Medscape, LLC is pleased to provide online continuing medical education (CME) for this journal article, allowing clinicians the opportunity to earn CME credit.

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Medscape, LLC and Preventing Chronic Disease. Medscape, LLC is accredited by the ACCME to provide continuing medical education for physicians.

Medscape, LLC designates this Journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

All other clinicians completing this activity will be issued a certificate of participation. To participate in this journal CME activity: (1) review the learning objectives and author disclosures; (2) study the education content; (3) take the post-test with a 70% minimum passing score and complete the evaluation at www.medscape.org/journal/pcd (4) view/print certificate.

Release date: May 23, 2012; Expiration date: May 23, 2013

Falls and fall-related injuries are a public health issue; they often have serious consequences for older adults and can lead to loss of independence. Every year, 36% to 40% of adults aged 65 or older fall at least once (1,2); falls are the leading cause of unintentional injuries and injury deaths among adults aged 65 or older. The total direct cost of fall-related nonfatal injuries for this population in 2000 in the United States was approximately $19 billion (3). The prevalence of falls and fall-related injuries in South Carolina is similar to that for the United States (1).

Falls and fall-related injuries are not necessarily a result of aging. Environmental, physical, and behavioral factors contribute to increased fall risk. Fear of falling is an additional factor contributing to falls (4,5); it can affect gait and is often a barrier to participation in physical activity (6,7). Inactivity further increases the fear of and risk for falls, creating a downward spiral that can lead to loss of function and disability. Fall prevention programs are effective in reducing fall risk factors and thereby the rate and number of falls (2,7-9). Providing community-based, affordable, and accessible fall-prevention programs to older adults of all ages and functional abilities is a proactive approach to prevent falls.

As part of an Administration on Aging grant to mobilize states to implement evidence-based programs in local communities, we partnered with the Aging Network (Area Agencies on Aging and aging service providers), the Lieutenant Governor's Office on Aging (LGOA), the South Carolina Department of Health and Environmental Control (DHEC), and the University of South Carolina (USC) School of Public Health to implement a 3-year project in South Carolina (2006-2009). In year 2, we implemented A Matter of Balance/Volunteer Lay Leader (AMOB/VLL) Model (10,11), an evidence-based program designed to address fear of falling in older adults (10,12-14). The primary objective of this study was to describe the implementation and dissemination of AMOB/VLL in a predominantly African American and largely underserved population in 3 regions where agencies and stakeholders had limited experience with such programs. The secondary objective was to examine potential benefits of the program using quantitative measures of mobility and perceived ability to manage falls.

The study was a quasi-experimental design with pre-post assessments and no control group. The institutional review boards of DHEC and USC approved study procedures and protocols. All participants could withdraw from the study at any time and signed a written consent before programs and testing began.

We received demographic information on 150 participants from 13 programs in 2 regions. Demographic data from 5 programs were missing. Not all 150 participants completed all survey questions. Fifty-seven percent of participants were African American, 62% had an annual income of less than $15,000, and 69% had a high school education or less (Table 1).

Fifteen lay leaders conducted 18 AMOB/VLL classes in 3 regions at 16 sites (Table 2). The 18 AMOB/VLL classes reached 235 older adults. Attendance data were available for 215 participants; 175 participants (81%) attended at least 5 of 8 sessions.

Major barriers included lack of awareness about the availability of programs, insufficient knowledge of the potential benefits of such programs, and lack of easy access to program sites. Barriers for program leaders were related to implementation of programs, such as lack of knowledge or skills regarding 1) evidence-based programs, 2) program fidelity and its importance, and 3) how to administer, collect, and record pre-post assessment data. Facilitating factors included the state-level leadership in guiding the project; the history of the state, regional, and local groups working successfully together on other projects; the structure of the Area Agencies on Aging; the recruitment of participants through these agencies; and the commitment of local groups to providing their facilities for use in delivering the program.

We received fidelity checklists for 13 programs; 117 sessions were conducted (13 programs A- 9 sessions) and 116 fidelity checklists were completed. More than 80% of program content was delivered appropriately in all 13 programs. Nine programs covered more than 90% of program content.

For the 108 FMS and 113 TUG participants for whom data were available, analyses showed significant improvement in self-reported falls management (FMS) and objectively measured mobility (TUG). Age-adjusted mean (standard deviation [SD]) scores on the FMS improved from 2.3 (0.07) at baseline to 1.8 (0.07) post-intervention (P < .001); TUG age-adjusted performance times decreased from a mean (SD) of 13.0 (0.47) seconds to 11.7 (0.47) seconds (P < .001).

AMOB/VLL programs can be successfully implemented and disseminated in rural and underserved areas where agencies have limited experience with evidence-based programs. The program was successfully disseminated to 3 regions. The popularity of programs in terms of numbers of programs offered and numbers of attendees suggests that older adults in South Carolina, many of whom are poor, have low literacy, and often are not aware of available community-based programs, are interested in and will participate in such programs when encouraged.

We reached a majority–African American population with lower education and income levels than participants in AMOB/VLL programs in other states (17). Dissemination efforts in Texas indicated that 30% of participants belonged to racial/ethnic minority groups, 40% had an annual income of $15,000 or less, and 82% had completed high school. In South Carolina, 57% of participants were African American, 62% had annual incomes less than $15,000, and 69% had a high school education or less.

Major barriers were helping regional teams understand the concept of evidence-based programs and the importance of adhering to program content. We used various approaches and devoted considerable time through training sessions to develop this understanding. The success of these efforts is reflected in the number of programs implemented and the number of lay leaders who volunteered for training and instructed classes.

Evaluating program fidelity and outcomes was necessary; therefore, we attempted to ensure that lay leaders were comfortable with procedures for administering pre-post assessments and recording and transferring data (many lay leaders had not previously used a stopwatch). No demographic data were available from 5 programs; in addition, attendance forms were missing for 20 participants. Still, we had data on most participants who completed 13 programs. Deviation from delivery of prescribed program content was minimal and occurred most frequently in the final 2 sessions. This was due, in part, to the participation of guest health professionals in these sessions. AMOB/VLL content encourages the use of guest speakers, but often their participation took time away from other program content.

Facilitating factors included the leadership provided by the state agencies in guiding area partners in planning and implementing programs and the structure of the Area Agencies on Aging for delivering services to older adults. These groups had a history of collaboration. Another factor was the decision to recruit participants from organizations that already served older adults. Commitment of partner groups to offer use of facilities as sites for program implementation was integral to project success. Such commitment facilitated participant recruitment and expedited program implementation.

To our knowledge, this is the first time that AMOB/VLL program outcomes were evaluated by using a quantitative assessment of mobility. Although exercise was only 1 component of the AMOB/VLL program, we found a significant improvement in mobility. This outcome suggests that participation in even minimal physical activity may be enough to bring about small improvements in mobility; other intervention studies with older adults have reported similar findings (18,19).

This study had several limitations. Without a control group, outcomes must be interpreted with caution; because all participants were volunteers and not randomly selected, outcomes cannot be generalized to all older adults. Loss of data from 5 programs was greater than desired. Data from these programs were either not submitted or were lost. Future research should address the length and type of training needed to fully prepare lay leaders to conduct tests and gather and report outcome data appropriately.

Before this study, AMOB/VLL programs had been implemented primarily among white populations (12,13,17). Although 28% of the population in South Carolina is African American (20), we had double that percentage in AMOB/VLL programs. Compared with AMOB/VLL participants in other studies, our participants had less income and education. Our data suggest the potential value of evidence-based programs for a substantial proportion of older adults, African Americans, and those with less income and education. Our project provides data on successful implementation of the AMOB/VLL program among older African Americans and suggests that disadvantaged older adults of different races can benefit from such programs.