Falls Risk Assessment, Outcome Measures, and Interventions
A Clinical and Community Education Service Project in Guatemala
By: Anjali Paintal, SPT
Background
Third-year students are given the opportunity each year to participate in a service-learning trip to Guatemala alongside faculty members and clinicians. The purpose of this trip is to foster an exchange of physical therapy related skills with the therapists in Guatemala, to provide recommendations and supplies at community health fairs, to learn how a different healthcare system functions (especially within a resource-constrained environment), and to gain a unique clinical experience working alongside physical therapists at Las Obras Sociales at Virgen del Socorro (Las Obras) long-term care facility.1,2 This year, 15 people participated including three faculty members, one clinician, and eleven students: Lisa Johnston, Karen McCulloch, Cathy Howes, Katie Ollendick, Mara Argyriou, LaCorey Cunningham, Kristen Fontela, Sarah Galante, Erica Ghigliotty, Karla Graves, Shelby Miller, Leslie Rainey, Emma Shirley, Austin White, and myself. The Guatemala service-learning trip was an opportunity that directly aligned with my professional interests, as it integrated my passions of serving Latino and underserved communities, using the Spanish language, and physical therapy. I was very much looking forward to making more of a long-lasting, sustainable impact during the trip by providing clinical education to Guatemalan physical therapists and physical therapy students at Las Obras.
Las Obras is a unique association that provides many of its services at two locations in Antigua, Guatemala: the hospital at Santo Hermano Pedro and the long-term care facility at Virgen del Socorro.1 Las Obras is a non-profit, Christian association with a mission of serving the poorest and neediest citizens of Guatemala by providing high-quality healthcare, education, and rehabilitation.1 The association is primarily donation-based and provides services such as surgeries, dental care, rehabilitation, among other healthcare services.1
Most of our clinical time was spent at the long-term care facility at Virgen del Socorro which holds 248 residents.1 Most of these are permanent residents with cerebral palsy, psychomotor impairments, and other disorders necessitating long-term care.1 Several of the residents have been abandoned by their families and have nowhere else to go.1
Many of us were apprehensive to go on the trip due to the news regarding the recent COVID-19 outbreaks, which at the time, were primarily affecting China and several countries in Europe – not the Americas. Little did we know that the pandemic would completely derail our entire service-learning trip. Soon after we arrived in Antigua, the pandemic started spreading within the Americas, causing much alarm within Guatemala. Within a few days, the first case in Guatemala was discovered, and soon after, travel restrictions and flight cancelations ensued as the country implemented measures to contain the virus. Unfortunately, on the day that I was scheduled to present the in-service and lab components of my capstone project to healthcare providers at Las Obras, we were not allowed entry into the facility. Due to rapidly changing conditions as well as the mandate to shelter in place, I quickly adapted my in-service presentation and lab to present to the UNC students and faculty on the trip. Fortunately, I was still able to utilize the educational handout component of my capstone project to disseminate evidence-based recommendations to older adults in the community regarding falls risk.
Read more about our experience during the Guatemala service-learning trip at: http://uncptoutreach2.blogspot.com/
Statement of Need
I met with Lisa Johnston, my advisor and coordinator of the Guatemala service-learning trip, to brainstorm potential capstone topic ideas. During our discussion, I expressed to her that I would be interested in creating a capstone project for the Guatemala trip, but I was unsure how my professional interests in geriatric physical therapy would align with the needs of the professionals practicing in Guatemala. After discussing potential options, we agreed that a Capstone on falls risk assessment, outcome measures, and interventions would both meet a need within Las Obras and relate to my professional interests. Although the residents in Las Obras long-term care facility are primarily wheelchair-bound, there is a small population that is ambulatory. Additionally, Lisa informed me that there were physical therapy students at Las Obras who may benefit from professional education regarding falls, as they can apply this clinical knowledge throughout their careers.
Moreover, the issue of falls in the older adult population is a major global issue, as it is one of the primary causes of morbidity and mortality within this population.2 Surprisingly, falls are the second leading cause of unintentional death, just after motor vehicle accidents and account for 80% of disability due to unintentional injury.2,3 Furthermore, about 1/3 of people aged 65 and older fall every year and 10% of fallers require medical care.2,4 Since there is a growing number of older adults globally, there will be a greater need to reduce falls risk.2
Purpose
The purpose of my capstone project was to facilitate a dialogue about this important issue, as well as to provide professional education on evidence-based findings regarding falls risk assessments, outcome measures, and interventions. I mainly focused on collecting and synthesizing findings from studies conducted within long-term-care facilities (as this fits the setting at Las Obras), but I also included information from a few studies focused on community-dwelling older adults and mixed populations. The purpose of the lab portion of the Capstone project was to provide hands-on practice using five evidence supported outcome measures to assess falls risk. The associated outcome measure handouts translated in Spanish were intended to provide Guatemalan physical therapists and students a tangible tool that they could reference and use to enhance their clinical practice. Lastly, the educational handouts were intended to aid in providing recommendations regarding falls prevention to community members at the health fairs that we organized. The falls prevention education focused on exercise recommendations and home modifications.
Since I was not able to present to my intended audience for the in-service and lab components of my capstone project, the purpose of the presentation was modified as following: 1.) to facilitate a dialogue between UNC students a faculty about falls risk factors and current research; 2.) to provide a review on falls risk factors, outcome measures and interventions; 3.) to provide an opportunity to learn physical therapy- related Spanish vocabulary; and 4.) to engage students in a review of evidence supported outcome measures and practice disseminating them in Spanish.
Project Overview
1. In-service presentation: Spanish/ English
Title: Falls Risk Assessment, Outcome Measures, and Interventions
Objectives:
– Identify the most important components of a thorough falls risk assessment
– Identify main risk factors associated with increased falls risk
– Demonstrate the ability to utilize at least 3 evidence-based outcome measures
– Become better equipped to identify and treat falls risk patients in clinical practice
2. Lab handouts: Spanish/ English
Falls outcome measures:
– Modified Falls Assessment Tool
– Timed Up and Go
– 5 Times Sit to Stand
– Berg Balance Scale
3. Health fair educational handouts: Spanish/English
Topics:
– Exercise recommendations
– Home modifications
Evaluation
I worked closely with Lisa Johnston, my advisor, while creating my capstone materials. She provided me with invaluable, ongoing feedback throughout the whole process. Her feedback was crucial in creating an effective and interactive presentation of appropriate health literacy. My committee members Charron Andrews and Karen McCulloch also provided feedback to improve my presentation to better address the needs and interests of my audience. Sarah van der Horst evaluated the quality and accuracy of my Capstone Spanish material and provided me with helpful suggestions, as well.
Since I was unable to present to my intended audience, I created a survey (in English) through Google Forms that was more appropriate for the audience of UNC students, faculty, and clinicians. The survey asks audience members to assess my delivery, organization, effectiveness, extent to which objectives were met, and to provide any additional feedback.
Google Forms link: https://docs.google.com/forms/d/e/1FAIpQLSfdoBzlA5MIXoVIzM1rQ9ZKRK5hdilQ1FgbZoWaFcsROe5z2A/viewform?usp=sf_link
Self-Reflection
Although the delivery of my Capstone in-service and lab did not turn out as expected due to COVID-19, I am very pleased that I chose a project that required me to step outside my comfort zone by delivering a professional presentation to an audience all while using my Spanish skills in a clinical capacity. I was disappointed that I was not able to present my in-service to the physical therapists and physical therapy students at Las Obras, as I wanted to provide a sustainable and lasting impact during the Guatemala service-learning trip through the delivery of clinical education in Spanish. Nevertheless, I am grateful that the UNC students, faculty, and clinicians were an engaging and supportive audience.
Additionally, I am grateful that I was still able to impact the Guatemalan community by providing falls prevention education in Spanish at the community health fairs. During these educational sessions, I shared information about three simple evidence-based exercises and basic home modifications to prevent falls. One woman (pictured above) stood out in particular, as she was very responsive to the recommendations provided, was extremely motivated to engage in activities that would improve her health, and open to discussing her own health concerns. She and I practiced each exercise included in the handout together and had a long conversation about the purpose of each exercise, the importance of carrying out household activities during daylight, and the effectiveness of Kegel exercises in addressing incontinence issues. It was a pleasure to engage in conversations with older adults within the community in Guatemala, understand their unique experiences, and share evidence-based recommendations that will hopefully prevent future falls.
While preparing for the presentation, I was very surprised to discover that most outcome measures that I selected for the lab portion of my Capstone project were not available in Spanish. I hope that the students will be able to reference the Spanish lab handouts in their future practice while working with Spanish speaking patients (along with an interpreter) to better serve this population. I also hope to make this translated material readily available online for other clinicians to access, since this seems to be a need within the field of physical therapy.
During the development of my Capstone project, I was unsure about the health literacy level of my intended audience, as I had never been to Guatemala or Las Obras before. It took many meetings with Lisa Johnston and multiple revisions of my in-service presentation to create a product that was engaging and appropriate for my intended audience. I appreciated my committee’s patience as I worked through these revisions (in both Spanish and English) as well as their timely feedback before our trip on March 10th, 2020.
This project has improved my ability to critically appraise research, find best evidence, synthesize research findings in an engaging and appropriate format for my intended audience, use Spanish within a professional setting, among many other skills.
In the near future, I hope to identify additional clinicians, students, and/or practices that may benefit from the Capstone material that I have created and translated into Spanish.
Acknowledgments
I would like to thank Lisa Johnston first and foremost for brainstorming this Capstone idea with me, consistently meeting with me, and providing continual feedback throughout the process. I deeply admire Lisa Johnston’s commitment to the Guatemala trip and her passion to organize this trip every year in the spirit of service-learning. Thank you to my committee members, Karen McCulloch and Charron Andrews, for your patience and for providing me with feedback before the trip to make my presentation more salient and engaging to my audience. Thank you to Sarah van der Horst for reviewing all of my material in Spanish, providing me with helpful suggestions, and reassuring me that my Spanish material was appropriate and professional. Thank you to Erica Ghigliotty for your words of encouragement and for selflessly letting me practice the delivery of my in-service presentation and lab in Spanish with you. Lastly, I am forever grateful for all the students and leadership who participated in the Guatemala service-learning trip – thank you for being a wonderful and interactive audience, for supporting each other through the unexpected and distressing situation we found ourselves in due to the COVID-19 pandemic, and for sharing unforgettable memories.
References
1. Obras Sociales del Hermano Pedro. n.d. INICIO – Obras Sociales Del Hermano Pedro. [online] Available at: <https://obrashermanopedro.org/> [Accessed 17 April 2020].
2. Stewart Williams J, Kowal P, Hestekin H, et al. Prevalence, risk factors and disability associated with fall-related injury in older adults in low- and middle-incomecountries: results from the WHO Study on global AGEing and adult health (SAGE). BMC Med. 2015;13:147. Published 2015 Jun 23. doi:10.1186/s12916-015-0390-8
3. Alshammari SA, Alhassan AM, Aldawsari MA, et al. Falls among elderly and its relation with their health problems and surrounding environmental factors in Riyadh. J Family Community Med. 2018;25(1):29–34. doi:10.4103/jfcm.JFCM_48_17
4. Ek S. Risk factors for injurious falls in older adults: The role of sex and length of follow-up. Journal of the American Geriatrics Society (JAGS). 02/2019;67(2):246-253. doi: 10.1111/jgs.15657.
7 Responses to “Falls Risk Assessment, Outcome Measures, and Interventions”
Katherine Carter
Anjali,
I really enjoyed your project. I thought you created some great resources that I am sure will be helpful when working with patients who are at an increased risk of falling. I wish I could have seen your presentation in person, but I could tell that it was well researched, clear, concise, and included the pertinent information needed to design and execute an effective falls risk screen and intervention. I thought the evidence you found to support your selection of tests was very compelling, and I am sure that this information and the resources you created will be useful to many clinicians in the future.
I saw in reviewing your evidence table that there was some conflicting evidence regarding vitamin D and calcium recommendations pertaining to falls. What are your thoughts on the effectiveness of this intervention based on the evidence you found? And do you think that physical therapists should ask about this in an evaluation?
I am glad to know that you have made a Spanish language version of these tests available. I have seen many instances when there is a language barrier between a therapist and a patient and there is not an interpreter available during the entire appointment. While an interpreter should always be used to ensure that there is a clear and open line of communication between medical providers and their patients, a resource like this may help to improve the effectiveness of a treatment session until the interpreter is able to join.
Overall, I was really impressed by the quality of your products and I could tell that you care very deeply about helping this population group. I think your project was well designed and executed to fit the need that you identified.
Great job!
Erica Ghigliotty
Anjali,
First of all, I am so grateful that I was able to experience Guatemala with you. Long ago, we discovered our shared passions, and I know that the both of us had been looking forward to this trip for a long time as a result. It turned out to be more of an adventure than either of us ever anticipated, huh!?
I can certainly attest to your successful ability to adapt during stressful times, and your new objectives match that. You presented your capstone blisfully and effortlessly, and I enjoyed every second of it! We all got to practice our Spanish-speaking skills as we attempted to teach others how to perform the outcome measures that you discussed, and I know that everyone appreciated that. I am sure there will be a way to make sure the therapists at Las Obras have access to this information, and perhaps there can be a way to present this in the future since it is so interactive. Like you said, some residents at Las Obras could still benefit, but also students doing their rotations there and even older family members! You put in so much work researching, organizing, and putting together a wonderful project, and I think it should reach them one way or another. Of course, their priority now (like ours) is to keep their residents safe from COVID-19, so maybe some time in the future would be more appropriate. I hope they are all ok!
I am so excited to have your materials accessible online! During my first clinical rotation, I noticed that many outcome measures lack a Spanish translation, and that it is up to us to make it happen – which you did! I wonder if you can contact the Shirley Ryan Rehabilitation Measures Database (rehabmeasures@sralab.org or 312-238-2802) to see if they can add your translations to their website. This would allow therapists nationally and perhaps globally to access your materials!
Again, I am SO proud of you. I was glad to help you practice and prepare for this. You certainly delivered. I know we will continue to stay in touch beyond graduation because of our bond strengthened by our interest in working with older adults, utilizing our Spanish, and simply 3 years in PT school together.
!Buen trabajo, amiga!
Erica
Shelby Miller
Hi Anjali,
Congratulations on completing such a wonderful Capstone! I am so proud of you!! I am thankful to have had the experience of traveling with you to Guatemala and hearing your presentation in person. You did an amazing job in both the presentation and also all of your deliverables! I thought your intention of creating a long-term and sustainable impact through the method of providing education to local therapists is very commendable and wise.
Furthermore, I think your materials could be disseminated to other communities to have an even more widespread impact. The Spanish language components of this project are so beneficial in specific international settings, but they could also be very relevant and useful in many local communities in the states. After working in the SHAC pro-bono clinic that many of the UNC DPT students volunteer in weekly, I have seen how Spanish translated resources could monumentally benefit many of the patients that we see there who are in the Spanish-speaking community.
I really appreciate your inclusion of educational handouts in your project, which is an important part of aiding clinical practice! The use of visuals as an international language makes them even more effective. Plus, the handout is a great balance of being both informative and simple! One suggestion that I have for the handout would be to create a version that included the English and Spanish side-by-side in one handout. This might be a useful way for English-speaking therapists to use the handout as an educational tool with Spanish-speaking patients across a language barrier. The ability to look at and refer to the same handout during patient care might enhance the effectiveness of the education.
I think that the home modification component of your handouts is especially helpful to addressing individual elements contributing to falls risks. In your research or experience, did you discover any common home dynamics contributing to falls risks that you were not expecting? I imagine that various social determinants of health could also impact patient experiences and potentially introduce barriers to reducing falls risks. Considering Guatemala specifically, did you notice any particular barriers that contributed to the ability for patients to modify their environments in order to reduce falls risks?
As a participant in your presentation in Guatemala, I especially loved the lab portion of your project! I am a hands-on learner, so this part of the experience was very helpful for my learning. I think you did a great job incorporating elements tailored to various learning styles in your project! This makes it an effective tool for audiences with diversity in learning styles. I also really appreciated the opportunity to enhance my Spanish vocabulary specifically related to physical therapy practice. As someone who is interested in continuing international service work throughout my career, I greatly benefitted from the learning and practice! Thank you!
You did a great job on this project and I love your commitment to enhancing patient care for Spanish-speaking communities! Fantastic work on this project! Thank you!!!
Jennifer Tompkins
Hello Anjali,
I enjoyed your Capstone project/products. The PowerPoint presentation is great, even just reading the slides and not being present for it. The information you provided on specificity and sensitivity for each outcome measure is often not included in presentations and is much needed. I learned that we should do 2 assessments to asss falls risk! Your images and pictures within the presentation were excellent and kept my attention.
What a great project! Congratulations on a job well done.
Jennifer
Kristen Massey
Anjali,
I was fortunate enough to be one of the students that got to witness your capstone presentation in Guatemala, so I know of some of the changes that occurred quickly. However, as we told you then, you faced these changes with grace and flexibility, and still presented a wonderful capstone experience, despite your changed audience. I agree that this presentation would have been extremely useful to physical therapists and especially physical therapy students in this setting or even in other Spanish-speaking settings where they may not have access to outcome measures outlined in Spanish, as you mention here. Have you looked into being able to send your resources to settings like this? I know that we students were able to benefit from your capstone presentation, but I truly think that you could make a lasting impact on Spanish-speaking communities with the resources that you took so much time to create and translate.
While you were unable to present this information to its intended audience, were you able to apply any of it to the other experiences we had in Guatemala? Did you use any of this education during consults at health fairs?
Regarding your products…
Your PowerPoint is extremely well created. The information is informative but not wordy, and the graphics you have throughout are helpful too. My only suggestion for your PowerPoint is to include more graphics or pictures that you find useful just to break up some of the text and to continue to engage your audience. However, I love the images you selected for each of the outcome measures! They are informative while also accessible and friendly.
I remember reading your lab handouts during your presentation and really appreciating their clarity and organization. Looking at them again now, I still think they are very organized and clear! They are wonderful and very effective tools.
Lastly, based on your evidence table, it is clear that you have done a great amount of research to support this capstone. At this point, your evidence table is less of a table and more of an outline, but I’m sure that this is because you found an outline to be the most effective way for you to organize all of the information you found. While an outline format may be a bit wordy and more difficult to find concise answers to questions in, I still appreciate that you provide as much information that you do about each study. You could go either way with this – have less information in a table and encourage people to read the sources; or, have more words/information so people don’t “have to” read the sources. Totally personal preference!
Again, great job on this capstone. I especially admire how you chose a topic that aligns so well with your professionals interests.
Debbie Thorpe
Anjali
I enjoyed reading through your presentation and evidence table. Your health fair handouts were very engaging. I am sorry that you did not get to present in Spanish to therapists and PT students in Guatemala, but the materials that you developed will be very helpful to them in the future. Way to hang in there and adapt!
Best Wishes
Karen McCulloch
You captured the process and essence of what happened with your project well, but would like to see you at least mention how you saw the application of the information about falls prevention during the health fairs in Guatemala – including that adorable lady you befriended at Brillo de Sol.
I’ll send other comments via the feedback form. KMac