Research Letter |
Factors associated with the initial acceptance of hip protectors amongst older people in residential care
SIR—Hip fractures in older people are a major public health problem. Hip protectors have been advocated as a means of preventing hip fractures in this group [1]. The impact of hip fracture and methods of prevention can be found in Appendix 1 of the supplementary data on the journal website (http://www.ageing.oxfordjournals.org/).Many older people refuse hip protectors when initially offered [2–6]. Across a range of studies, initial acceptance of hip protectors ranged from 37 to 72% with a median of 68% [7]. Increasing acceptance rates is an important goal, therefore.
The National Patient Safety Agency (NPSA) is interested in the use of hip protectors as a way of preventing fractures amongst older people. ‘Slips, trips and falls’ accounted for 53% of incidents reported to the NPSA during January–June 2003. Two per cent of all incidents resulted in serious harm (NPSA, unpublished report).
The NPSA commissioned this work to answer the following questions for older people living in residential care homes:
- What factors influence the acceptance of hip protectors?
- Do those factors account for the variations in acceptance between care homes?
There are published studies relating to residents of nursing homes and amongst community-dwelling older people that consider a limited range of predictive factors for initial acceptance [3, 5, 6]. There has been no previous published work, however, relating to residential care homes that sought answers these questions.
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Method |
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This investigation used data from The East Kent Hip Protector Study, a prospective study with 6 months follow-up amongst people aged 65 and over living in residential care homes with 20 or more beds. The methods used in this study were presented elsewhere [4]. A synopsis is presented in Appendix 2 in the supplementary data on the journal website (http://www.ageing.oxfordjournals.org/). Research ethical approval was obtained prior to the start of this work.
The mean age of the study subjects was 86, they were predominantly female (80%), and many had difficulty with ambulation (e.g. 55% used a walking aid).
Assessment
Every resident was offered a single assessment (developed for this work), on entry to the study by a project nurse, to identify modifiable risk factors for falling. It included questions on the demographic characteristics of the residents, long-term medical problems (i.e. arthritis, stroke, diabetes and Parkinson’s disease), dizziness, ability to transfer, assistance with walking and with stairs, use of walking aids, use of a wheelchair, vision problems, continence problems, and falls and fracture history. Furthermore, the resident was invited to complete a fear of falling questionnaire based on that developed by Tinetti and colleagues [8].
Lying and standing blood pressures were measured. Postural hypotension was defined as a reduction of either systolic or diastolic blood pressure (DBP) of at least 20 mmHg within 2 minutes of standing following 10 minutes lying. A person was classified as hypertensive if they had a DBP of 95 mmHg or greater lying or standing. These were consistent with definitions used in East Kent at the time.
Definition of initial acceptance
Consistent with the definition proposed by van Schoor in 2002 [7], initial acceptance rate was defined as the percentage of persons who agree to wear the hip protector. In this study, 25 residents agreed to wear hip protectors but subsequently never wore them. These were included in the numerator of the acceptance rate.
Statistical analysis
The data were pre-processed before analysis: a third category was created for dichotomous variables to model the effect of missing values.
The individual factors listed above were investigated for bivariate associations with initial acceptance. The following care home-related factors were also investigated: number of beds in the home, number of residents at baseline, history of fractured neck of femur over the previous 4 years and during the last year, average number of admissions to hospital, and Primary Care Group (PCG) area.
All of the individual-level variables were investigated for independent association using a mixed-model logistic regression analysis. All variables were entered into the analysis and backward elimination used to remove the least significant term at each iteration until all terms left in the model were significant at the 20% level. The care home-related variables were then entered into the model, and the process repeated. The results for all terms remaining in the model were reported. Only those terms that had a P-value of 0.05 or less are described as statistically significant.
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Results |
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A total of 299 residents were offered hip protectors, and in 51% they were initially accepted. The resident refused them in 30% of cases, it was a staff decision to refuse them in 10%, hip size was too large to fit the hip protectors in 2%, and information on reason for refusal was missing for 7%. The specific reasons for patient and staff refusal were not collected.
The bivariate associations between each of the resident factors and the initial acceptance of hip protectors are shown in Table 1.
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The results of the mixed effects logistic regression analysis are shown in Table 2. Increased initial acceptance of hip protectors was associated with dizziness, and reduced activities due to fear of falling. Decreased initial acceptance of hip protectors was associated with increasing age and hypertension. Male gender and difficulty seeing distant objects were associated with reduced acceptance, although neither was statistically significant at the 5% level.
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Increased initial acceptance was associated, but not significantly, with the following characteristics of the care home in which they lived: lower number of recorded fractured femurs, increased rate of previous admissions to hospital and a smaller number of residents in the home. The addition of a term in the model to represent PCG gave a significant improvement in fit (chi-squared=12.19, df=4 and P=0.02).
The variance between homes in initial acceptance rates increased when homes were standardised according to individual-level characteristics. The further inclusion of care home-related factors and PCG resulted in a model that explained only 22% of the variance between homes.
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Discussion |
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TopMethodResultsDiscussionConclusionKey pointsSource of fundingConflicts of interestReferences |
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This study has added to our knowledge of what factors are independently associated with the initial acceptance of hip protectors. It was also found that these factors explain only a minority of the variation between residential care homes in initial acceptance. Consequently, we must look for other explanations. These include individual- and staff-level factors (e.g. knowledge and attitude towards hip protectors) or characteristics of the home not measured in this study. Work to investigate the effect of these factors on initial acceptance seems justified. Some authors have speculated that the following are important factors: older people’s inherent conservatism, the perception that they are not at risk of hip fracture, or that hip protectors do not work, as well as perceived discomfort, proper fitting, appearance, extra effort to wear hip protectors, laundering and cost [9–11]. Incontinence has been reported as a staff barrier to acceptance of hip protectors [9, 10].
The associations found in our study are discussed in relation to others work and this is presented in Appendix 3 in the supplementary data on the journal website (http://www.ageing.oxfordjournals.org/). Some (e.g. gender) of these associations are consistent with the work of others [3, 5, 12]. However, in contrast to others’ work, we found no independent associations with mobility problems or a history of falls or fracture [11, 12].
There is no obvious reason for the association between hypertension and a reduced likelihood of accepting hip protectors. In fact it appears counter intuitive since severe hypertension is associated with risk factors for falls including dizziness and impaired vision. Possible explanations are that it is a statistical artefact (i.e. a type I error), or it is confounded with some unmeasured factor that has a more plausible explanation (e.g. negative attitude).
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Conclusion |
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TopMethodResultsDiscussionConclusionKey pointsSource of fundingConflicts of interestReferences |
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We found a number of factors that are associated with initial acceptance of hip protectors. Some, but not all, of these associations are consistent with the limited work that has been published. The finding that variations between homes in initial acceptance rates remain following adjustment for these factors suggests that other factors are also of importance.
Parker and colleagues [1] found: ‘... some evidence that in institutions with high rates of hip fractures, the use of hip protectors may help reduce the risk of hip fracture, but with new evidence the effect has become less certain’. There should be further work aimed at improving initial acceptance, but this should take place in parallel with continued work to investigate efficacy of hip protectors in institutional settings; particularly, in those groups at very high risk of hip fracture. The effect on initial acceptance of individual-level, care home- and staff-related factors not included in this current work should be investigated further. It is recommended that these should include the following factors:
- the perceptions of older people in regard to their hip fracture risks;
- the perceptions of older people of the effectiveness of hip protectors;
- their attitudes to hip protectors;
- the influence of staff knowledge and attitude to hip protectors; and
- other institutional factors that may inhibit or encourage the wearing of hip protectors.
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Key points |
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TopMethodResultsDiscussionConclusionKey pointsSource of fundingConflicts of interestReferences |
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- Initial acceptance and continued adherence to wearing hip protectors have been shown to be a problem in many studies.
- Previous studies give little empirical evidence relating to what factors affect initial acceptance of hip protectors, and whether those factors explain the variability between care homes.
- In this study of older people living in residential care homes, increased initial acceptance of hip protectors was associated with dizziness, and reduced activities due to fear of falling. Decreased initial acceptance of hip protectors was associated with increasing age and hypertension.
- Following adjustment for individual-level and care home-related factors, including primary care group, there was still substantial variation in initial acceptance rates between homes. This could be due to variations between homes in staff or resident knowledge of and attitude towards hip protectors.
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Source of funding |
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TopMethodResultsDiscussionConclusionKey pointsSource of fundingConflicts of interestReferences |
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NPSA.
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Conflicts of interest |
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TopMethodResultsDiscussionConclusionKey pointsSource of fundingConflicts of interestReferences |
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None.
1 Centre for Health Services Studies, University of Kent, Canterbury, UK
2 Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, P O Box 913, Dunedin, New Zealand
3 East Kent Health Promotion Service, Canterbury, Kent, UK
4 National Patient Safety Agency, London, UK
* To whom correspondence should be addressed Email: colin.cryer{at}ipru.otago.ac.nz
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Acknowledgements |
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TopMethodResultsDiscussionConclusionKey pointsSource of fundingConflicts of interestReferences |
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This work was carried out when CC was employed by the Centre for Health Services Studies (CHSS), University of Kent. CHSS is supported by the Department of Health as a Research and Development Support Unit. The Injury Prevention Research Unit is jointly funded by the Accident Compensation Corporation and the Health Research Council of New Zealand. The research described was supported by the National Patient Safety Agency. The views expressed in this article are those of the authors and do not necessarily reflect those of the above organisations. We thank the Canterbury Hip Protector Project Team for permission to use their data.
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References |
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TopMethodResultsDiscussionConclusionKey pointsSource of fundingConflicts of interestReferences |
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- Parker MJ, Gillespie WJ, Gillespie LD. Hip protectors for preventing hip fractures in older people (review). Issue 3: The Cochrane Library, 2005.
- Parkkari J, Heikkila J, Kannus P. Acceptability and compliance with wearing energy-shunting hip protectors. Age Ageing 1998; 27: 225–9.
[Abstract/Free Full Text] - Hubacher M, Wettstein A. Acceptance of hip protectors for hip fracture prevention in nursing homes. Osteoporos Int 2001; 12: 794–9.[CrossRef][Web of Science][Medline]
- Cryer C, Knox A, Martin D et al. Hip protector compliance amongst older people living in residential care homes. Inj Prev 2002; 8: 202–6.
[Abstract/Free Full Text] - Patel S, Ogunremi L, Chinappen U. Acceptability and compliance with hip protectors in community-dwelling women at high risk of hip fracture. Rheumatology 2003; 42: 769–72.
[Abstract/Free Full Text] - Forsen L, Sandvig S, Schuller A, Sogaard AJ. Compliance with external hip protectors in nursing homes in Norway. Inj Prev 2004; 10: 344–9.
[Abstract/Free Full Text] - van Schoor NM, Deville WL, Bouter LM, Lips P. Acceptance and compliance with external hip protectors: a systematic review of the literature. Osteoporos Int 2002; 13: 917–24.[CrossRef][Web of Science][Medline]
- Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of fear of falling. J Gerontol 1990; 45: P239–P243.
- Cameron ID, Quine S. External hip protectors: likely non-compliance among high risk elderly people living in the community. Arch Gerontol Geriatr 1994; 19: 273–81.[CrossRef][Web of Science][Medline]
- Butler M, Coggan C, Norton R. A qualitative investigation into the receptivity to hip protective underwear among staff and residents of residential institutions. N Z Med J 1998; 111: 239–63.[Web of Science][Medline]
- Myers AH, Michelson JD, Van Natta M, Cox Q, Jinnah R. Prevention of hip fractures in the elderly: receptivity to protective garments. Arch Gerontol Geriatr 1995; 21: 179–89.[CrossRef][Web of Science][Medline]
- Zimmer Z, Myers A. Receptivity to protective garments among the elderly. J Aging Health 1997; 9: 355–72.
[Abstract/Free Full Text]
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