“Pisando Fuerte”: an evidence-based falls prevention program for Hispanic/Latinos older adults: results of an implementation trial

In the United States (US), every hour, three older adults die as a result of a fall, and by 2030 this number is expected to increase to seven older adults [1]. The risk of falling is similar across race and ethnicity [2], and although the age-adjusted death rate due to falls is higher for whites, the age-adjusted death rate for Hispanic/Latinos seniors has been climbing over the last few years [3]. This is concerning because the older adult Hispanic/Latinos population in the US is growing exponentially [4], and there is a dearth of evidence-based fall prevention programs designed for Hispanic/Latino seniors.

Risks factors for falls include certain medications, vision impairment, gait and balance impairments, muscle weakness, inadequate footwear, environmental hazards, and chronic conditions (e.g. arthritis, dementia) [5, 6]. Some evidence-based fall prevention programs that target risk factors for falls or fear of falling are available in Spanish, and they have been shown to reduce fear of falling or risk factors for falls, resulting in improve physical activity, balance, and/or lower extremity strength. However, they have not shown a decrease in falls among Hispanic individuals [7‐10].

The process to select one fall prevention initiative to implement usually involves a needs assessment process at the community/organization level, which takes into account the cost of the delivery, preferences of participants, capacity of staff, among others. According to Hanlin et al., seniors in Hispanic communities in Milwaukee (Wisconsin, US) would prefer a multi-faceted program that combines exercise with education in Spanish, and with the participation of a healthcare provider [11]. Stepping On is a multifaceted intervention with similar characteristics to those described as desired by Hispanic communities in Wisconsin. It has been documented to decrease the risk of falls among Australian older adults by 31% [12‐14], and is available in English in 22 states within the US.

Given the growing population of Hispanic older adults, and the need to provide a culturally and linguistically tailored multifaceted fall prevention program for Hispanic seniors, we adapted Stepping On to develop Pisando Fuerte for use with Hispanic/Latinos older adults whose primary language is Spanish.

The primary objective of this paper is to describe the implementation of Pisando Fuerte at two community organizations in Wisconsin using the RE-AIM framework [15], which includes a characterization of the reach, adoption, pre-post outcomes, implementation fidelity and costs, and maintenance of behavior change by individuals. The secondary objectives include to: 1) identify the barriers and facilitators for adoption and implementation from the perspective of leaders and program coordinators, and 2) describe the effects of the program in terms of participants’ uptake of behaviors that have been shown to be effective in preventing falls: practice of strength and balance exercises, and protective health behaviors (e.g. avoiding hazardous conditions, using adequate footwear).

This study shows that Pisando Fuerte significantly improves the behaviors that are associated with a decrease in the frequency of falls, as shown by the improvement of the FaB, and continued execution of exercises for balance and strength and safety strategies to prevent falls by older adults whose primary language is Spanish. It is important to note, our participants had low literacy levels, with 45% of participants having less than primary education, and 37.5% having difficulty reading in Spanish. This is substantially different from the experience with Stepping On participants, where participants with less than high school education are less than 20% [14, 21]. This highlights the need to perform more than translation, but the linguistic and cultural adaptation of the program.

Our study showed a promising reduction in falls (68%), which is similar to the results for Stepping On implementation, which have ranged between 31 and 48% [12, 13]; however, our results are not statistically significant because the sample size was not powered to identify a significant reduction in falls. Additionally, we collected two intermediate outcomes that are used as predictors of falls: FaB [24, 26] and TUG [23, 27]. Our study showed a significant improvement in FaB similar to other Stepping On studies [13]; however, TUG results had a non-significant trend to worsening, i.e. greater time required to execute the task. Several factors may explain the increased TUG times. First, many participants reported that as a result of this program they were “walking slower” and “taking their time” when changing positions, and per evaluator recollection, older adults were proud of doing tasks at a slower pace. With the TUG participants were told to “walk at a comfortable pace” similarly to other studies [23, 34]; we suspect that they may have slowed their walking with the TUG to demonstrate that they were now walking more safely. Other studies have used the TUG with instructions to walk “quickly” or “as quickly as you can in a safe way” [27]. We chose not to use these instructions as the focus of Pisando Fuerte is on walking more safely, including not walking too fast. In addition, some studies have also suggested that the TUG might not be a good tool to measure the risk of falling, because it might not have the sensitivity required to identify falls risk among older adults whose TUG scores are close to normal values [35, 36]. Lastly, there is limited information about the normative values of the test in Hispanic/Latinos populations in the US [37]. Regarding the uptake of protective health behaviors (Table 6), Pisando Fuerte can’t be compared with the original study published by Clemson et al. [12], because of the different methodologies used to evaluate the changes, per example, in our study maintenance was evaluated at 6-months, while Clemson et al. evaluated the changes at 14 months.

We identified several barriers for adoption by workshop leaders and organizations. First, Leaders were required to be fluent in English to complete the training, which narrows the number of individuals who could be trained to facilitate Pisando Fuerte. Second, the time required for preparing and delivering the program might be cost prohibitive for many organizations. Third, some of the materials in the leader manual were not translated into Spanish, and those that were translated were at too high of a language level for use with older adults with little formal education. As a result, leaders needed more preparation time to review the information provided, and adjust the language of the program as written in their leader manual to the language used by participants, especially around key words that have multiple variations across Latin America (e.g. calf muscle is known as chamorro in Mexico, batata in Puerto Rico, pantorilla in Venezuela, and gemelos in Panama and Central America).

Fidelity of delivery was evaluated following protocols established for Stepping On leaders [14]. For Stepping On it is expected that new leaders deliver at least 80% of elements in a satisfactory manner, however, this benchmark was established empirically from the identification of key elements [20, 21, 38]. In our study, the overall fidelity of delivery was below the pre-established benchmark of 80%, with substantial differences between sites, where site 1 had higher performance that site 2. We suspect that one of the reasons for the lower fidelity at site 2 was related to the leaders’ background, and the context (setting) where the classes were held. Site 1 had access to more resources based on the location of the workshops, the leaders had more experience facilitating group activities with Hispanic/Latino older adults, and the organization had experience delivering similar programs. Meanwhile, site 2 (senior housing building) had limited resources, one of the leaders was also the housing coordinator, which created logistical difficulties, and the organization had no previous experience in organizing this type of event. This correlates with the experience of Stepping On, where the implementation of the program in independent living facilities was cumbersome because the staff in charge of delivering the program were not given additional time or resources to implement the program, delivery of health promotion programs was not central to the organization’s mission [14].

Although most of the leaders had previous experience in teaching health education classes, not all of them had been trained in health promotion and behavior change techniques, which affected the delivery of the program, and potentially influenced the seniors’ adherence to the program, and their uptake of the protective behaviors Another important aspect to consider, is the familiarity that the leaders had with the participants. According to our previous experiences, when the leader is a recognized local champion, it facilitates recruitment to the program and subsequent adherence.

Because of the small number of participants per site, it is not possible to assess if the health outcomes, and uptake of health behaviors were affected by the lapses in fidelity, or by the backgrounds of participants (Table 2). Compared to site 1, participants in site 2 were more likely to be male, with low educational attainment and living alone, which is in itself different than the typical participant in a fall prevention program: white older female with some college education [39].

These differences may have affected adherence and uptake and maintenance of behavior change, highlighting the importance of future research studies that assess how participant characteristics may affect outcomes of falls prevention programs, particularly in the setting of cultural adaptation, where adaptations must take into account cultural and socio-demographics differences of the end-users.

Our study population is also different from the original Stepping On, in that our participants had a lower rate of falls at baseline. Clemson et al. [12] described that Stepping On is more effective among those with had multiple falls in the previous year. Future research studies will be powered to assess the effectiveness of Pisando Fuerte in fall rate, and other health outcomes.

The process of linguistic and cultural adaptation of Stepping On to Pisando Fuerte was performed in a previous study, and not described at length in this paper. However, it was characterized by the inclusion of community advisors, older adult stakeholders, leaders, and experts in the field in a process of iterative adaptations. Our study did not assess the cultural adaption per se, but rather the fidelity of delivery for cultural adaption elements, which was low. We hypothesize that this might be a result of the evaluation tool used. As seen in Table 3, leaders needed to refer to 6 different cultural values during session-3 to obtain a “satisfactory” evaluation; however, there is no evidence that all the values need to be displayed to increase understanding. Based on the overall results of this pilot, we believe that we achieved our goal for cultural adaptation: to promote participation in the program and maintenance of the desired behaviors by appealing to cultural values that are delivered in an understandable way [18, 40].

In conclusion, Pisando Fuerte is a culturally acceptable program to prevent falls among Hispanic/Latinos communities that increases adoption of behaviors to prevent falls. It provides similar benefits as Stepping On [13, 14], even in light of bigger challenges that needed to be overcome to adopt and implement the program. Although Pisando Fuerte was well accepted by instructors and participants alike, more work is required to be able to disseminate the program, including: (1) Develop and implement the Spanish language training for leaders; (2) Improve training around elements that had poor fidelity during implementation; (3) Revise materials to assure that cultural adaptation of the program is relevant to a diverse group of Hispanic/Latinos individuals. The rigorous evaluation we conducted was essential to identifying the remaining gaps with program adaptation, and how they relate to the context where the program is implemented. Our findings support the value of conducting a rigorous evaluation of implementation metrics with any cultural adaptation of a behavior change intervention, to ensure that the adapted program has adequate adoption and maintenance, can be implemented with good fidelity and minimal barriers, and can retain effectiveness similar to the original program.