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Preplanned Studies: Evaluation of the Effectiveness of “5E” Comprehensive Injury Prevention Strategy for Fall Prevention Among the Rural Elderly — Six Pilot Villages, Yunnan Province and Chongqing Municipality, China, 2018–2023

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  • Summary

    What is already known about this topic?

    The mortality rate and disease burden associated with falls among the elderly in China are on the rise. Interventions can play a crucial role in preventing and managing falls.

    What is added by this report?

    The application of the “5E” injury prevention strategy led to a decrease in both the occurrence of falls and the likelihood of subsequent falls. Regular physical activity and maintaining a positive outlook were identified as protective measures against falls, while sleep issues and hearing impairment were found to increase the risk of falling.

    What are the implications for public health practice?

    The group-based comprehensive intervention strategy is crucial as it offers an innovative intervention model and empirical evidence for decreasing fall rates among elderly individuals living in rural areas.

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  • Funding: Supported by the Kadoorie Charitable Foundation
  • [1] China Geriatric Health Service and Standardization Branch of the Chinese Geriatric Health Medical Research Association, Editorial Committee of the Journal of Chinese Geriatric Health Medicine. Expert consensus on fall risk assessment for older adults in China (Draft). Chin J Geriatr Care 2019;17(4):47-8,50. http://dx.doi.org/10.3969/j.issn.1672-2671.2019.04.013. (In Chinese). 
    [2] Zhao HH, Zhao JJ, Han H. Evaluation of fall intervention effect in rural elderly by risk difference. Chin J Women Child Health 2016;7(5):1 − 6. https://doi.org/10.19757/j.cnki.issn1674-7763.2016.05.001CrossRef
    [3] Zhuang Y, Zhang SY. Application research of "5E" prevention strategy in fall risk management of hospitalized elderly patients. J Nurs Admin 2017;17(9):673 − 5. https://doi.org/10.3969/j.issn.1671-315X.2017.09.023CrossRef
    [4] Shi L, Zhang JJ, Jiang L, Shi LY, Chen FH. Effect of 5E prevention strategy on falling risk management system apply for inpatients in general hospitals. J Xinjiang Med Univ 2020;43(12):1636 − 40. https://doi.org/10.3639/j.issn.1009-5551.2020.12.024CrossRef
    [5] NARI. Falls risk for older people in the community: FROP-Com. 2008. https://www.nari.net.au/frop-com. [2023-12-3].
    [6] Department of Health & Human Services. Falls risk assessment tool(FRAT). 1998. https://www.health.vic.gov.au/publications/falls-risk-assessment-tool-frat. [2023-12-3].
    [7] Ding XB, Yang XX, Gao Y, Xu J, Huang ZL, Liu YY. Incidence rate and related factors of recurrent falls among the elderly in Chongqing Municipality. Pract Prev Med 2022;29(2):149 − 52. https://doi.org/10.3969/j.issn.1006-3110.2022.02.006CrossRef
    [8] Xu T, Han H. Prevalence of falls among the rural elderly — three PLADs of western China, 2017–2018. China CDC Wkly 2020;2(46):877 − 80. https://doi.org/10.46234/ccdcw2020.239CrossRef
    [9] Li JM, He MY, Ye CY. Research progress on fall intervention for the elderly in the community. Chin J Gerontol 2021;41(22):5158-64. http://qikan.cqvip.com/Qikan/Article/Detail?id=7106038235. (In Chinese). 
    [10] Xu PM, Liu Y, Chen ZG, Guo ZX, Wang X. Prevalence rate of fear of falling in the elderly: a meta-analysis. Occup Health 2022;38(5):695 − 8,703. https://doi.org/10.13329/j.cnki.zyyjk.2022.0104CrossRef
  • TABLE 1.  Univariate analysis of the impact factors of falls among rural elderly pre- and post-intervention in six pilot villages, Yunnan and Chongqing, China, 2018–2023.

    Item Post-intervention χ2 P Pre-intervention χ2 P
    Number Number of falls (%) Number Number of falls (%)
    Sex 2.899 0.089 0.489 0.484
    Male 737 11 (1.49) 635 75 (11.81)
    Female 799 22 (2.75) 641 84 (13.10)
    Ethnicity 5.729 0.126 4.903 0.179
    Han 426 15 (3.52) 316 46 (14.56)
    Tujia 423 7 (1.65) 453 61 (13.47)
    Lahu 469 6 (1.28) 317 29 (9.15)
    Other 218 5 (2.29) 190 23 (12.11)
    Age (years) 2.981 0.225 6.353 0.042
    60– 773 12 (1.55) 698 73 (10.46)
    70– 551 14 (2.54) 417 65 (15.59)
    ≥80 212 7 (3.30) 161 21 (13.04)
    Educational level 10.750 0.005 4.871 0.088
    Illiterate 969 28 (2.89) 827 112 (13.54)
    Primary school 506 3 (0.59) 327 39 (11.93)
    Junior high school and above 61 2 (3.28) 122 8 (6.56)
    Occupation 7.821 0.020 0.485 0.785
    Housework 416 14 (3.37) 513 67 (13.06)
    Farming 1,075 16 (1.49) 721 86 (11.93)
    Other 45 3 (6.67) 42 6 (14.29)
    Alcohol consumption 0.329 0.566 1.456 0.228
    Yes 441 8 (1.81) 456 50 (10.96)
    No 1095 25 (2.28) 820 109 (13.29)
    Having sleeping problems 7.498 0.006 3.757 0.053
    Yes 169 9 (5.33) 389 59(15.17)
    No 1,367 24 (1.76) 887 100(11.27)
    Physical exercise 10.054 0.002 4.661 0.031
    Yes 964 12 (1.24) 541 80 (14.79)
    No 572 21 (3.67) 735 79 (10.75)
    Having chronic disease 0.001 0.971 1.322 0.250
    Yes 554 12 (2.17) 368 52 (14.13)
    No 982 21 (2.14) 908 107 (11.78)
    Vision 7.845 0.049 14.512 0.002
    Normal 504 8 (1.59) 338 29 (8.58)
    Slightly blurred 835 17 (2.04) 609 79 (12.97)
    Often unable to see clearly 176 5 (2.84) 192 22 (11.46)
    Blurred 21 3 (14.29) 137 29 (21.17)
    Hearing 7.894 0.048 11.647 0.009
    Normal 672 8 (1.19) 694 68 (9.80)
    Sometimes cannot hear 689 20 (2.90) 367 62 (16.89)
    Often cannot hear 139 5 (3.60) 131 19 (14.50)
    Severe hearing loss 36 0 84 10 (11.90)
    Mentality 6.793 0.009 8.881 0.003
    Positive 1,025 4 (0.39) 971 106 (10.92)
    Loneliness, anxiety or depression 511 29 (5.68) 305 53 (17.38)
    Download: CSV

    TABLE 2.  Multivariate logistic regression analysis of the impact factors of falls among rural elderly pre- and post-intervention in six pilot villages in Yunnan and Chongqing, China, 2018–2023.

    Impact factors (Reference groups) β S.E. Wald χ2 P OR 95% CI
    Pre-intervention
    With exercise (No) −0.392 0.174 5.100 0.024 0.68 0.48, 0.95
    Vision (Blurred vision) 8.417 0.038
    Normal vision −0.259 0.241 1.159 0.282 0.77 0.48, 1.24
    Slightly blurred −0.829 0.313 7.028 0.008 0.44 0.24, 0.81
    Often unable to see clearly −0.110 0.324 0.116 0.733 0.90 0.48, 1.69
    Mentality (Loneliness, anxiety or depression) −0.466 0.188 6.173 0.013 0.63 0.43, 0.91
    Post-intervention
    Having sleeping problems (No) 1.050 0.440 5.686 0.017 2.86 1.21, 6.77
    With exercise (No) −1.089 0.387 7.897 0.005 0.34 0.16, 0.72
    Hearing (Normal) 8.464 0.037
    Sometimes cannot hear 1.161 0.750 2.393 0.122 0.31 0.07, 1.36
    Often cannot hear 0.527 0.622 0.718 0.397 1.69 0.50, 5.73
    Severe hearing loss 18.903 6041.682 0.998
    Mentality (Loneliness, anxiety or depression) −1.534 0.557 7.571 0.006 0.22 0.07, 0.64
    Note: “−”:The number of falls due to severe hearing loss is zero.
    Abbreviation: S.E.=standard error; OR=odds ratio; CI=confidence interval.
    Download: CSV

    TABLE 3.  The comparison of the leading cause of falls among rural elderly, pre- and post-intervention in six pilot villages, Yunnan and Chongqing, China, 2018–2023.

    Cause of fall Post-intervention Pre-intervention
    N % N %
    Elderly themselves
    Leg weakness 14 16.67 30 8.33
    Poor body balance ability 11 13.10 64 17.78
    Distraction 11 13.10 30 8.33
    Vision problems 6 7.14 25 6.94
    Unwell episodes 3 3.57 45 12.50
    Surroundings
    Slippery grounds and obstacles 28 33.33 118 32.78
    Insufficient or blinding light 8 9.52 26 7.22
    Steps with large height difference 2 2.38 13 3.61
    Furniture too high or too low 1 1.19 7 1.94
    No handrails in bathroom 0 0 2 0.56
    Download: CSV

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Evaluation of the Effectiveness of “5E” Comprehensive Injury Prevention Strategy for Fall Prevention Among the Rural Elderly — Six Pilot Villages, Yunnan Province and Chongqing Municipality, China, 2018–2023

View author affiliation

Summary

What is already known about this topic?

The mortality rate and disease burden associated with falls among the elderly in China are on the rise. Interventions can play a crucial role in preventing and managing falls.

What is added by this report?

The application of the “5E” injury prevention strategy led to a decrease in both the occurrence of falls and the likelihood of subsequent falls. Regular physical activity and maintaining a positive outlook were identified as protective measures against falls, while sleep issues and hearing impairment were found to increase the risk of falling.

What are the implications for public health practice?

The group-based comprehensive intervention strategy is crucial as it offers an innovative intervention model and empirical evidence for decreasing fall rates among elderly individuals living in rural areas.

  • 1. National Center for Women and Children’s Health, Chinese Center for Disease Control and Prevention, Beijing, China
  • Corresponding author:

    Hui Han, hanhui@chinawch.org.cn

  • Funding: Supported by the Kadoorie Charitable Foundation
  • Online Date: April 05 2024
    Issue Date: April 05 2024
    doi: 10.46234/ccdcw2024.054
  • As of 2021, China has entered a phase of moderate aging, with a significant projected increase in the elderly population over the next decade due to a second baby boom starting in 1962. This demographic shift poses significant challenges for national finances, social healthcare services, and home assistance. Falls are the primary cause of fatal injuries and illnesses among Chinese individuals over 65 years old (1). Research indicates that about 1/3 of 65-year-olds and half of 80-year-olds have experienced a fall, with a high likelihood of recurrence for those with a history of falls. Prompt prevention and diagnosis of falls using clear criteria can yield visible results quickly (2). Preventing and managing falls among the elderly is a key priority for facilitating healthy and active aging in China. Domestic researchers have successfully implemented the “5E” strategy — Education, Environmental modifications, Engineering improvements, Enforcement measures, and Evaluation — to mitigate fall risks among elderly inpatients (3-4). Nonetheless, there is a scarcity of studies evaluating the efficacy of group-based fall prevention interventions for rural older adults.

    This study aims the effectiveness of a group-based comprehensive intervention strategy to prevent falls in older adults through a prospective cohort study conducted from October 2022 to September 2023. Using random cluster sampling, six project townships were chosen from Yunnan Province and Chongqing Municipality, with one project village selected from each township. The survey involved 1,536 rural elderly individuals aged 60 and above across 6 project villages. Baseline data from 1,276 rural elderly individuals aged 60 and over from the same villages collected from November to December 2018 was used for self-control. The research was part of the “Community Participation to Promote Rural Elderly Health – Phase II” project by the National Health Commission (NHC). Inclusion criteria included individuals aged 60 and above residing in the project area for at least six months, while exclusion criteria involved severe mental illness, paralysis, and epilepsy.

    The research team implemented a detailed, household-level investigation by deploying a specifically designed questionnaire. This questionnaire encompassed a wide array of topics, capturing essential resident demographics, lifestyle choices, daily activity capabilities, overall physical health, and impressions of the intervention project. The multifaceted “5E” strategy for injury prevention was employed, focusing on the following dimensions: 1) Provision of targeted health education, which addressed themes such as fall prevention and awareness, handling falls, the significance of physical activity, and safety measures associated with exercise. 2) Modification of the living environment in an age-sensitive manner, entailing upgrades such as smoothing out uneven surfaces, enhancing lighting in communal areas, bathroom repairs, handrail installations, and setting up fitness equipment. 3) Dispensation of age-friendly assistive devices that included items like reading glasses for presbyopia, portable commodes, walking sticks, and crutches aimed at reducing the fall risk for the elderly. 4) Oversight of the entire intervention process, from the development and procurement of necessary resources to the actual execution and subsequent assessment of the interventions. 5) Conducting risk evaluations for potential recurrent falls. Evaluation metrics involved measuring the frequency of falls, defined as the percentage of participants who reported experiencing a fall in the preceding year, as well as quantifying re-fall risk. For assessing re-fall risk, we employed the endorsed scoring systems of the Fall Risk For Older People-Community Setting (FROP-Com) (5) and the Falls Risk Assessment Tool (FRAT) (6), resulting in a comprehensive 37-point score with 13 primary factors, comprising: fall history, medications influencing fall risk, medical conditions affecting balance and flexibility, paresthesia occurrences, sleep quality, health literacy, urinary incontinence, nutritional health, environmental safety assessment, level of physical activity, proficiency in everyday activities, engagement in physical exercise, and emotional well-being.

    Data analysis was performed using SPSS statistical software (version 27.0, SPSS Inc., Chicago, IL, USA). This study was approved by the Ethics Review Committee of the National Center for Women and Children’s Health, China CDC, under the protocol (Ethics Review Number: FY2018-07). Before the intervention, participants were well-informed about the study procedures and provided their informed consent.

    The initial data indicated that 159 individuals suffered falls; however, in the subsequent survey, only 33 reported falls. The prevalence of falls decreased from 12.46% to 2.15% following the intervention (Table 1). The mean scores for the reassessment of fall risk decreased from 9.64±2.99 to 7.79±2.44. Analysis using a regression model revealed that regular physical activity [odds ratio (OR): 0.34, 95% confidence interval (CI): 0.16, 0.72] and a positive attitude (OR: 0.22, 95% CI: 0.07, 0.64) were protective factors, while sleep disturbances (OR: 2.86, 95% CI: 1.21, 6.77) and hearing impairment (Wald χ2=8.46, P=0.037) were identified as risk factors for falls. Visual impairments such as blurred vision can be corrected with the use of presbyopia glasses (Table 2). The ratio of falls attributed to intrinsic factors versus environmental factors was approximately 1∶1. Slippery surfaces or obstacles in the surroundings (33.33%) were identified as the primary causes of falls (Table 3).

    Item Post-intervention χ2 P Pre-intervention χ2 P
    Number Number of falls (%) Number Number of falls (%)
    Sex 2.899 0.089 0.489 0.484
    Male 737 11 (1.49) 635 75 (11.81)
    Female 799 22 (2.75) 641 84 (13.10)
    Ethnicity 5.729 0.126 4.903 0.179
    Han 426 15 (3.52) 316 46 (14.56)
    Tujia 423 7 (1.65) 453 61 (13.47)
    Lahu 469 6 (1.28) 317 29 (9.15)
    Other 218 5 (2.29) 190 23 (12.11)
    Age (years) 2.981 0.225 6.353 0.042
    60– 773 12 (1.55) 698 73 (10.46)
    70– 551 14 (2.54) 417 65 (15.59)
    ≥80 212 7 (3.30) 161 21 (13.04)
    Educational level 10.750 0.005 4.871 0.088
    Illiterate 969 28 (2.89) 827 112 (13.54)
    Primary school 506 3 (0.59) 327 39 (11.93)
    Junior high school and above 61 2 (3.28) 122 8 (6.56)
    Occupation 7.821 0.020 0.485 0.785
    Housework 416 14 (3.37) 513 67 (13.06)
    Farming 1,075 16 (1.49) 721 86 (11.93)
    Other 45 3 (6.67) 42 6 (14.29)
    Alcohol consumption 0.329 0.566 1.456 0.228
    Yes 441 8 (1.81) 456 50 (10.96)
    No 1095 25 (2.28) 820 109 (13.29)
    Having sleeping problems 7.498 0.006 3.757 0.053
    Yes 169 9 (5.33) 389 59(15.17)
    No 1,367 24 (1.76) 887 100(11.27)
    Physical exercise 10.054 0.002 4.661 0.031
    Yes 964 12 (1.24) 541 80 (14.79)
    No 572 21 (3.67) 735 79 (10.75)
    Having chronic disease 0.001 0.971 1.322 0.250
    Yes 554 12 (2.17) 368 52 (14.13)
    No 982 21 (2.14) 908 107 (11.78)
    Vision 7.845 0.049 14.512 0.002
    Normal 504 8 (1.59) 338 29 (8.58)
    Slightly blurred 835 17 (2.04) 609 79 (12.97)
    Often unable to see clearly 176 5 (2.84) 192 22 (11.46)
    Blurred 21 3 (14.29) 137 29 (21.17)
    Hearing 7.894 0.048 11.647 0.009
    Normal 672 8 (1.19) 694 68 (9.80)
    Sometimes cannot hear 689 20 (2.90) 367 62 (16.89)
    Often cannot hear 139 5 (3.60) 131 19 (14.50)
    Severe hearing loss 36 0 84 10 (11.90)
    Mentality 6.793 0.009 8.881 0.003
    Positive 1,025 4 (0.39) 971 106 (10.92)
    Loneliness, anxiety or depression 511 29 (5.68) 305 53 (17.38)

    Table 1.  Univariate analysis of the impact factors of falls among rural elderly pre- and post-intervention in six pilot villages, Yunnan and Chongqing, China, 2018–2023.

    Impact factors (Reference groups) β S.E. Wald χ2 P OR 95% CI
    Pre-intervention
    With exercise (No) −0.392 0.174 5.100 0.024 0.68 0.48, 0.95
    Vision (Blurred vision) 8.417 0.038
    Normal vision −0.259 0.241 1.159 0.282 0.77 0.48, 1.24
    Slightly blurred −0.829 0.313 7.028 0.008 0.44 0.24, 0.81
    Often unable to see clearly −0.110 0.324 0.116 0.733 0.90 0.48, 1.69
    Mentality (Loneliness, anxiety or depression) −0.466 0.188 6.173 0.013 0.63 0.43, 0.91
    Post-intervention
    Having sleeping problems (No) 1.050 0.440 5.686 0.017 2.86 1.21, 6.77
    With exercise (No) −1.089 0.387 7.897 0.005 0.34 0.16, 0.72
    Hearing (Normal) 8.464 0.037
    Sometimes cannot hear 1.161 0.750 2.393 0.122 0.31 0.07, 1.36
    Often cannot hear 0.527 0.622 0.718 0.397 1.69 0.50, 5.73
    Severe hearing loss 18.903 6041.682 0.998
    Mentality (Loneliness, anxiety or depression) −1.534 0.557 7.571 0.006 0.22 0.07, 0.64
    Note: “−”:The number of falls due to severe hearing loss is zero.
    Abbreviation: S.E.=standard error; OR=odds ratio; CI=confidence interval.

    Table 2.  Multivariate logistic regression analysis of the impact factors of falls among rural elderly pre- and post-intervention in six pilot villages in Yunnan and Chongqing, China, 2018–2023.

    Cause of fall Post-intervention Pre-intervention
    N % N %
    Elderly themselves
    Leg weakness 14 16.67 30 8.33
    Poor body balance ability 11 13.10 64 17.78
    Distraction 11 13.10 30 8.33
    Vision problems 6 7.14 25 6.94
    Unwell episodes 3 3.57 45 12.50
    Surroundings
    Slippery grounds and obstacles 28 33.33 118 32.78
    Insufficient or blinding light 8 9.52 26 7.22
    Steps with large height difference 2 2.38 13 3.61
    Furniture too high or too low 1 1.19 7 1.94
    No handrails in bathroom 0 0 2 0.56

    Table 3.  The comparison of the leading cause of falls among rural elderly, pre- and post-intervention in six pilot villages, Yunnan and Chongqing, China, 2018–2023.

    • The introduction of an intervention led to a decrease in fall incidence from 12.46% to 2.15%. Additionally, re-fall risk assessment scores dropped from an average of 9.64±2.99 to 7.79±2.44. Both the reduced fall incidence and lower re-fall risk assessment scores were statistically significant, demonstrating that the intervention effectively minimized falls among elderly individuals in the research locations and mitigated the risk of recurring falls. Consequently, the study affirms that a group-based holistic intervention approach notably diminishes fall rates among older adults residing in rural areas.

      The initial fall incidence rate of 12.46% aligns with prior research in Chongqing Municipality (10.45%) (7) and Yunnan Province (9.60%) (8), affirming the baseline data’s reliability. This study consistently involved participants aged 65 years and older across all sites, excluding those unavailable for follow-up. New local residents joining during the intervention phase maintained the data’s comparability. Results demonstrated that physical exercise is an effective fall prevention strategy. According to Li Jinmei (9), balance is a modifiable fall risk factor. Practices such as Tai Chi and Baduanjin — a series of Qigong exercises — can enhance postural stability when walking or standing, and fortify the lower body’s strength and endurance in the elderly. A positive mindset also corresponds to a reduced fall occurrence. In our study, 19 individuals (57.58%) experienced a fear of falling (FOF), paralleling Xu Peimei’s (10) meta-analysis findings on FOF prevalence. FOF may curtail activity levels and diminish physical activity, leading to a decline in muscle strength and balance, hence raising the fall risk and perpetuating a detrimental cycle. Consequently, organizing recreational events, fostering social interaction, and providing emotional sustenance via caregivers is crucial (9-10). Moreover, the hazard of falls is heightened by the distractions and sluggish reactions stemming from sleep disturbances and sensory degradation. Auditory issues delay the elderly’s response to auditory fall-risk warnings, while visual impairments directly disrupt their vision and wayfinding abilities. Improvement in visual acuity after prescribing appropriate glasses significantly mitigates the fall risk, underscoring the value of investing in suitable assistive devices for the elderly in fall prevention efforts.

      The research sites in Yunnan and Chongqing, situated in mountainous regions with high seasonal rainfall, present challenging environmental conditions that elevate the risk of falls among the elderly, particularly within the Tujia and Lahu ethnic communities residing in traditional stilt houses. Approximately one-third of older adults experience falls due to slippery surfaces or obstacles, influenced by the unique geography, climate, and living conditions. Prior studies indicate that enhancing the living environment through personalized age-appropriate modifications indoors and outdoors can significantly reduce fall occurrences. Hence, feasible intervention strategies include decluttering and incorporating age-appropriate adjustments like slope modifications at home.

      The comprehensive injury prevention strategies known as the “5E” approach, which involves age-appropriate modifications and aids, demonstrated substantial and swift efficacy in decreasing fall rates. It is essential to tackle root causes like slippery surfaces and obstacles to prevent falls effectively. These findings offer empirical support for health departments in devising future fall prevention initiatives and equipping healthcare workers with efficient strategies for preventing falls in elderly populations.

      This study is subject to some limitations, including the absence of a control group due to its prospective cohort design and the omission of socialeconomic factors that may influence falls. Moreover, the study did not assess the long-term effects of the interventions. In summary, a group-based comprehensive intervention strategy demonstrated efficacy in decreasing fall rates and re-fall risks among older individuals.

    • No conflicts of interest.

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