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

Presentation speaking notes

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

4. Evidence Table

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.