small incentives. These might include a night light or non-slip bath mat from the dollar store to reinforce what is taught in the workshop; a raffle for small items that would be meaningful to the population; certificates of completion; or a pin or other sign of course completion.  
• Hold a graduation ceremony at the end of each program and invite tribal leaders and other stakeholders to recognize participants and keep them engaged.  

Six steps to reduce falls among AI/AN elders 

Although falls can negatively affect the health and well-being of elders, the good news is that many falls can be prevented. To reduce the risk of falling, encourage elders to take these six simple steps that were developed by the NCOA, the Centers for Disease Control and Prevention, and IHS Injury Prevention:¹⁵ 

2. Talk to their health care provider. It is important for elders to have an assessment of their risk of falling and to share their history of falls with their doctor.  
3. Find a good balance and exercise program. Programs that build balance, strength, and flexibility help to reduce the risk of falling.  
4. Regularly review medications with their doctor or pharmacist. Some side effects can increase the risk of falling. Medications should only be taken as prescribed. 
5. Get their vision and hearing checked annually and update their eyeglasses. Tribal leadership can be encouraged to consider adding hearing and vision tests to available services in the community. 
6. Keep their home safe. Encourage elders and their families to remove tripping hazards, increase lighting, make stairs safe, and install grab bars in key areas. Provide elders with a good home safety checklist which they can use to evaluate their home. 
7. Talk to family members. Falls prevention is a family affair. Children can be taught to pick up toys, straighten rugs, and wipe up spills. Communities can be informed about watching out for fall risks in their elders’ lives.  

Evidence-based falls prevention programs offer proven ways to reduce falls and falls risks and are being implemented in many tribes across the country. As stated by Nancy Bill, Principal Injury Prevention Consultant, Indian Health Service, “Fall prevention programs enhance the quality of life for our Indigenous elders who are imperative to cultural and linguistic survival.” Four “best practice” tribes disseminating evidence-based falls prevention programs and other strategies are highlighted below.  

Tribal Falls Prevention Best Practices 

Absentee Shawnee Tribe, Oklahoma 

The Absentee Shawnee Tribal (AST) Injury Prevention Program is implementing Tai Chi to reduce unintentional falls among its elders. Their Tribal Injury Prevention Cooperative Agreement Program (TIPCAP) Coordinator is a Tai Chi instructor and conducts these classes monthly, with additional classes offered weekly by other clinic staff. Within a one year period, a total of 62 elders attended the Tai Chi classes. The program partners with local health providers, such as primary care physicians and physical therapists, to obtain referrals for exercise and Tai Chi training. Physical therapists participate in the class to conduct balance assessments and subsequently monitor those that do not pass their assessment. Elders engaged in the classes have shown improvement and tend to be more active with exercise activities. Overall, these elder fall prevention activities have been so successful that tribal leadership has now begun providing executive support and funding to continue the site’s work on environmental risks for elders living in their homes.¹⁶

Gila River Indian Community, Arizona 

In January 2014, Gila River Injury Prevention Program (GRIPP) successfully implemented the evidence-based program A Matter of Balance (MOB) as a strategy to reduce the risk of falls within the community. A Matter of Balance is a structured 8-week program that emphasizes practical strategies to reduce fear of falling and increase activity levels. Throughout the course of the program, the participants acquired information on how to set goals to increase physical activity, make changes to reduce fall risks at home, and exercise to increase strength and balance. In addition, an occupational therapist provided a gait and balance test to screen the elders for risk of falling.

After completing MOB, participants stated that they gained knowledge on exercise and movement and learned healthy behaviors to incorporate into their lives.

They demonstrated significant improvements in their levels of exercise and falls management and control. Overall, participants were very pleased with the training delivered and plan to recommend the class to their family and friends. To help sustain the program, GRIPP is working with A.T. Still University for eligible students to support delivery of the program, recruit participants, and provide coaches.¹⁷

Match-E-Be-Nash-She-Wish Band of Pottawatomi Indians, Michigan 

In 2014, the Gun Lake Tribe of the Match-E-Be-Nash-She-Wish Band of Pottawatomi Indians received a two year U.S. Administration for Community Living grant to implement the evidence-based falls prevention program Stay Safe, Stay Active. The program is a weekly community-based group workshop of moderate intensity exercise with additional exercises performed at home by participants. When attendees asked if they could invite extended family members and neighbors who were at risk of falling to participate in the class, the Tribal Health Director approved the request. To ensure sustainability, tribal staff and community members were trained in a modified form of Tai Ji Quan: Moving for Better Balance at the end of the first grant year so that classes could be integrated into future Health and Human Services programing. As word about the program spread through the surrounding community, class size increased, with an overall total of 70 attendees completing initial data collection forms for the program in year one, and 68 completing initial data collection forms in year two. Total attendance in both years of the grant exceeded project goals by almost double. In a survey, program participants were asked whether the class was helpful; over 88% of survey respondents gave the class the highest rating. 

Sokaogon Chippewa Community, Wisconsin 

The Sokaogon Chippewa Community received a U.S. Administration for Community Living grant to implement Stepping On, an evidence-based falls prevention program. Stepping On classes are conducted once a week for seven weeks and cover a range of issues, including falls and risk, strength and balance exercises, home hazards, safe footwear, vision and falls, safety in public places, community mobility, coping after a fall, and understanding how to initiate a medication review. Over 60 elders participated in the program over the two year grant period, exceeding their grant participant goal by 13%.

As stated by the tribe’s Stepping On program administrator, “Our elders absolutely love the Stepping On program, and it has helped them tremendously. I see them walking around better, more focused on their walking, and making sure the area around them is free of clutter.”

To ensure sustainability after the grant period ends, several tribal members became Stepping On leaders. Additionally, the Sokaogon Chippewa Health Clinic committed to continue to provide weights for the program participants. 

Connecting with State and Local Falls Prevention Efforts 

Many states and local communities have falls prevention coalitions that work toward a common goal of reducing elder falls risks, falls-related injuries, and falls-related deaths. Since no single organization is responsible for addressing all aspects of falls prevention, coalitions bring together organizations and providers that need to collaborate to reduce falls, identify state or community needs, recommend policy changes, and build capacity.¹⁸ Tribes can contact their state Fall Prevention Coalition lead(s) to join the coalition, find a fall prevention program near them, or learn about state and local fall prevention efforts.  

Falls Prevention Awareness Week

Led by the NCOA’s Falls Free® Initiative, Falls Prevention Awareness Week (FPAW) is held aorund the first day of fall each year to raise awareness about the impact of falls among elders, educate about falls prevention strategies, and advocate for the expansion of evidence-based falls prevention programs. Tribes are encouraged to participate in FPAW by engaging elders in activities that will resonate with them. Explore free resources and learn more about this annual event. 

Resources  

• Centers for Disease Control and Prevention’s STopping Elderly Accidents, Deaths, and Injuries (STEADI) Toolkit. A toolkit for health care providers to identify patients at risk for falling, identify modifiable risk factors, and offer effectives interventions. Available at http://www.cdc.gov/steadi/ 
• Learn more about evidence-based falls prevention programs
• Falls prevention resources for elders and caregivers

This tip sheet and the National Falls Prevention Resource Center are funded by the Administration on Aging (AoA), which is part of the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) through the 2014 Prevention and Public Health Fund (Grant No. 90FC2000-01-00). Grantees carrying out projects under government sponsorship are encouraged to express freely their findings and conclusions. Therefore, points of view or opinions on this website do not necessarily represent official AoA, ACL, or HHS policy. 

 

Sources

1. Centers for Disease Control and Prevention. (2017). Important facts about falls. Found on the internet at http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html  

2. Centers for Disease Control and Prevention. (2016). Falls and fall injuries among adults ≥ 65-United States 2014. Morbidity and Mortality Report Weekly. Found on the internet at http://www.cdc.gov/mmwr/volumes/65/wr/mm6537a2.htm  

3. Centers for Disease Control and Prevention. (2017). Important facts about falls. Found on the internet at http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html  

4. Vieira ER, Tappen R, Engstrom G, da Costa BR. Rates and factors associated with falls in older European Americans, Afro-Caribbeans, African-Americans, and Hispanics. Clinical Interventions in Aging. 2015;10:1705-1710. doi:10.2147/CIA.S91120.  

5. Indian Health Service. (2016). Disparities. Found on the internet at http://www.ihs.gov/newsroom/factsheets/disparities/  

6. Blackwell, D.L., Lucas, J.W. & Clarke, T.C. (2014). Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2012. National Center for Health Statistics Vital Health Stat, 10(260).  

7. CDC. (2011). Diabetes Among American Indians and Alaskan Natives, Found on the internet at https://www.cdc.gov/vitalsigns/aian-diabetes/index.html

8. Murphy T, Pokhrel P, Worthington A, Billie H, Sewell M, Bill N. Unintentional injury mortality among American Indians and Alaska Natives in the United States, 1990–2009. American Journal of Public Health. 2014;104(Suppl 3):S470-S480. doi:10.2105/AJPH.2013.301854. Found on the internet at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4035871/  

9. U.S. Department of Health and Human Services, Office of Minority Health. (2017). Profile: American Indian/Alaska Native. Found on the internet at http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=62  

10. Kaiser Family Foundation. (2013) Health Coverage and care for American Indians and Alaskan Natives. Found on the internet at http://kff.org/disparities-policy/issue-brief/health-coverage-and-care-for-american-indians-and-alaska-natives/  

11. National Rural Health Association. (2016). American Indian and Alaskan Native Health. Found on the internet at https://www.ruralhealthweb.org/getattachment/Advocate/Policy-Documents/AmericanIndianandAlaskaNativeHealthPolicyPaperFeb2016.pdf.aspx?lang=en-US

12. Centers for Disease Control and Prevention. (n.d.) Risk factors for falls. Found on the internet at https://www.cdc.gov/steadi/pdf/STEADI-FactSheet-RiskFactors-508.pdf

13. Fjeldstad C, Fjeldstad AS, Acree LS, Nickel KJ, Gardner AW. The influence of obesity on falls and quality of life. Dynamic medicine : DM. 2008;7:4. doi:10.1186/1476-5918-7-4.  

14. Korda, H.; Erdem, E.; Woodcock, C; Kloc, M.; Pedersen, S.; Jenkins, S. (2013). Racial and ethnic minority participants in chronic disease self-management programs: Findings from the Communities Putting Prevention to Work initiative. Ethnicity & Disease, 23, 508-517.  

15 NCOA (2016). Six steps to prevent a fall. Found on the internet at https://www.ncoa.org/article/video-6-steps-to-prevent-a-fall

16. Indian Health Service. (March 2015). Tribal Injury Prevention Cooperative Agreement Program Newsletter. Found on the internet at https://www.ihs.gov/injuryprevention/tipcap/tipcapnewsletters/

17. Indian Health Service. (March 2015). Tribal Injury Prevention Cooperative Agreement Program Newsletter. Found on the internet at http://www.ihs.gov/injuryprevention/includes/themes/newihstheme/display_objects/documents/tipcap-newsletters/March2015.pdf  

18. Falls Prevention Center of Excellence. (2015). Coalitions/networks. Found on the internet at http://stopfalls.org/coalitionsnetworks/