Home safety in falls prevention:

A closer look at the CHEP programme

Li Ruijie, MSc OT
Senior Research Analyst
HSOR
The evidence behind your decisions
Contents
Introduction
Research design
Results
Discussion
Conclusion
Introduction
Introduction:
CHEP
The Community Health Engagement Programme
(CHEP) aims to engage the seniors in an active and
fulfilling lifestyle.
The objectives are:
- Equip residents in the community with skills to keep them
in the community.
- Integrate Tan Tock Seng Hospital (TTSH) with community
services within specific geographic locations to ensure
smooth transition of care.

Introduction:
"Stepping Out"
"Stepping Out" is the falls prevention component of CHEP.
Components of the "Stepping Out" include:
- Screening for geriatric problems.
- Exercises to improve gait and strength.
- Home visits to
> Assess home safety.
> Monitor medication compliance.
- Health talks on home safety and dietary needs.
- Training of volunteers to give assistance and guidance to elders.
Introduction:
"Stepping Out"
Several outcome measures collected within the "Stepping
Out" programme
- Falls
- Bergs Balance Scale (BBS)
- Falls Efficacy Scale (FES)
- Refactored SAFER HOME version 3
These outcome measures allow us to better understand
the factors associated with falls.
Introduction:
Research question
What are the factors associated with falls
within the "Stepping Out" programme?
Research design
Research design:
Enrolment
Potential participants were
- Selected from predetermined precincts.
- Assessed by physiotherapists and occupational therapists.
Participants with moderate to high risk of falls were
enrolled for a year.
For the purposes of this study, only the first 3 months
data are used.
Research design:
Outcome measures
Falls
- Number of falls
Falls Efficacy Scale (FES)
- A scale to measure the fear of falling.
- (Higher score implies more confidence)
Research design:
Outcome measures
Bergs Balance Scale (BBS)
- A scale to measure a persons ability to balance.
- (Higher score implies better balance)
SAFER HOME
- An instrument designed to measure home safety.
- (Higher score implies worse home safety)
Outcome measures:
SAFER HOME
The SAFER HOME was refactored to provide alternative
insights into the concept of home safety.
Various sources of inputs and evidence provide validity
to the refactored instrument.
- Theoretical model (Model of Human Occupation).
- Expert opinion from occupational therapists.
- Statistical justifications using confirmatory factor analysis.

Outcome measures:
SAFER HOME
Original factors
1. Bathroom & Toilet
2. Communication & Scheduling
3. Eating
4. Environmental hazards
5. Household
6. Kitchen
7. Leisure
8. Living situation
9. Medication, addiction & abuse
10. Mobility
11. Personal care
12. Wandering
New factors
1. Environment
2. Performance capacity
Outcome measures:
SAFER HOME
Refactored instrument consist of 2 factors:
- Environment
> Defined as items amendable to environment modification.
- Performance capacity
> Defined as items amendable to remediation of different domains
of the participant (e.g. physical, cognitive etc.)
Research design:
Outcome measures
Month 1 Month 2 Month 3
Baseline measures
Falls
BBS
FES
SAFER HOME
Follow-up measures
BBS
FES
SAFER HOME
Follow-up measures
Falls
Research design:
Outcome measures
Change scores were computed for the following
measures:
- BBS
- FES
- SAFER HOME
Change score is computed by: Month 3 Month 1
- A positive score indicates an increase in the score from
baseline.
Research design:
Analysis framework

"Generalised Linear Model" (GLM) was used to model

the variables.

Dependent variable
- The number of falls in the follow-up period.

Independent variables
- Change scores of the various assessments.

Covariates
- Demographic variables and baseline characteristics.

Research design:
Analysis framework
As the dependent variable is "falls" which is the count of falls,
Poisson regression is typically used.
2 problems often arise in the analysis of count data:
- Over dispersion
- Excessive zeroes
May need to consider the use of
- Zero-inflated models
- Negative binomial regression
- Both
Research design:
Analysis framework
Given the large number of
zeroes in "falls", a zero-
inflated model would be
adopted.
A zero-inflated negative
binomial model was
eventually adopted as the
model of choice for
analysing the data.


Results
Results:
Descriptive statistics
Sample size 371
Age, Mean (SD) 73.086 ( 7.846)
Gender, Count (%) Female 274 (73.854)
Ethnicity , Count (%) Chinese 309 (83.288)
Malay 44 (11.860)
Indian 13 ( 3.504)
Others 5 ( 1.348)
Results:
Modelling diagnostics
The negative binomial distribution was adopted to
account for possible over dispersion after accounting for
the excess zeroes.
The Vuong test was used to determine which is the
superior model (zero-inflated vs. non zero-inflated)
- Test-Statistic = 4.200, p < .05
- Test results suggest that the zero-inflated model is a more
suitable model.
Results:
Modelling results (Demographics)
Estimate Std. Error z value Pr(>|z|)
Age -0.110 0.030 -3.716 0.000 *
Gender (Female) -1.736 0.517 -3.358 0.001 *
Ethnicity (Malay) 0.054 0.502 0.107 0.915
Ethnicity (Indian) 2.674 1.068 2.505 0.012 *
Ethnicity (Others) 0.573 1.133 0.506 0.613
Results:
Modelling results (Baseline)
Estimate Std. Error z value Pr(>|z|)
Falls 1.237 0.296 4.174 0.000 *
BBS -0.135 0.042 -3.203 0.001 *
FES 0.466 0.228 2.046 0.041 *
Environment 0.118 0.135 0.876 0.381
Performance capacity 0.091 0.110 0.820 0.412
Results:
Modelling results (Change scores)
Estimate Std. Error z value Pr(>|z|)
BBS -0.276 0.070 -3.972 0.000 *
FES -0.005 0.176 -0.027 0.979
Environment 0.330 0.165 -1.993 0.046 *
Performance capacity -0.128 0.162 -0.787 0.431
Results:
Modelling results (Significant variables)
IRR
Demographic
Age 0.896
Gender (Female) 0.176
Ethnicity (Indian) 14.502
Baseline
Falls 3.445
BBS 0.873
FES 1.593
Change scores
BBS 0.759
Environment 1.391
Results:
Modelling results (Zero model)
None of the variables were significant in the zero model.
- Zeroes were not well modelled.
- However the Vuong test indicates that the zero-inflated
model is superior to the non zero-inflated model.
Discussion
Discussion (Demographics)
Older people have lower number of falls.
Females have lower number of falls than males.
Chinese have a lower number of falls than Indians
Discussion (Baseline)
People with lower number of falls at baseline have a
lower number of falls at follow-up.
People with better balance have lower number of falls.
People with more fear of falling have a lower number of
falls.
Discussion (Change scores)
People with an improvement in balance have a lower
number of falls.
People with better home safety in "Environment" have a
lower number of falls.
Discussion
2 findings run contrary to established literature:
- Older age associated with lower number of falls.
- More fear of falling was associated with lower number of falls.
Possibly related to different stages of improvement in function.
- With decreased participation as an intermediary.
Requires further work to understand the trajectory of
improvement in relation to falls.
Discussion
Performance capacity was not significant may be due to a
lack of sustainability in change.
A change in items susceptible to environmental
modification suggests that environmental modification
may be an effective way to reduce falls.
Conclusion
Several factors associated with less falls were uncovered.
2 of the factors (age and FES) have results that run
contrary to established literature and a possible
explanation is proposed.
The refactored SAFER HOME suggests that
environmental modifications has a significant impact on
falls.
Acknowledgements
I would like to thank my collaborators for giving me the
opportunity to work on this problem and providing
insightful feedback on the interpretation of analysis.
- Ms Ng Lip Chin (TTSH OT Department)
- Dr Noor Hafizah (TTSH Geriatrics Department)
I would also like to thank Professor John Fox (McMaster
University) for generously providing advice on resolving
some of the issues I had with analysis.
Refactoring of the SAFER HOME
Li Ruijie, MSc OT
Senior Research Analyst
HSOR
The evidence behind your decisions
Introduction
Original SAFER HOME
conceived using Person-
Environment-Occupation
(PEO) model.
Influence of PEO can be
seen in the subscales of the
instrument (e.g. Kitchen,
Personal care etc.)
Occupation
Person Environment
Introduction
Other models exist that can possibly conceptualise the
different concepts of home safety.
Using a sound theoretical model and tapping on the
experience of therapists working on the ground, it is
possible to develop an alternate grouping of the
subscales of the SAFER HOME.
Adopting an alternate model can offer a new perspective
on the constructs revolving falls and home safety.
Introduction
The model of interest is the Model of Human
Occupation (MOHO).
The primary building blocks of the model are:
- Volition
- Habituation
- Performance capacity
Introduction
Environment
PERFORMANCE
CAPACITY
Occupational
Adaptation
Performance
Participation
Skill
Occupational
Competence
Occupational
Identity
HABITUATION
Habits
Roles
VOLITION
Values
Interests
Personal causation
Introduction
For this study, we would be focusing on
- Performance capacity
> Defined as the capacity in the various functional domains
(physical, cognitive etc.) to perform various tasks.
- Environment
> Defined as the environment within which tasks are performed.
Introduction
The aim of this study is therefore to
- Use MOHO and expert knowledge to regroup the items
within the SAFER HOME
- Use the regrouping to gain additional insights into
relationship of falls with home safety.
Research design
Research design:
Refactoring
The items within SAFER HOME would refactored using the basic
elements of MOHO:
- Environment
- Performance capacity
The items would be reframed by considering if it was modifiable
by
- environment modification or
- performance capacity changes.
This is a highly contextual way of regrouping the items in a bid to
find a local theory.
Research design:
Refactoring
Volition & habituation were not considered as the
premise was to select components for refactoring that
were relevant to the context of Stepping Out.
Volition & habituation deemed to be not easily
observable or measured, much less influenced within this
context.
Research design:
Refactoring
Surveyed 5 occupational therapists (average 5.18 years of
experience, > 2 years in Stepping Out)
The OTs were asked to classify each item to determine if it is
more amendable to:
- Environmental modification
- Performance capacity modification
- Both
An additional option was available if the OTs deem the item
unnecessary and could be deleted.
Research design:
Refactoring
The reclassification was tallied and the highest votes
wins.
A series of rules were used to break a tie. In general:
- Items would be retained where possible.
- Items split between categories would go into both.
Using the rules, there was no tie unbroken.
Research design:
Refactoring analysis
After reclassifying the items, it is necessary to examine if
the data fits the new structure.
- Confirmatory factor analysis (CFA) used.
- CFA would determine if the refactored structure is
comparable to the old factor structure in terms of data fit.
Research design:
Refactoring analysis
If refactored structure is found comparable to the original
factor structure, regression modelling would proceed similar to
the previous study.
Refactored scores would be calculated and used in the
modelling.
Similar to the previous study:
- Dependent variable: Falls
- Independent variable: Change scores
- Covariates: Demographics & baseline measures

Research design:
Enrolment
A total of 928 complete administration of the SAFER
HOME was used to conduct the CFA.
These were conducted during the course of the Stepping
out programme.
Results
Results:
Refactoring
Original categories No. of items
Bathroom & Toilet 11
Communication & Scheduling 3
Eating 2
Environmental hazards 13
Household 9
Kitchen 8
Leisure 1
Living Situation 3
Medication addiction & Abuse 3
Mobility 10
Personal Care 8
Wandering 1
Refactored categories No. of items
Environment 22
Performance capacity 32
Both 16
Delete 4
Results:
Confirmatory factor analysis (Path diagram)
I01
.
.
.
.
I72
I02
Error I01
Error I02
Error I72
Living situation
Wandering
.
.
.
.
Results:
Confirmatory factor analysis (Path diagram)
I01
.
.
.
.
I72
I02
Error I01
Error I02
Error I72
Environment
Performance
capacity
For illustration purposes only, the items do not correspond to assigned categories.
Results:
Confirmatory factor analysis (Fit indices)
The fit indices suggest that the data fit the models well.

RMSEA SRMR
Recommended
(Hu & Bentler, 1999)
<.060 <.080
Original structure .049 .056
Refactored structure .050 .057
Discussion
Discussion
The results suggest that the model fit of the 2 models are
comparable.
While the refactored model may not have a better fit than
the original model, the primary aim of the refactoring
was to offer different insights into the home safety
phenomenon.