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

Older adult falls remain a significant public health problem amenable to preventive interventions (CDC, 2009; CDC, 2011). Despite 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 (Noonan, Sleet, Stevens, 2011). Newton and Scott-Findlay (2007) point out that the translation of basic scientific knowledge into clinical studies, and from clinical studies to improvements in health services and public health practices, remain major obstacles to widespread adoption.

Donaldson and Finch (2013) showed the feasibility of applying implementation science to sports injury prevention and Li et al (2008) demonstrated how an exercise and balance program (Tai Chi) can successfully be translated into a community program. As important, Li and colleagues maintained program fidelity and adherence to their intervention, at least over the short term, to prevent older adult falls. Manson et al (2013) showed positive results taking a Tai Chi program to low-income older adults, concluding that “non-(Tai chi) culturally related ethnic groups did not experience a barrier to participation in an older low-socioeconomic population sample” (p270). 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 article in this issue “Implementing an evidence-based Tai Ji Quan Program in a Multicultural Setting: A Pilot Dissemination Project” (Fink and Houston, in press) extends these findings and takes the next step. Specifically, they 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 the intervention meets three criteria:

1. Native Language: Intervention is translated and delivered to participants in their native language. It is also important for program leaders to be bilingual.

2. Community Organization Engagement: Intervention is implemented by a broadly imbedded community organization such as an Area Agency on Aging.

3. Program fidelity: Intervention is delivered with fidelity to specified research-tested protocols.

This article demonstrates that by adhering to these three elements, a community-based organization can successfully implement a Tai Ji Quan Program in a multicultural setting. The pilot study also reinforces the notion that interventions shown to be effective using randomized control trials require additional adaptation and translation before they can be successfully implemented in community setting. This study suggests that this is possible - even within multi-cultural communities.

Another important component of this program was the use of an appropriate infrastructure or delivery system – essential for widespread adoption and sustainability. In this study, the Minnesota Area Agency on Aging served in this role, but other groups, such as community health organizations, faith-based organizations, or senior centers which have wide reach, could also be employed to implement the program. This “system integration” is essential and can be achieved in cooperation with community-based organizations like an Area Agency on Aging, or through other community agencies, public health departments, or health and aging service providers.

The Minnesota program also demonstrated the importance of “knowledge brokers” to bridge the gap between knowledge generated from research and applications of knowledge to community programs involving older adults from different cultural backgrounds and languages. Local community organizations served as knowledge 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. (2008) highlight the importance of following the rigorous public health model in older adult fall prevention programs. A lynchpin to successfully reduce older adult falls is the utilization of RCT-tested interventions in program delivery. The Tai Ji Quan program meets these criteria and its multi-ethnic applicability makes it especially appealing.

Equally important, it is critical for rigorous falls screening to occur within health care provider settings to triage and refer older adults to an appropriate community-based program like Tai Ji Quan. CDC developed the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) toolkit to foster this screening, treatment, and referral (Stevens and Phelan, 2013). Among the many benefits of this approach, this connection can help integrate clinical medicine and public health, and assure improved patient outcomes. It will 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-AIM (Gaglio, Shoup, Glasgow, 2013; Shubert, Altpeter, Busby-Whitehead, 2011) might be considered. RE-AIM can help measure the 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, Askew, Purcell, et al (2013) already demonstrated that RE-AIM can successfully be used 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.