Background
Community consultation is important in the planning and implementation of community-based health programs [
1]. It allows for communication between community members, program developers and funding bodies, ensuring community-based health programs address the issues affecting the health and wellbeing of local populations. Community consultation has shown to be particularly valuable in the development of health programs for Indigenous populations worldwide [
2]. Consultation not only allows for programs to respond to the unique needs and priorities of Indigenous populations, but importantly, allow Indigenous people to become active partners in identifying key problems and solutions for themselves and their communities [
3], facilitating self-determination.
Falls and fall-related injury are becoming a growing concern for global Indigenous populations as they age [
4‐
6]. For Australia’s Aboriginal and Torres Strait Islander population, fall injury rates have increased by an average of 10.2% per year from 2007 to 08 to 2010–11, compared to a 4.3% average annual increase for other older Australians [
7]. Falls are now the second most common cause of injury for all Aboriginal and Torres Strait Islander people in Australia [
8], with the highest fall-injury rates reported for females aged 65 years and above, and males aged 60–64 years [
9]. For older people, there is a high likelihood that a fall can cause injury, potentially resulting in significant functional decline or even permanent disability [
10]. Experiences of past falls can also lead to an increased fear of falling, preventing people from performing daily tasks and limiting their independence [
11].
Despite high and rapidly increasing fall-injury rates, there is little knowledge about the impact of falls in Aboriginal and Torres Strait Islander people in Australia, or in older Indigenous people worldwide [
12]. Further, while there are a variety of fall prevention programs currently run in community settings, it is uncertain whether these programs are accessed by older Indigenous people or whether they are effective or acceptable for these populations. Previous research has shown that successful health programs implemented in Indigenous communities have different content, structure and methods of delivery than those developed for the general population [
13]. Indigenous leadership and community ownership of health programs ensures they answer to local community needs, can be modified readily to suit changing community priorities and are run corresponding to local belief systems and practices [
14,
15].
Yarning Circles are a method of storytelling, education and preserving cultural knowledge, used for thousands of years by Indigenous people in Australia, Canada and North America [
16]. ‘Research Topic Yarning’ is well-documented and has been previously used to gain community input for the design/delivery of community-based health programs for Indigenous populations [
17,
18]. It is compared to a semi-structured interview and described as ‘a yarn with a purpose’ [
19]. It enables researchers to learn from the stories and experiences of Yarning Circle participants in relation to a specific issue or question.
Within this study, Yarning Circles were used by our team of Indigenous and non-Indigenous researchers to explore three key areas: 1) investigate the impact of falls on the health and wellbeing of older Aboriginal and Torres Strait Islander people; 2) assess the level of existing knowledge older Aboriginal and Torres Strait Islander people have on fall prevention; and 3) to identify desirable elements of a fall prevention program from the perspective of older Aboriginal and Torres Strait Islander people.
As the majority of the New South Wales (NSW) Aboriginal and Torres Strait Islander population is Aboriginal (97.2%), this population will be referred to as ‘Aboriginal’ in this manuscript.
Discussion
The Yarning Circles highlighted concerns around falls and the significant impact falls have on social and community life for older Aboriginal people. The importance of community consultation was demonstrated, with many issues discussed surrounding falls and fall prevention being unique to the older Aboriginal population. In line with previous research [
2,
3], a strong and consistent theme that emerged from the Yarning Circles was the need for fall prevention services specifically designed and delivered for Aboriginal people. Yarning Circle participants voiced a strong preference for a group-based program, tailored to suit local interests and health priorities. It was essential that all community members were included and able to participate in the program. The provision of transport as part of the program was considered important and a small donation was viewed as appropriate for program use.
The limited research available investigating falls and fall-related injury in older Indigenous populations suggests different patterns and outcomes of falls when compared to equivalent mainstream populations [
23‐
26]. Despite this, many issues surrounding falls documented from general populations mirror those discussed by Aboriginal Yarning Circle participants. Common issues included sustaining serious injuries that cause chronic pain and disability, a loss of independence, loss of confidence, depression and developing a fear of falling [
27‐
29]. The loss of family and community responsibilities were additional issues discussed by Yarning Circle participants.
The previous uptake of fall prevention programs by other older populations has been reported to be low. Typically, 10–50% of an eligible population participates in fall prevention interventions at a community level [
29]. These low rates are associated with people not viewing themselves as ‘at risk’ of falling, or being unaware that falls are preventable. In previous studies, falls have been associated with a loss of control and seen as an indication of a transition into old age [
30]. Previous studies have also documented older people as being very reluctant to discuss falls due to embarrassment. On the contrary, Yarning Circle participants were very willing to discuss personal stories of past falls within each group, listening to each other’s experiences with interest and providing suggestions on how to prevent future falls from occurring, or how to manage resulting health issues. A lack of awareness about fall prevention interventions emerged as the predominant reason for Yarning Circle participants not using existing fall prevention programs. Service providers working in Aboriginal aged care within NSW have provided similar feedback, stating that few older Aboriginal clients access fall prevention services as they are unaware they are available [
31].
There was unanimous agreement by participants that the program should be Aboriginal-specific, acknowledging issues of particular importance and relevance to older Aboriginal people. Previous studies have identified a number of health and social issues that affect Indigenous populations and mainstream populations differently [
32,
33], leading to different areas needing to be prioritised by health services and health programs for Indigenous communities [
34]. Yarning Circle participants additionally expressed the need for a program with the flexibility to be customised to suit the diverse range of Aboriginal communities across the state, while remaining evidence-based and effective. Ensuring cultural safety through providing an Aboriginal-specific program was also stated as important by Yarning Circle participants. Previous studies have documented Indigenous people’s experiences of discrimination, judgement and communication difficulties when accessing mainstream health services [
35‐
37].
The inclusive, group-based setting requested for a fall prevention program by Yarning Circle participants has previously been identified as an effective approach towards community participation and promoting community ownership of a program [
38]. Community ownership has been reported as a key contributor to the success of Indigenous health services and health programs worldwide [
39,
40]. Previous successful Indigenous-specific programs delivered in ‘safe and supportive group environments’ have led to a greater sense of participant well-being and support amongst group members [
41]. The request for a long-term, ongoing program is not unique to this study. Many initiatives run in Aboriginal communities are a product of short-term grants which do not get funded in the long term [
42]. Similar issues have been reported for the funding of Indigenous health services worldwide [
39].
Costs associated with accessing health services have been reported as a barrier to their use by approximately one third of Australia’s Aboriginal population [
43], particularly when costs are ongoing [
44]. Nearly all existing fall prevention programs run in NSW charge an attendance fee ranging from a donation to $22 per session [
45]. Although the majority of Yarning Circle participants agreed that a small donation was appropriate for program use, there were concerns that other community members may not be able to afford this and would therefore be excluded. Transport to and from regular program sessions introduces a secondary barrier to program use, particularly in remote communities. Long distance, poor roads and a lack of public transport cause people living remotely (particularly older people) to have a strong reliance on private and community transport options, which can be expensive and in high demand [
46]. Transport availability and cost were highlighted by participants as a concern and ongoing programs would need to address this.
The strengths of this study include the involvement of Aboriginal people in all aspects of study design, participant recruitment, data collection, data analysis and manuscript preparation. To our knowledge, this is the first qualitative study which documents the views of older Indigenous people regarding healthy ageing, worldwide. A greater proportion of women participated in the study than men. This may mean that perspectives from older Aboriginal men may not have been appropriately considered. Furthermore, this study only reflects the views of Aboriginal community members from NSW, Australia. Although the results of this study are anticipated to be generalizable, repetition of this study within different Indigenous populations, both within Australia and internationally, would be valuable for comparison. Nonetheless, there are many similarities in the health and social issues that affect Indigenous populations worldwide and it is anticipated the findings of this study may inform the development of prevention programs for other older Indigenous populations.
Conclusions
Yarning circles with older Aboriginal people facilitated important discussions of the impact of falls. Many Yarning Circle participants shared stories of falls impacting their health, well-being and connection to family and community. Existing mainstream fall prevention programs were generally not used by Yarning Circle participants due to their lack of availability in certain areas, no referral provided for fall prevention services by GPs and/or being unaware of existing programs. Despite few Yarning Circle participants receiving formal fall prevention education, significant knowledge was shared from past experiences and individual ideas for minimising fall risk and managing recovery from fall-related injury. Feedback from participants highlighted that an ongoing, Aboriginal-specific, group-based fall prevention program was preferred, that could be run through established Aboriginal organisations with the flexibility to be tailored to specific communities while remaining effective and evidence based. Multiple issues discussed by participants in relation to falls and fall prevention were unique to the older Aboriginal population and were not being met by existing services, highlighting the importance of community consultation, but also Aboriginal leadership and program ownership. The findings of this study will guide the development and implementation of appropriate fall prevention programs for older Indigenous populations worldwide.