Population Health Initiative on Falls: Making the Connections to Tackle Stairs and Grab Bars

A Forum hosted by the University of Ottawa Institute on Health of the Elderly associated with SCO Health Service and the Community Health Research Unit
Ottawa, Ontario
March 25-26, 2003

Introduction

First off, and again, THANK YOU for participating in this two-day forum. This was a history-making opportunity to bring together scholars, policy makers, programmers, and other decision-makers and advocates with a vested interest in addressing environmental concerns and falls prevention.

Goals of the forum were to:

1. Stimulate intersectoral dialogue on a population health approach to promote access to safe grab bars and safe stairways in Canada.
2. Identify grab bar and stairway designs that are most likely to facilitate independent living at home by older persons

Objectives of the forum were:

1. To share information about:
• current knowledge on preventing falls, grab bar safety, stairway safety/usability;
• surveillance systems and information technology tools that may inform modifications to the built environment for fall prevention;
• how National codes are developed and enforced;
• how research can be used to support recommendations for changes to building codes.
2. To come to consensus on recommendations for safe stairs and grab bars and the role of bodies, such as CPHA, in promoting these recommendations.
3. To develop an action plan and strategies for establishing and sustaining inter-sect oral collaboration to improve research transfer to decision makers
4. To identify strategies to mobilize communities to support safe stairs and universal access to grab bars

Participants

The forum was attended by 57 participants from 29 different local, provincial, national, and international organizations. Included were policy makers, researchers, public health programmers, housing officials, homebuilders, surveillance specialists, advocates for safe stairs, and legal representatives.

Overview of forum

The first afternoon consisted of a series of presentations on relevant topics, including:

• community research on stairs
• community research on grab bars
• lab studies on stairs
• lab studies on grab bars
• the role of information technology and surveillance systems in injury prevention
• the process of development, modification, and implementation of National Building Codes
• challenges to effecting changes in National Building Codes

NOTE: These presentations are available electronically upon request.

The second day began with 2 panel discussions that centered on:

• identifying ways in which intersectoral collaborations can be better established and nurtured
• specific recommendations for changes to National Building Codes for stairs and grab bars and evidence required to better advance these recommendations.

The forum concluded with three working groups:

• one group was tasked to begin a draft communiqué to be presented as a motion at the 2003 CPHA annual general meeting.
• one group discussed how to improve the transfer of research to policy and practice decision makers.
• one group discussed strategies to increase awareness, acceptance, and expectations around safe stairs, grab bars, and other home safety devices designed to prevent injuries.

Outcome of working groups

Working group on draft communiqué:

Participants:

• Lisa Ashley
• Larry Chambers
• Michelle Coghlan
• Sabrina Farmer
• Bonnie Lee
• Donna Lockett
• Jake Pauls
• Carolyn Williams

A draft communiqué was initiated. As a follow-up, Donna Lockett and Lisa Ashley continued to work and refine the draft, entitled "Falls among seniors as a priority public health issue". Feedback on the draft was provided by members of the working group and by CPHA. A final version was presented as a motion to CPHA by Dr. Larry Chambers and Jane Underwood on May 9, 2003. The motion was accepted by CPHA. In the motion, the CPHA was challenged to:

1. Urge the federal government to develop policy and recommendations to the National Building Code of Canada for building codes related to stair design and installation of grab bars to bathtubs.
2. Encourage the Canadian Institutes of Health Research and the federal, provincial and territorial governments to establish national working and research groups comprised of inter-sectoral, multidisciplinary leaders in the field to promote research and development on falls prevention.
3. Urge the federal government to establish a national surveillance system for tracking falls and related injuries.

In addition, members of this forum submitted input into the public consultation process and recommended building code changes proposed by the National Building Codes and Ontario Provincial Building Codes.

Working group on research transfer:

Participants:

• John Archer
• Ian Brodie
• John Cook
• Nancy Edwards
• Robert Howlett
• Lian Kitts
• Frank Knoefel
• Marilynn Kuhn
• Julie Levesque
• Jeff Levitt
• Tammy Lipskie
• Karen McNaught
• John Miller
• Tom Parker
• Barbara Schulman
• Jennette Toews
• Eileen Woodford

The group discussed challenges to developing codes, given the current state of research. Knowledge and transfer were discussed.

The key challenges to developing evidence-based codes discussed were:

• The tradition of the National Research Council to base decisions on "hard" sciences, as opposed to social sciences.
• The vast volume of information available and the need to better synthesize information for decision makers.
• The challenge of enforcing codes at the provincial level.
• The potential conflict of interest for the NRC to conduct "human factor" research.
• The fact that many professionals are not aware of the need or options to address barrier-free design or are resistant due to perceived cost implications.
• The diversity and intersectoral nature of sources of information on this issue that are not captured in more traditional literature.

Recommendations to improve research transfer were identified:

• When framing questions related to the built environment, researchers need to think about how they can frame their questions with codes in mind.
• Information needs to flow bi-directionally, that is, from academics to decision makers and from decision makers to academics.

The peer review process should include people whose work relates to the built environment.

• Curricula for relevant professions (e.g. architects) should include concepts such as "barrier-free design".
• Policy practicums for population health PhD students in built environment policy settings should be considered.
• A course on working with and engaging policy makers should be included in post-graduate university programs.
• Nancy Edwards' interns and PhD students should tour the NRC research facilities.
• Potential sources of funding need to be explored, e.g. Industrial Research Assistance Program (IRA), CIHR, NSERC, Federal government policy research funding, research chairs programs.

Working group on community mobilization:

Participants:

• Dot Bonnenfant
• Mary Lou Boudreau
• Jean-Remi Champagne
• Lynn Chisholm
• Rob Howlett
• Cathie Kissick
• Margaret Levy
• Maryan O'Hagan
• Verna Popejoy
• Scott Puddicombe
• Vanessa Secan
• Darene Toal-Sullivan
• James Watske
• Claire Zanetti

The group discussed the need to increase awareness around environmental risk factors for falls and injuries and the need to "normalize" devices such as bath grab bars and handrails for stairs.

They discussed reasons why have groups with the greatest vested interest (e.g. seniors) not been pushing for safe stairs/railings/grab bars:

• Marginalized people don't see themselves as a driving force.
• People don't want to 'see' disability or frailty in themselves.

Recommendations for promoting normalization were identified:

• Using a multigenerational approach, for example, getting children and youth involved in advocacy via school curriculum (eg: geometry, problem solving, family studies), programs, projects and community service.
• Using financial incentives such as:
  • Insurance reductions for installation of grab bars, stair railings, 7-11 stairs
  • Tax deductions (or rebates) for cost of installing grab bars and making changes to increase stair safety.
• Targeting industry and business professionals, including:
  • Renovators and homebuilders to increase awareness of how addressing features that increase safety can increase the value and desirability of a house;
  • designers/manufacturers to enhance options for improved style and aesthetics of grab bars;
  • retailers to provide evidence-based information and greater access to assistive devices.
  NOTE: The Tools for Living Well Project, a HC/VAC funded project sponsored by the University of Ottawa and CAOT, is working with businesses in these capacities.
• Make this a "Hot Topic": Education and information needs to be presented in a format that is compelling and interesting. Messages need to reflect capacity and interest of audience:
  • Messages to Governments:
    • fall prevention (correcting stairs, installing grab bars) keep people out of hospitals;
    • fall Prevention is a cost savings for our health care system;
    • building codes need to be brought up to date using latest research results.
  • Messages to the public and professionals (e.g. through PSAs);
    • falls are due, in part, to environmental features such as unsafe stairs, lack of grab bars, lack of light, unsafe rails;
    • falls don't have to happen and risk can be lowered by making basic environmental safety changes (e.g. fixing stairs, installing proper grab bars and railings);
    • falls can affect all ages and modifying the environment can increase safety for children, youth, pregnant women, adults, disabled, older adults.

Feedback from the forum

Overall the comments suggested that the forum was very informative and provided an opportunity for intersectoral dialogue. Feedback from the forum indicated that participants found the information provided by the presentations and panel discussions to be useful and relevant (means 4.4 each on a scale of 1-5). Forum participants found the action planning session to be good as well (mean 4.0 on a scale of 1-5).

The need for follow-up opportunities (that is, a follow-up forum) was expressed by participants via suggestions that more time be provided to:

• explore individual issues in greater detail;
• allow for more dialogue;
• deal with concrete follow-up issues, such as who will take a lead, potential timing-scheduling of events, how follow-up will be established.

Conclusion

This two-day forum was a stimulating opportunity for academics, policy makers, and program decision-makers to share knowledge, identify challenges and opportunities to developing better intersectoral collaborations, and develop strategies to ensure that building codes are evidence-based and reflect a broader population health approach to preventing injuries related to falls. However, this event was but a first step. We need to build upon the momentum that was generated during this two-day event. We need to reach out to each other to continue dialoguing, problem solving, and taking action to prevent falls. We would encourage participants to consider taking a lead on a follow-up opportunity to build on the action planning that was initiated during this inaugural forum.

As stated by Nancy Edwards during her opening remarks, "like the minuet, at first glance choreographing fall prevention looks simple but we actually find it to be exceedingly complex. A wide array of perspectives is required to put together the dance that prevents a fall." However, like an improvisation, falls prevention will require that we "think of the possibilities, listen to the music….(and just)… move. This two-day forum brought together some of the key perspectives that are required to tackle the problem of environmental hazards related to falls. We have thought of the possibilities; listened to the discourse, dialogued and debated. Now let's move.

Nancy Edwards speaking at the Fall Prevention Forum, Ottawa, March, 2003.